COVID-19 is a rapidly evolving global health crisis. Healthcare professionals are at the forefront of the COVID-19 outbreak response. Hence, their risk of infection is greater than the general population . Therefore, it is vital that healthcare professional have adequate KAP regarding diagnosis, treatment and prevention of COVID-19. Here we assessed the KAP of medical interns toward COIVD-19 prevention in KSA. Our results reveal that there are gaps in KAP of medical interns training in KSA regarding COVID-19 prevention. To the best of our knowledge, this is the first study in KSA to assess medical interns’ KAP regarding COVID-19. Our results have implications for the relevant authorities in KSA.
Healthcare professionals’ good knowledge, attitude and practice in complying precautionary measures helps to create awareness among patients and community people . Medical interns in KSA are not deployed as frontline healthcare professional to combat COVID-19. However, evidence suggests that there are high chances of having undiagnosed COVID-19 patient contact at some point of time in healthcare settings . Therefore, they are at risk of contracting and spreading the infection. Evidence suggests that non-frontline healthcare workers have lower confidence in protecting themselves from the virus . On the other hand, frontline healthcare workers receive greater material support and care from the health systems, and they are more confident in their ability to protect themselves from the virus .
Knowledge forms positive attitudes and promotes positive behaviors . Our results suggest gaps between the current evidence on COVID-19 and the depth of knowledge among medical interns- particularly about the mode of transmission, the events require practicing hand hygiene, and minimum time requires to disinfect hands with soap and water or with alcohol-based hand sanitizer. However, over 99% interns know the population most vulnerable to COVID-19 infection and complications. This is much higher than that reported in Vietnam, where only 79% hospital healthcare workers correctly identified the vulnerable population . Over 99% interns know that washing hands with soap and water or rubbing hands with alcohol-based sanitizer reduce chances of getting infected with SARS-CoV-2. This is like that of reported by Giao et al in Vietnam among hospital health workers . We found that 96% of medical interns in KSA know the main symptoms of COVID-19 which is higher than the proportion reported among hospital health workers in other countries [23, 24]. We found that 61% of the interns know the mode of transmission of SARS-CoV-2. This proportion is higher than the proportion (39%) reported by Bhagavathula et al. among doctors and allied health workers of different countries , but lower than the proportion (98%) of dental practitioners as reported by a multinational study . Studies from other countries also reported a similar proportion (62–67%), such as among medical students in India  and among hospital healthcare workers in Vietnam .
We found that the vast majority (97%) of the interns have positive attitude towards the efficacy of quarantine of suspected COVID-19 cases for 14 days in reducing the spread of the infection. A lower percentage (66%) was reported among hospital healthcare workers in Vietnam . In addition, most of the medical interns (92%) positively believe that there is a need to declare recent travel history before rejoining work even if having no symptoms. This agrees with the findings reported by Bhagavathula et al. . Similarly, healthcare workers in Henan, China  believes that visitors with any close contact with a confirmed case or recent travel to an area with community transmission should disclose their exposure history. Most medical interns in KSA are positive toward staying home, isolating him/herself, and informing his/her superior if having fever or cough even if they have not been exposed to COVID-19 patients or recently returned from a travel. This agrees with a Vietnam study , where 98% health workers accept isolation in health facilities if getting COVID-19 exposure. More than two thirds of the medical interns in KSA (73%) rightly think that there is no need to wear N95 mask at work all time to avoid getting infected with SARS-CoV-2. This is in line with the findings of Modi et al in India . In Uganda , 17% healthcare workers believe that wearing general medical masks is not protective against COVID-19 contrary to findings by Ng et al. , which showed adequate protection. In addition, WHO recommends rational use of masks and other PPE in both healthcare and community settings . The surprising negative attitude of our studied group was about participants' awareness about the measures taken by their hospitals to address COVID-19 pandemic as well as visual triage checklist from the Saudi MoH for COVID-19 patients. This indicates the importance of improved communication and training provisions and materials on COVID-19 by the hospitals to strengthen preventive strategies including raising awareness of health workers including medical interns.
Our findings suggest that over 90% medical interns in KSA are proactively practicing social distancing or avoiding going out unnecessarily and practicing hand hygiene more vigilantly than any previous time. Similar findings are also reported among hospital healthcare workers in Uganda . However, our findings suggest gaps in getting fitted for N95 mask, attending training on performing nasopharyngeal swab, hand hygiene and safe use of masks. It is important to note that one third of the interns reported that the reason behind not getting fitted for N95 mask is not having access to fitting test or their hospital didn’t provide them with N95 masks. Healthcare professionals come in close contact with different patients. Hence, at the time of epidemic they have a higher risk of exposure to infected cases and are at higher risk of getting an infection. In this regard, the COVID-19 epidemic offers a unique opportunity to the Saudi MOH to provide all health settings with the required PPE for the healthcare workers to protect their safety and control the spread of the infection in the healthcare settings.
