Knowledge & Awareness of Measles among Foreign Workers Screened for Employment in Qatar

Background: Measles is still of an enormous global concern from preventive perspectives. The importance of knowledge & awareness level about it is not negotiable. Objective: To assess knowledge and awareness about measles, clarify the history of measles and its vaccine, and calculate the awareness level score among newly recruited workers in Qatar. Method: A cross-sectional study was used. A total of 422 workers attending the medical commission were studied. An interview administered questionnaire and awareness level score was calculated. Results: It was determined that (66.4%) of participants who know measles demonstrated an average level of measles awareness, while (22.4%) had an above-average level of awareness. Among those participants who know measles, most of them (81.8%) are aware of the existence of the measles vaccine, and (44.3%) gave a history of taking it. The majority were unaware of measles mode of transmission or preventive measures, except that (61.1%) know that its vaccine is protective. Most study participants (92.7%) have access to health information, and (84.4%) accept to take the vaccine if offered. ConClusion: These findings demonstrate the importance of delivering the proper health information to this subgroup, educating these workers about measles mode of transmission and preventive measures through multi-lingual, informative, and straightforward messages using different tools irrespective of their measles awareness status.


Introduction
Measles has a major global public health importance as it can lead to serious illness or even death, although being preventable through a safe and a cost-effective vaccine. The World Health Organization (WHO) estimated that about (85%) of the world's children received one dose of measles vaccine by their first birthday through routine health services [1]. In 2012, the WHO's measles and rubella initiative launched a Global Measles and Rubella Strategic Plan which provides strategies to achieve from 2015 to 2020 measles & rubella control and elimination goals [2]. Goals by the end of 2015 was to achieve regional measles & rubella/ Congenital Rubella Syndrome (CRS) elimination, which was later extended till 2020 to achieve elimination in at least five WHO regions, including the Eastern Mediterranean Region (EMR) [3].
The population in Qatar is considered of a unique structure where foreign workforce contributes to more than (70%) of the total population [4]. Nevertheless, construction employers in Qatar principally attracts people from Southeast Asia, the Indian subcontinent, the Arab world, and some African countries [5]. Some of these countries are known to contribute to the global measles morbidity and mortality, and possibly add to the liability of measles importation to Qatar [1]. Review of the communicable diseases surveillance data in Qatar collected by the Ministry of Public Health (MOPH) during (2013) showed that many confirmed measles cases were among young and middle aged non-Qatari adults, usually referred to as foreign workforce. The (2013) data revealed (61) total confirmed measles cases, (36.1%) of them are males, (63.9%) are non-Qatari, and (29.5%) belong to age group (20-44) years [6].
By the local regulations, all workers are invited for an obligatory medical examination in the national's Medical Commission (MC) operated by MOPH. Clearance from the MC is mandatory to acquire an official work permission in Qatar.
The knowledge & awareness about measles and its related vaccination history are well-recognized factors that limit the measles outbreaks. Knowledge and awareness regarding measles is the product of multiple inputs of information in a more accumulative manner, which subsequently end to subjective judgment. Knowledge and awareness play a significant role in an individual's response to its immunization, preventive measures, and disease confrontation [7,8].
Medical literature focuses more on studying the knowledge and awareness among the parents or the health care workers rather than workers coming originally from high prevalence countries [9,10]. This is the first study to assess the knowledge & awareness under the background of vaccination status about measles in Qatar among foreign workers.

Aim and Objective
Assessment of the knowledge & awareness about measles is fundamentally vital for the health promotion and prevention programs in Qatar toward forging workers. Study objectives are: To assess knowledge and awareness about measles, among newly recruited workers in Qatar. Further, to clarify the history of measles and its vaccine among these workers. Also, to calculate the awareness level score for measles among these workers.

Study Settings and Design
Cross-sectional study design was conducted at the MC in Doha-Qatar. It is an independent department under the MOPH; it consists of the administrative, medical, laboratory, and radiology units. It is a common pathway where all foreign workers before getting the work permit are obligatorily screened against a group of respiratory and blood-borne agents.

Study Population
All the calculated sample size of newly recruited workers attending MC for employment screening during the study period. On a daily average (2000-2500), applicants tested per day.
Eligibility criteria were both genders, aged between (18 and 60) years, applying for the MC examination to get a work permit in Qatar and willing to participate. The exclusion criteria were applicants for other reasons rather than getting the work permit (e.g., study residency permit and extension of travel or visit visas) and declined participation.

