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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 1  |  Page : 367-378

Physicians' awareness toward the diagnosis and treatment protocol for corona virus disease-19


1 Department of Family and Community Medicine, College of Unaizah Medical and Medical Sciences, Qassim University, Qassim Province, Kingdom of Saudi Arabia; Department of Community Medicine and Public Health, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Community Medicine and Public Health, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission21-Jul-2020
Date of Decision22-Aug-2020
Date of Acceptance30-Aug-2020
Date of Web Publication27-Mar-2021

Correspondence Address:
Shaimaa S Soliman
Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Yasin Abdel Ghafar Street, Shebin Elkom City, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_246_20

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  Abstract 


Background
The emergence of corona virus disease-19 (COVID-19) globally, coupled with its unknown etiology and its high transmission rate, has created an unprecedented state of emergency worldwide. Physicians' awareness about COVID-19 diagnosis and treatment protocols is essential in suppressing its pandemic status.
Aim
To assess the awareness of Egyptian physicians toward diagnosis and treatment protocol for COVID-19.
Patients and methods
An online cross-sectional survey was conducted from March 31 to April 20 2020 involving a total of 391 physicians across Egypt. Data were collected through a self-administered questionnaire about 'The Egyptian Diagnosis and Treatment Protocol for COVID-19' to assess their awareness toward the protocol, and the higher the score, the higher the awareness. Participants were classified according to their specialty into frontline specialties (chest, emergency/intensive care, anesthesia, and tropical medicine) and other nonfrontline specialties. Univariate and multivariate linear regression analyses were used to identify predictors of awareness score.
Results
The mean age of the participants was 40.72 ± 7.46 years. Overall, 58.1% were females, 77.2% were working in urban hospitals, and 32.7% of the physicians worked at both governmental and nongovernmental hospitals. The mean overall score was 18.33 ± 3.79. It was significantly higher among physicians of frontline specialties (20.88 ± 2.13) than other specialties (16.29 ± 3.59) (P < 0.001). Univariate and multivariate regression analyses revealed that male sex, working in urban health care settings, frontline specialties, working experience more than 5 years, medical doctorate degree, and working in a COVID-19 management place were significantly associated with higher awareness score.
Conclusion
Physicians with frontline specialties had knowledgeable awareness regarding the protocol. Continued professional education interventions and campaigns are advised for Egyptian physicians especially for those in nonfrontline specialties.

Keywords: awareness, corona virus, diagnosis, physicians, treatment protocol


How to cite this article:
Al-Batanony MA, Gabr HM, Soliman SS. Physicians' awareness toward the diagnosis and treatment protocol for corona virus disease-19. Menoufia Med J 2021;34:367-78

How to cite this URL:
Al-Batanony MA, Gabr HM, Soliman SS. Physicians' awareness toward the diagnosis and treatment protocol for corona virus disease-19. Menoufia Med J [serial online] 2021 [cited 2021 Oct 23];34:367-78. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/367/312032




  Introduction Top


The recent outbreak of respiratory illness caused by a novel corona virus, named COVID-19 or 2019-nCoV2, has been recognized as a serious public health threat by United States Centers for Disease Control and Prevention (CDC) and has gained attention globally [1]. As of January 30, 2020, the WHO declared the outbreak of COVID-19 as a Public Health Emergency of International Concern (PHEIC) [2].

Organizations such as the CDC and WHO have developed preparedness and prevention checklist of 2019-nCoV2 infection to be used by the public and health care professionals [1],[2],[3]. At present, no specific antiviral medication or vaccine is available, and infected patients are managed with supportive care [1].

WHO provides intended document for health ministers, health system administrators, and other decision-makers. It is meant to guide the care of COVID-19-infected patients as the response capacity of health systems is challenged, to ensure that COVID-19-infected patients can access life-saving treatment, without compromising public health objectives and safety of health workers. It promotes two key messages: key public health interventions regardless of transmission scenario and key action steps to be taken by transmission scenario to enable timely surge of clinical operations.

The pandemic fighting measures include activation of multisectorial coordination mechanisms; active surveillance and screening at points of entry; training health care providers on contact tracing and case definition for suspected and confirmed cases; case management and the infection, prevention, and control measures; distributing personal protective equipment to health facilities, including at points of entry, for managing suspected and confirmed cases; activating/alerting rapid response teams; and distributing information education and communication materials to raise public awareness and counter rumors and misinformation [4].