For prevention and control of infectious disease in healthcare settings, healthcare workers should place a high value on safely putting on, removing and disposing PPE . When removing contaminated PPE such as gowns, gloves, medical masks, and face shield in high-risk settings, it is necessary to follow strict safety regulations to prevent further contamination and spread of infection . However, we found that only half of the medical interns in KSA attended training on wearing and removing face mask (or N95 mask) and gloves safely during the COVID-19 pandemic. Kumar et al.  reported that 89% of healthcare workers in an orthopedic surgery setting in Pakistan believe that they know the proper steps of wearing a surgical face mask; however, only 35% performed well in answering the procedural questions. Another study in India, reported that only 45% healthcare workers are aware of the correct procedure for the application of a mask/respirator . A study with healthcare workers in China suggests that careful removal of PPE is positively associated with higher education level and work experience . Therefore, hospital administration should arrange repetitive training and demonstrated competency in putting on and removing PPE for healthcare workers , specially targeting novices like medical interns.
One of the very vital practices to prevent transmission of COVID-19 from patients to patients, patients to healthcare workers and vice versa is hand hygiene. Hand hygiene must be practiced after blowing nose, coughing or sneezing; visiting a public place; touching surfaces outside of the home or money; before, during and after caring for a sick person and before and after eating. We found that only 62% correctly identified all presented events require practice hand hygiene. In contrary only 70% attended training on hand hygiene during COVID-19 pandemic.
Our findings reveal that although majority of the interns rely on formal websites and resource for COVID-19 information, 24% relies on social media, newspaper, television, friends or family for the same. Use of social medias and informal network is evident among healthcare workers in other countries too [23–25]. This finding has implications for the Saudi MoH and hospitals. It is important to consider a variety of channels, including official websites and social media, to update and disseminate knowledge and learning materials about this epidemic. Overall, our findings show that the prevalence of moderate or good practice among medical interns in KSA is only 24%. This gaps in practice might be attributable to their lack of experience and not being deployed to treat COVID-19 patients directly. Studies suggest that good practice is associated with age of the healthcare workers , work experience, working time  and qualification ; all of which are deficient among medical interns.
Regarding overall knowledge, attitude and practice, our results suggest that prevalence of good knowledge, attitude and practice among medical interns are 38%, 55% and 24%, respectively. This is much lower than the prevalence estimate reported by studies conducted in other countries [18, 20, 23, 24, 26, 30]. However, in our study, interns responded greater or similar proportion of correct answers. Low prevalence of good KAP in our study is largely attributable to the methodological differences in calculating total knowledge, attitude and practice between our study and the other. We used more criteria of scoring. In our study, negative score was given for wrong answers, whereas in other studies wrong answer received zero. This stricter scoring criteria contributed to lower total knowledge score in our study. We argue that it is vital to give negative score when assessing KAP of healthcare professionals. Since poor KAP of healthcare professional may lead to catastrophic consequences. Knowledge of COVID-19 is evolving everyday this perhaps explain the knowledge gaps regarding COVID-19 among healthcare professional globally. Health authorities must regularly update information and disseminate up-to-date information to all healthcare professionals including medical interns.
Our multivariable logistic regression analysis suggests significant association between knowledge and the type of graduating medical colleges; and attitude and the type of medical colleges. Medical interns graduated from government colleges are more likely to have good knowledge and positive attitude toward COVID-19 prevention and control measures than interns from private or foreign colleges. This could be attributable student recruitment strategies, quality of faculty, resources and overall academic environment in governmental colleges. However, this need further investigation since only 14% of the participants were from private or foreign medical colleges. Our findings also suggest that non-Saudi medical interns are more likely to positive attitude toward COVID-19 prevention measures compared to Saudi interns. This might be attributable to perceived lack of support from friends and family in times of a personal crisis when living in a foreign country without or with only immediate family members. Regarding practice, our result suggests significant association between region and moderate/good practice. Medical interns from the west (Mecca and Medina) and the north (Hail, Jouf, Tabuk & Northern borders) regions are more likely to have moderate/good practice than the interns from the central region (Riyadh and Qassim). During the time of data collection west and north regions were the worst hit by COVID-19 than the central and other regions of KSA. This perhaps explain the more careful practice of the interns from west and north region. Other studies found that the most significant associated factors with KAP scores were age of the healthcare workers (more than 40 years with knowledge and practice), qualification (holding a diploma with practice) , occupation (pharmacists with knowledge and attitude)  or working experiences and job category  (5–9 years of experience and frontline status with attitude and practice) .
Our study findings should be interpreted with caution because of its methodological limitations. Given the lockdown measures in KSA and the urgent need to know the COVID-19 KAP status of this neglected healthcare professional group, we did a rapid online survey using the popular social medias to recruit participants. Nevertheless, the study participants are from all over KSA, thus, generalization of the results is possible.