Study design and setting
This is a cross sectional study of HCW working at the medical cities of the Saudi Ministry of National Guard Health Affairs (MNG-HA). MNG-HA provide healthcare services to national guard service members and their dependents through large medical cities located in the 3 most densely populated regions of KSA, namely the Central, Western and Eastern regions. All facilities have been Joint Commission International (JCI) accredited since 2006. During the COVID-19, and following the first reported case in KSA, MNG-HA has taken drastic infection control measures that included the reduction of elective surgeries, stopping in person outpatient services, and introducing ER workflow to minimize Covid-19 cases flow through the main ER.
Subjects and sampling technique
The target population of the current study was all HCW employed by the MNG-HA at all three regions. An e-mail with an anonymous link to an electronic survey was sent to all HCWs who were on duty during the data collection period (~1400 HCWs), across all departments and specialties. This electronic survey was structured using the option that allowed for every participant to participate only once. The target sample size for the survey was estimated assuming a prevalence of high concern among HCW of 25.2% which was observed in another study in the same setting.16 We estimated the sample needed for the survey to be 800 participants, assuming 95% confidence limits and 3% precision. Those who agreed to participate and who responded with completed questionnaires totaled 844 HCWs, with a response rate of 60.2%.
A structured, self-administered survey of HCWs was conducted via email, using a concern scale to assess their concern about Covid-19 pandemic. This survey was designed based on a validated concern scale previously used in a study of the concerns of HCWs with regard to MERS-CoV16. The scale consists of 32 statements that cover 5 domains; self-satisfaction, social status, work environment, infection control measures, government action and activities.16 The scale was modified to also include a statement about the perception of HCWs towards curfew: “I feel safe that government implemented the curfew and the movement restriction periods”.
Data on gender, age, nationality, marital status, level of education, living status, professional characteristics and contact with patients were collected. HCWs were categorized according to their direct contact with Covid-19 patients to “Direct contact group”, or “Non Direct contact group”. The Direct contact group included all subjects caring directly for patients in the ER, Ward, or ICU. All statements were coded using 4 points Likert scale, taking values from 0 (“strongly disagree”) to 3 (“strongly agree”) resulting in a total concern score that ranges from 0 to 96. Participants were further classified into one of three groups based on their total concern score. The first group included subjects below the first quartile of the concern score (score of 39 and below), the second group included subjects with concern score between the 25th percentile (concern score of 40) and 75th percentile (concern score of 55) and the third group included subjects above the 75th percentile (score of 56 and above).16
The survey was distributed in the English language, as an electronic survey, to all HCWs via a link attached to a mass e-mail distribution, with no identifiers. A cover letter was attached to an email as a link sent to HCWs in their office emails, during the period between 15 and 30 of April, 2020. Study participants were expected to complete the survey and return it back without identifiers.
Participation in this study was voluntary. HCWs were assured in a written informed consent that their responses would remain anonymous and would not affect their performance evaluations, work status or compensations. HCWs were asked to respond to the survey if they agree on the informed consent. This study was approved by the institutional review board of the MNG-HA in Riyadh, Saudi Arabia (April 15, 2020; RC 20/173/R).
All categorical variables including age, gender and occupation status were summarized and reported using frequency and proportions. The total concern score was summarized and reported using mean and standard deviation. Association of categorical variables with the different levels of concern was analyzed using the Chi square test for homogeneity. All continuous variables were compared across the different concern levels using the student-t test and one-way ANOVA. Multiple linear regression analysis was used to determine significant predictors of high concern scores to Covid-19 pandemic. For all statistical analyses, significance was considered at a p value of ≤0.05. All analyses were performed in the Statistical Package for the Social Sciences software (SPSS version 26.0; IBM Corporation, Armonk, NY, USA).