The Egyptian Ministry of Health (MOH) on February 14 announced the first confirmed case of the COVID-19 in Africa with non-Egyptian nationality. WHO reported that confirmed cases in Egypt are currently being managed as per standard protocol. Countries in the Eastern Mediterranean Region have developed and implemented national preparedness and response plans to activate intensified measures and actions (and related Standard Operating Procedures), in coordination with WHO [5].

Health care workers (HCWs) are the entrusted persons for facing this pandemic. A poor understanding of the disease among HCWs can result in delayed identification and treatment leading to rapid spread of infections. It is therefore of paramount importance that HCWs have adequate knowledge about all of the disease aspects from clinical manifestation, diagnosis, proposed treatment, to established prevention strategies. Empowering them with adequate knowledge will place them at the forefront of health education to give the public correct information and refute myths and false information about COVID-19. Guidelines for HCWs and online refresher courses have been developed by WHO, CDC, and various governmental organizations in various countries, including Egypt, to boost the knowledge and prevention strategies. Information about the Egyptian health system and health professionals' awareness for combating 2019-nCoV has not been assessed, to our best knowledge. As HCWs' awareness in diagnosing and managing 2019-nCoV infection is important to prevent further spread of the disease, this study aimed to assess the awareness of Egyptian physicians toward diagnosis and treatment protocol for COVID-19.


  Patients and methods Top


A cross-sectional survey study was carried out from March 31 to April 20 2020. A convenient nonprobability sample of Egyptian physicians of different specialties in any health care facility (governmental or nongovernmental) who met the inclusion criteria were invited to join the study. Inclusion criteria were Egyptian physician of any age and sex, working in a health care facility, having internet access, and agreed to participate in the study. By using Google Form, an online self-administered questionnaire, in English language, was developed by the authors and the generated link was shared on social media (i.e., Facebook, What's App) physicians' groups. The link was also shared personally to the contact list of investigators. The questionnaire was based on 'The Egyptian Diagnosis and Treatment Protocol for COVID-19' [Appendix 1] prepared by the Egyptian Ministry of Health (MOH), released on March 23, 2020 [6] (version 1.1), and was followed by all the Egyptian health facilities dealing with COVID-19-infected patients. The questions and their answers were formulated by the authors and carefully revised by a panel of health care professionals, which included one epidemiologist, two chest physicians, and one emergency/intensive care specialist. The questionnaire was further validated by a pilot survey on 10 physicians; their results were not included in the study. This validation aimed to evaluate the time needed to complete the questionnaire, assure that all the questions are phrased clearly and appropriately for comprehension, and to avoid information bias that might otherwise affect the results. Moreover, more validation was done for reliability coefficient with Cronbach's alpha, which was of 0.79, which indicates acceptable internal consistency [7]. The questions were either of short answers, multiple checkboxes, or multiple-choice questions. The survey was completely anonymous, and the aim was clearly written before beginning answering the questions.

Operational definition: HCWs are defined as all people engaged in activities whose primary intention is to improve health (World Health Organization, The World Health Report 2006: Working Together for Health. Geneva: World Health Organization, 2006). Frontline HCWs are described as HCWs who provide routine and essential services in a medical practice (Menehan, K. Jobs to Careers: Transforming the Front Lines of Health Care, Robert Wood Johnson Foundation, December 2012). For the purpose of this study, Egyptian physicians from different specialties in any health care facility (governmental or nongovernmental) were enrolled.

The sample size was calculated using EPI 7 info program (CDC, Atlanta, Georgia, USA) [8]. Based on 95% confidence interval and 5% margin of error and a supposed awareness prevalence of 50% (as to our knowledge there was no previous prevalence was reported), the estimated sample size was 384 individuals. By the end of the date, the responses exceeded the required sample size, and the submission to the form was closed. The total number of submitted forms was 409, and after exclusion of 18 incomplete forms, 391 valid responses were analyzed.

The questionnaire composed of two main parts:

  1. Part one included sociodemographic data of the participants, like age in years, sex, specialty, working place, duration of experience, etc.
  2. Part two included 12 questions related to the Egyptian Diagnosis and Treatment Protocol for COVID-19 and its contents of case definitions, diagnostic criteria, and treatment modalities for different stages of COVID-19.