Sample Size and Sampling Technique
The following equation was used [11]: Where n: sample size, Z = Z statistic for an α error of (0.05) corresponding to a (95%) confidence level (1.96), P: the prevalence estimated for measles sero-susceptibility (50%), and the d: error rate of (0.05). The calculated sample was (384). For compensation of the non-response or any missing data, a (20%) new number was added, and the final total sample became (460). A systematic random sampling technique was employed to recruit study participants. Participants were enrolled through communication with the authorized local administrator who provided lists of served applicants, routinely recorded. The first participant enrolled every day was chosen randomly, followed by the next one systematically every other (88) new applicant till the end of the working day. This systematic sequence was determined after calculating the required time to accomplish each interview. Subsequently, the number of interviews can be accomplished during the working hours, taking into consideration the average daily applicants visiting the MC. Participants were enrolled until the fulfilment of the calculated sample size. Fieldwork took the period from November (2014) until the end of January (2015).
The manager of the MC was contacted officially by the investigator before data collection. He was informed about the study's objectives and importance, and he aided and facilitated contact with the working team.

Research Instruments
The questionnaire was developed by The Principle Investigator (PI). It included information about the followings:

Socio-demographic
Data including gender, age, nationality, marital status, educational level, proposed job, and income in the home country.

Access to health care and information about measles
Answers were categorized into four groups (private healthcare facilities, health insurance, free governmental health services, and finally, the absence of a regular healthcare provider). While, access to health information, was categorized into two main groups (either no access or presence of access). Among those got access; the source was categorized into three main groups: printed materials (i.e., books, posters, booklets, etc.) and audio-visual messages (i.e., through T.V. and/or radio), and finally the internet. Responses to this section were designed not to be mutually exclusive.

Measles knowledge & awareness, history, and vaccination questions
Participants were asked if they knew what measles is; responses were either one of two categories; they had ever heard about measles or not. According to the response to this question, participants were either asked all questions (if they ever heard about measles) or asked non-measles specific questions [12][13][14].
Question about measles modes of transmission, categorical variable, six choices: (airborne, proximity as in hugging and kissing, aerosol droplets as in coughing and sneezing, indirect transmission through contaminated surfaces, skin contact, and/or blood contact), participants can choose more than one answer or chose to declare is not sure.
Measles recorded history; it includes questions about the history of acquiring measles (answer could be yes, no or not sure), recall of common symptoms (five categories: fever, rash, cough, running nose, and/or red eye), history of any fever with rash incidence and/or hospitalization related to it, if any (answer could be yes, no or not sure).
Question about measles prevention measures; categorical variable with seven choices demonstrate direct, indirect transmission modes, uncommon or wrong measures, include avoiding (airborne transmission, proximity as in hugging and kissing, indirect transmission through contaminated surfaces, skin contact and/or blood contact, and taking the specific anti-measles vaccine).
Measles vaccine-related history: the following questions were asked (knowledge about the presence of measles vaccine, intake of the vaccine, and if the participant did not take the vaccine; his/her explanation was recorded in one of four possible categories. Also; the place of vaccination, it's timing (written in months and years or since childhood, later were categorized according to the most frequent duration into two options, less than two years / 2 years or more or during childhood), personal opinion about its benefit and the reason for taking it). All the responses are categorical variables.
Additional questions about the intake of any vaccine before arrival to Qatar (categorical variable with the options of either yes or no answers). Vaccine type (seven different options together with an open-end question for any other potential vaccine). The personal opinion about getting a protective vaccination against measles or any other infectious disease (answers could be one out of four different options). Participants declared disagreements about vaccine intake after arrival were asked for the possible reason, and the responses were classified into five possible answers (categorical variables).
Measles related history among household contacts; it includes history about the incidence of measles, fever with rash, or hospitalization related to it if any (categorical variables).

