COVID-19 health awareness among the United Arab Emirates population

In response to the global COVID-19 epidemic, the United Arab Emirates (UAE) government is taking precautionary action to mitigate the spread of the virus. The aim of this study was to evaluate the knowledge and practices toward COVID-19 among the general public in the UAE during the current outbreak. A cross-sectional online survey of 1356 respondents in the UAE was conducted during the epidemic outbreak between 9th to 24th June-2020. The questionnaire consisted of three sections: Socio-demographic, knowledge, practices. Independent-samples t-test, one-way analysis of variance (ANOVA), chi-square and binary logistic regression was used. A p-value of (p < 0.05) was considered statistically significant. The total correct score of knowledge and practice questions was high 85% and 90%, respectively. Male’s sex, other marital status, and illiterate/primary educational levels had a lower level of knowledge and practices than others. Participants aged 18–29 had little higher knowledge than other ages but had a lower level in practices, people who live in Abu Dhabi had better knowledge and practices than other emirates, employed people had a lower level of knowledge but higher in practices. Binary logistic regression analysis presented that females, 18–29 years, and married participants significantly associated with a higher score of knowledge, while female, over 30 years old, the martial status of singles, college-level and higher, unemployed, were significantly associated with high mean practices score. This study provided a full screening of the knowledge and practices among a sample of residents in The UAE toward COVID-19, continuing to implement the health education programs pursued by the UAE is highly important to maintain the appropriate level of awareness among the public.


Introduction
Coronavirus disease 2019 (COVID- 19), is a respiratory tract infection caused by a new strain of coronavirus, which began in Wuhan, China during the current pandemic. An invitation message using WhatsApp with a link to the survey was sent inviting people above the age of 18, from all nationalities, and currently residing in UAE to participate. The professional and personal networks of the researchers were used to reach a high number of participants to complete the survey. Participation in the current study was voluntary and anonymous. Informed consent was sought from all the respondents prior to data collection by sending a standardized general invitation letter with the survey link to accept or decline to participate in the study. The participant who declined consent were not permitted to open the survey and participate in the study, and participants could withdraw from the survey at any time in line with stipulations of the World Medical Association Declaration of Helsinki Ethical principles [9]. The members who clicked on the link were directed to the Google forms and to avoid the missing data, the participants were requested to fill all the questions of the survey or else could not proceed to the next section. The total number of respondents was calculated, and out of 1367 survey received from members, only 1356 participants were included in this study.

Questionnaire and data collection
A total of 1356 residents from four different emirates in UAE (Abu Dhabi, Dubai, Sharjah, and Ajman) included in this study. The survey was created after a thorough search of the literature, Ministry of Health and Prevention (MOHAP) in the UAE and World Health Organization (WHO) reports [10][11][12]. The survey was designed in English and Arabic languages in order to encourage the people to participate, and it was reviewed, validated and pilot tested by the research team and 15 individuals using telephone interviews to clarify and correct any question resulting in a few modifications. The survey questionnaire consisted of an interface page and three main sections with a total number of 37 questions. The interface of the questionnaire included the title, the objective of the study, information on participants' confidentiality, and instructions to fill in the survey. The three main parts of the questionnaire included: "socio-demographic data", their past COVID-19 testing status and COVID-19 test result. The second part on "knowledge regarding COVID-19" consisted of 17 questions includes: Clinical characteristics of virus (K1-K5), the spread of the virus (K6-K9) prevention (K10-K13) and risk factors (K15-K17). The third part of the questionnaire consisted of 11 questions that investigated "practices of individuals toward COVID-19 outbreak". Each questionnaire took approximately10-15 minutes to answer. The survey is attached as a (S1 Appendix) in this study.

Data analysis
Data analysis conducted using Statistical Package for Social Software (SPSS) version 22. Scale reliability was performed to ensure data consistency, (Cronbach's alpha coefficient = 0.729) indicating good consistency. Socio-demographic characteristics frequencies, knowledge, and practices answers along with descriptive statistics were presented in mean ± stander deviation SD, while qualitative data were presented in frequency (number\percent). Participants' knowledge and practices scores were compared with demographics factories using independentsamples t-test, one-way analysis of variance (ANOVA).
To evaluate the knowledge, respondents were given yes, no, and not sure response options each question, A correct response (yes) of each question assigned 1 score, while assigned 0 scores for incorrect respondent (no and not sure). Total knowledge scores ranged from 0-17. Practice response options of always sometimes and never were assigned 2 scores for always, sometimes 1 score, and never 0 scores. Total practice scores ranged from 0-22.
Pearson's chi-square as appropriate is used to determine the association, correlation, and homogeneity between variables. Binary logistic regression analyses using backward stepwise method were used to identify factors associated with good, poor knowledge and practices. A pvalue of less than 0.05 (< 0.05) was considered statistically significant.

Ethics approval
The study was approved by the Research Ethics Committee (RIC) at University of Sharjah, UAE. The reference number is REC-20-05-31-01, as of 14/06/2020.