A model answer was prepared for the scientific questions where the response of each participant was checked accordingly. The correct answer was given two points, 'I do not know' one point, and wrong answer was given zero point (aggregated score ranged from 0 to 24 points). The mean score of all the 12 questions for each participant was summed, where the higher the score, the higher the awareness about the protocol (the total score was 24 points). The studied participants were then classified into two groups, named frontline COVID-19 specialties (chest, emergency/intensive care, anesthesia, diagnostic radiology, and tropical medicine) and other nonfrontline specialties (surgery, obstetrics/gynecology, ophthalmology, etc.).

Data management and analysis plan

Data were coded and tabulated by Statistical Package for the Social Sciences, version 23 (SPSS Inc. 2011. IBM SPSS statistics for Windows, version 20.0; IBM Corp., Armonk, New York, USA). Quantitative data were expressed as mean ± SD, where Student t test or analysis of variance (with least significant difference as post hoc) was used. Number and percentages were used to represent qualitative data where χ2 or Fisher's exact tests were used for analysis. Univariate and multivariate linear regression analysis models were used to assess the association (risk) of independent factor (s) with dependent factor (outcome). Differences were considered significant at two-sided P value less than 0.05.

Ethical considerations and consent to participate

Ethical approval was obtained before the study from the Institutional Review Board at Faculty of Medicine, Menoufia University, Egypt. The study was done in accordance with the 1964 Helsinki declaration and its later amendments. All participants were volunteers and had the right to withdraw from the questionnaire at any point.

Consent for publication

An informed consent to participate and publish was attached to the first part of the questionnaire before participation. All the data were kept confidential and used only for research purposes.


  Results Top


The mean age of the studied physicians was 40.72 ± 7.46 years, ranging from 28.0 to 55.0 years. The sample included 58.1% female physicians. Most of the participants worked at urban hospitals (77.2%) and 32.7% of the physicians worked at both governmental and nongovernmental hospitals. The overall awareness score was 18.33 ± 3.79 (range: 24.0–11).

Those who were in frontline specialties represented 44.5% of the studied group. Physicians working in frontline specialties were significantly male (P < 0.001), older (P < 0.001), with more working experience than 5 years (P = 0.014), with diploma as a highest qualification (P < 0.001) as well as working at COVID-19 management places (P = 0.042) than those working in other nonfrontline specialties [Table 1].
Table 1: Comparison between physicians in frontline and nonfrontline specialties regarding their characteristics

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It was obvious that male physicians, working in frontline specialties, working in urban health places, having diploma or doctorate degree, and with working experience more than 5 years had significantly higher mean awareness score about the protocol than others (P = 0.016, P < 0.001, P < 0.001, P < 0.001, and P < 0.001, respectively). Moreover, physicians who were working in health facilities managing COVID-19 had a significant higher mean awareness score about the protocol than those who were working in other health facilities (P = 0.016) [Table 2].
Table 2: Relationship between participants' characteristics and their mean awareness score

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In comparing physicians in frontline with nonfrontline specialties, it was clear that the prevalence of awareness reflected by the percentage of correct answers for all questions was significantly higher between physicians in frontline specialties than other specialties (P < 0.001) [Table 3].
Table 3: Comparison between frontline and nonfrontline specialties regarding awareness questions about Egyptian Diagnosis and Treatment Protocol for COVID-19

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Univariate linear regression analysis showed significant independent association between awareness score and each of age, sex, specialty, working practice area, highest qualification, years of experience, and working at COVID-19 places (P < 0.001, P = 0.016, P < 0.001, P < 0.001, P < 0.001, P = 0.001, and P = 0.011, respectively). On performing multivariate regression analysis for the significant factors, all remained significant except the age [Table 4].
Table 4: Univariate and multivariate regression analysis model of the possible determinants of awareness among the studied group

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  Discussion Top


Health care professional's good knowledge and practice in complying precautionary, diagnostic, and treatment measures creates awareness among patients as well as gives an important message in the society. This study was a cross-sectional survey carried on 391 Egyptian physicians to assess their awareness toward diagnosis and treatment protocol for COVID-19.

Male participants had significantly higher mean awareness score regarding 'The Egyptian Diagnosis and Treatment Protocol for COVID-19' than females (P = 0.016). This could be attributed to the higher percentage of male physicians working in the frontline specialties like emergency/intensive care and anesthesia in Egypt. Additionally, as more male physicians had their own private clinics or working at private hospitals facing many COVID-19-infected patients, they were under pressure to read and learn to raise their knowledge and keep abreast of the ship of awareness than female physicians. Physician with frontline specialties had significantly higher mean awareness score about the protocol than nonfrontline specialties (P < 0.001). This finding is not surprising as physicians in frontline specialties are the main persons involved in management of COVID-19, so they should become updated by the protocol. Another expected finding is significantly higher awareness score of the protocol among physicians who were working in facilities already managing COVID-19 than those who were not (P = 0.016).