Calculated awareness level score
The current applied awareness score divides those answered that they do know measles (n=384) into three levels based on a calculated score, where the higher score indicates a higher level of measles awareness. These levels are (Below average, average, and above average) [15,16]. The range of the score is between zero and 14. The level was set at one standard deviation above or below the calculated mean.
The following four questions were used to generate the measles awareness score: "According to your knowledge, how measles communicated 1.
between people?" Answers were of seven different choices where score (1) was given to each correct answer, and score (0) was given to each wrong answer or is not sure.
"In your opinion, how to protect yourself from acquiring 2.
measles infection?" Answers were of eight different choices where score (1) was given to each correct answer, and score (0) was given to each wrong answer or is not sure.
"Do you think there is a vaccine for measles?" Answers were 3.
given a score of (2) for yes, (1) for being not sure, and (0) for no.
"If there is a vaccine for measles, it is beneficiary?" Answers 4.
were given a score of (2) for yes, (1) for being not sure, and (0) for no.
The questionnaire`s content and face validity were established by literature review, consultation of experts in the field. It was prepared in English and translated into Arabic with back translation at Hamad Medical Corporation (HMC) accredited translation center to ensure its validity and reliability. Furthermore, PI trained four multi-lingual data collectors that are officially assigned by the MC management.
The management also assigned a devoted nurse to help in the logistic issues. The pretesting for the questionnaire was conducted on (50) workers before the actual data collection clarified the average completion to the research team. Refinements were made based on feedback from the pre-test. Pilot participants excluded from the main study stream.

Ethical approvals
The study granted approvals from the Institutional Review Board (IRB) of HMC, and the MC management. Study participants were asked to sign a generic consent form declaring their agreement. Both participant's privacy and information confidentiality were ensured during the study.
The PI entered all collected data from completed questionnaires and extracted spreadsheets into an Excel ® sheet daily, and later all data was exported to a "Statistical Package of Social Science" version 20.0 (SPSS ® ) software database for analysis [17]. Different questions included in the interview questionnaires were coded and entered regularly. Descriptive statistics were used as appropriate.

Socio-demographic data
The majority of participants were male as they constituted (94.1%) of the sample. The mean age of participants was (31.35 years + 8.76 SD). As regards nationalities encountered, more than one-third of the sample were from the Philippines (36.5%). Marital status categories were (single, married, widowed, and divorced), it was observed that (56.1%) of participants were married.
Moreover, most of them have either a "secondary" or a "university or above" level of education constituting (43.9 & 41.9%, respectively). While (55.5%) were currently seeking manual jobs. Around (42%) of them have a sufficient income to meet their routine expenses, as shown in Table 1.

Access to health care & information about measles
Furthermore, the majority (92.7%) of the participant has access to health-related information. While most of the interviewed foreign workers got one or more sources to access health-related information, the commonest was access through audio-visual sources (88.4%) followed by the access through printed material and the internet (75.4% and 73.2%) respectively, as shown in Table 2.

Measles knowledge & awareness, history, and vaccination questions
Participants were asked screening questions about their general knowledge regarding measles, around (91%) declared being knowledgeable about the disease, as seen below in Figure  1. Participants were asked screening questions about their general in Table 3 amongst those participants who know about measles, most of them (81.8%) knew that there is a vaccine for measles, and (97.1%) considered that a vaccine against measles is beneficiary, while only (2.6%) disagreed. When these participants were asked whether they have ever been vaccinated against measles; (44.3%) reported a history of vaccination, (36.5%) were not sure and (19.2%) reported not being vaccinated. Furthermore, among those who took the measles vaccine (n=170), they reported that the reason behind taking it was either routine intake or an obligation for traveling (43.5% and 40%), respectively.  More than half of them (57.7%) mentioned that they took it in the private sector, and (39.4%) took the vaccine at a governmental setting. Besides, from those who took the vaccine, a majority (54.7%) stated that they took the vaccine more than two years ago or during childhood, while (45.3%) have taken it within the last two years. Among those who were not vaccinated against measles (n=74), they reported that they were never offered the vaccine, representing the majority (75.7%).
When they were asked about their view about vaccine intake after their arrival to Qatar, (84.4%) mentioned that they would agree to take vaccines when offered to them.
However, only two (2) participants said that they are not going to take a vaccine by any means, one was advised by others not to take any vaccine what is so ever, and the other thing that taking a vaccine may affect his future job.
The majority of participants stated that they did not take any vaccine before they arrived in Qatar (71.8%), but (27.7%) of them did. The MMR vaccine was taken by (13.7%) of the studied participants before their arrival, and (11.1%) took the measles mono-vaccine, as shown in Table 4.