Physicians working in urban areas, having diploma or doctorate degrees had significantly higher mean awareness scores than those working in rural area hospitals and having MBBCh or master's degree (P < 0.001). This finding agrees with that, in Egypt, all isolation and management hospitals for COVID-19 are in urban governmental areas which required at least a specialist to be involved in COVID-19 management. Few private hospitals began to open for COVID-19 isolation and management. Physicians with working experience of more than 5 years had significant higher awareness score about the protocol than participants with 5 years or less (P < 0.001). This may be explained by that after 5 years of working, most of the physicians have gained their diploma or master's degrees and have become specialists, and most of them have been assigned to work in COVID-19 isolation or management hospitals.

Overall, 100% of physicians with frontline specialties knew the correct definition of COVID-19-suspected case, how to deal with mild/asymptomatic cases, the antipyretic of choice, required patient criteria for hospital isolation, and the recommended drugs for mild, moderate, or severe COVID-19 cases as supportive care in the protocol (100%). Most of them knew correctly the primary assessment of COVID-19-infected patient (72.4%), how many negative PCR samples are required for a COVID-19-infected patient before discharging (67.2%), drugs recommended for hospitalized noncritical cases (66.1%), dose and duration of hydroxycholorquine (68.4%) and its alternatives if contraindicated (61.5%), dose and duration of antiviral drugs (75.9%), and when to consider therapeutic anticoagulants for critically ill patients with invasive mechanical ventilation (69%). From our point of view, it is accepted that the answers of some questions may exceed only 66% by the frontline specialties at the time of this questionnaire, as they may keep copies of the protocol in their reach and follow it according to the patient's condition and had not memorized the fine details in their minds yet.


  Conclusion Top


Physicians with frontline specialties had knowledgeable awareness regarding the 'The Egyptian Diagnosis and Treatment Protocol for COVID-19.' Male sex, working in urban health care settings, frontline specialties, working experience more than 5 years, medical doctorate degree, and working in COVID-19 management places were significantly predictors for high awareness score.

Recommendations

On the level of the moment, in-service training is the action plan needed to achieve the awareness about the protocol between physicians. Soon, findings of this study may help health authorities organize the necessary educational programs to provide up-to-date information and deliver the best practice to control the COVID-19 disease. It is recommended to focus on the physicians with insufficient awareness about the protocol, especially from nonfrontline specialties, via additional education intervention and/or online campaigns/webinars to be ready if the situation in Egypt worsens and it became necessary to help other frontline specialties in this crisis.

Limitations

This study had some notable limitations. A limitation is in the comparison of our results with other studies, because COVID-19 is a novel corona virus and, to our best knowledge, there are no other published studies to compare with. Using a convenient sampling method, compared with random sampling, might be subjected to selection bias and thus decreased the internal validity. Moreover, there is a risk of bias owing to online data collection. Presence of physicians who are working in areas not involved in care of COVID-19-infected patients, as they only suspect cases and send them to isolation hospitals, makes some of them not familiar with the Egyptian Diagnosis and Treatment Protocol for COVID-19.

Acknowledgements

Researchers would like to thank the Deanship of Scientific Research, Qassim University, for funding publication of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendix 1













 
  References Top

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World Health Organization. Eastern Mediterranean Region office. update on COVID-19 in the Eastern Mediterranean Region. Available from: http://www.emro.who.int/pdf/media/news/updatee-on-covid-19-in-the-eastern-mediterranean-region.pdf?ua=1. [Last accessed on 2020 Apr 13].  Back to cited text no. 5
    
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Egyptian Ministry of Health and Population. Diagnosis and treatment protocol for COVID-19. Available from: http://www.mohp.gov.eg/QuickServiceDetails.aspx?subject_id=3686. [Last accessed on 2020 Mar 24].  Back to cited text no. 6
    
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Taber KS. The use of Cronbach's alpha when developing and reporting research instruments in science education. Res Sci Educ 2018; 48:1273–1296.  Back to cited text no. 7
    
8.
Dean AG, Arner TG, Sunki GG, Friedman R, Lantinga M, Sangam S, et al. Epi Info™, a database and statistics program for public health professionals. Atlanta, GA, USA: CDC; 2011.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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