View about vaccine intake after arrival to Qatar
Actively seek vaccine intake 5 (1.  On questioning the study participants who are aware about measles and reported history of acquiring it (n=116) according to the history of their measles associated symptoms. The majority of them (81%) recalled having fever and having a rash (86.2%), whereas only one participant (0.9%) gave a history of cough during his measles illness. Symptoms not recalled by them were either running nose (coryza or rhinitis) or red eye (conjunctivitis).
Moreover; when participants who knew about measles (n=384) were asked about their awareness about measles' mode of transmission as illustrated in Table 5, the minority of these participants replied appropriately that measles patients could infect others through airborne transmission (14.6%), through proximity as in hugging and kissing (21.3%), through aerosol transmission (36.4%), or indirect transmission by contacting contaminated surfaces (25.5%).  On the other hand, part of them has the wrong information that the measles virus could be transmitted from the patient to others through skin contact (45.1%) and through blood contact (16.9%).
Similarly, awareness about measles regarding its preventive measures, as seen in Figure 2. It showed that only the minority understand that avoiding the following practices are considered a preventive measure against transmission: avoid airborne transmission (15.1%), avoid proximity as in hugging or kissing a patient (20.3%), avoid exposure to aerosol from a patient during coughing or sneezing (33.9%), avoid touching a surface soiled with patient secretions after coughing or sneezing (25.2%). On the other hand, avoiding skin contact with a patient while he/she got rash was seen incorrectly as a preventive measure by (36.5%) of those participants, as well as avoiding contact with patient blood (13.5%). However; (61.1%) of those participants understand that taking the measles vaccine is a preventive method against the disease, and the rest disagreed.

Calculated awareness level score
Level of measles awareness was calculated and shows that among the (384) study participants who know about measles (66.4%) had scored average concerning measles awareness, around (22.4%) scored above average (high awareness) and only (11.2%) scored below average (low awareness). Furthermore, awareness score mean + SD was (6.5 + 3) (Figure 3).

Discussion
High measles virus incidence and frequent outbreaks or epidemics are reported frequently in many parts of the developing world, in the majority of cases due to low coverage of the measles vaccine. This vaccine awareness is an essential determinant for better public vaccination coverage [18][19][20].
The current study showed that although (91%) of participants claimed to be aware of measles, most of those who are aware answered incorrectly about its mode of transmission and preventive measures, even that only (61.1%) know that measles vaccine is protective. Limited references about the knowledge and awareness about the measles among workers made the comparison quite tricky. Nevertheless, such critical non-comparative data is available among parents and health care workers.
Such knowledge and awareness are profoundly affected by the social determinants of the participants. It is quite low in some communities, as mothers in low-income countries, while such knowledge is higher in health care workers.
A study evaluated coverage of mass measles vaccine awareness campaign done in (2011) that estimated parental awareness and the determinants for low/no coverage; household survey was conducted four months after the measles campaign in Karachi, Pakistan [21]. Parents of children younger than five years were administered a structured questionnaire about their knowledge and participation in the measles campaign of (1020) eligible households studied, only 282 (28%) parents knew about measles supplementary immunization activity, mainly from public announcements (49%). Of these, 174 (62%) children received the measles vaccine, whereas, 108 (38%) parents refused the measles vaccine. Overall, only (17%) of children received the measles vaccine during this campaign. Low maternal education, not having received the DPT/Pentavalent-3 vaccine, and routine vaccination from public Expanded Program on Immunization (EPI) facility were significant determinants for low vaccination coverage.
Similarly, in the current study, awareness was significantly lower among those who were lower in education and income. Many authors also confirmed similar findings of low knowledge [22][23][24][25][26].
The knowledge and awareness are much higher among health care workers due to mainly the medical and professional background. Petti, et al. addressed the higher level of knowledge and awareness among the dentists (60%) during a survey in Italy, however, this is lower for health care workers [27]. Also, Herzog, Raúl, et al. confirmed

Conclusion
Although (91%) of the studied workers claimed to be aware of measles; most of those who are aware answered incorrectly about its mode of transmission and preventive measures, except that (61.1%) know that the vaccine is protective, and (84.4%) of the participants accept to take a vaccine if offered. Among those participants aware of measles, the majority (81.8%) are aware of the presence of a vaccine for measles, (44.3%) declared taking it but (70%) took only one dose.
These findings demonstrate the importance of delivering the proper health information to this subgroup and educating these workers about measles mode of transmission and preventive measures through multi-lingual, informative, and straightforward messages using different tools irrespective of their measles awareness status.