Respondents' socio-demographic
" Table 1" Presents the socio-demographic data of the participants. Most of participants were females (72%) and (28%) were males. Of the respondents: (47%) were aged between 30-49 years, (39.8%) are aged between (18-29) years, and (13.2%) were between 50-�65 years. Most of participants are married (59.7%), and more than half of respondents are from Sharjah (57.4%), while other respondents were from Dubai, Ajman, and Abu Dhabi. With regards to their education level, most participants (65%) had a college degree. Moreover, (35.8%) of participants were employed, (40.6%) unemployed, and (23.5%) were students. Almost (19.0%) were Emiratis while, (81.0%) were non-Emiratis. None of the respondents tested positive for COVID-19, 88.1 and 11.9% included those who had tested negatively and those who stated that they did not know the result of the test, respectively.

Respondents' knowledge about COVID-19
" Almost (89%) answered necessity for children and young adults take action to prevent their self. Almost all participants (99%) answered that the virus is high risk in patients with chronic illness and elderly, while (74.3%) believed that smokers are likely to be more vulnerable to COVID-19 infection.

Respondents' practices toward COVID-19
" Table 3" Presents participants' practices toward COVID-19. The prevalence of good practice score among people was (1.16±0.47). The table shows that the total correct answer percentage was very high (90.14%). Most of the participants (94.2%) answered that they stay at home and go out only when necessary, almost (96%) started to wash or sanitize their hands regularly, and (96.5%) wear a mask when they go outside home. We found that (94.2%) of respondents keep a 2-meters distance between them and others, while (94.3%) of participants stopped going to crowded places recently. 88.5% participants indicated that they stopped visiting their relatives and friends during the outbreak. The majority of participants (95.6%) stopped hugging and kissing their relatives or friends, while (70.8%) starting to use a credit/debit card for payment. Our finding showed that (88.9%) stopped sharing their food with others, and (94.1%) stopped handshaking in greetings with others. Overall, two-thirds of participants (78.5%) follow regular updates on COVID 19 from various information sources.

Sources of information on COVID-19
Regarding the sources of information of participants on COVID-19, (75.2%) indicated that their main source of information were official websites and press releases from the Ministry of Health and Prevention (MOHAP) in the UAE. Among them (42.4%) indicated that they were following WHO press releases, while (40.7%) retrieved their information from different news outlet (Newspaper, Television, Radio) and (50.4%) were using social media (Twitter, Facebook, YouTube, WhatsApp, Instagram, and Snapchat). Lastly, 21.2 and 5.75% of participants indicated that their sources of information are mainly from family, friends, and other sources, respectively as displayed in "Fig 1". Correlation between socio-demographic characteristics with knowledge (K) and practices (P) score of participants, UAE "Table 4" Shows that total scores of knowledges (out of 17) significantly differed across gender, marital status, place of residence, education levels and employment status (p <0.05), practices scores (out of 11) also significantly differed across of practice with gender, age-groups, marital status, education levels, and employment status (p <0<0.05) while no significant correlation between place of residence and practices (p = 0.077) was identified.
The results score shows that females had a higher knowledge (15.09±1.88) and practice (20.18±1.87) than males, people aged of 18-29 years had a very little higher level of knowledge (14.94±1.44) compared with other age groups, while they had lower level in practice (19.62 ±2.48) than other ages. The knowledge (14.99±2.085) and practices (20.13 ±1.81) of married participants were a little higher than those who identified themselves single, widowed and divorced. Residents of Abu Dhabi showed a better knowledge (15.33±1.27) and practice (20.47±1.88) that other emirates. Participants with lower education showed lower level of knowledge (9.25±2.32) and practice (14.75±3.26) than those with higher education while employed showed lower knowledge (14.60±2.30) than unemployed and students, but they shared higher practices that unemployed and students (20.23±1.78) " Table 4".
Binary logistic regression associated with the knowledge (K) score (>14.5 and < 14.5) and practices (P) score (>19.5 and < 19.5) as (good and poor) of participants, UAE " Table 5" presents binary logistic regression analysis on variables significantly correlating with participants knowledge and practice toward COVID-19. The same table presents Odds ratios (ORs) and their 95% confidence intervals (CIs) in a bid to quantify the correlation between

Discussion
Our study demonstrated that UAE population and residents have a good to excellent knowledge about COVID-19 causes, risks, precautions, and best practices to avoid infection. It showed that almost 85% of our respondents are knowledgeable and aware of the risk, transmission mode, and hygienic and preventive measures. Being uneducated, unmarried and male were associated with lower knowledge COVID-19 and poorer precautionary measures practices.  To our knowledge, this is the first study to explore COVID-19 knowledge and practices toward the COVID-19 pandemic in the UAE and during the peak of the lockdown. Our study participants were young, non-Emiratis, of female gender with middle to higher education levels which represents the UAE population [13]. This also consistent with similar demographics of participants of surveys collected via online platforms [14]. Similar to our results reported that 86.0% of medical and health sciences students and 80.6% of the university students in UAE were females [15,16]. This study demonstrated that UAE population and residents have a good to excellent knowledge about COVID-19 and were aware of right practices to avoid the infection and its spread. Our results showed that almost 85% of our respondents were knowledgeable and aware of the risk, transmission mode, and hygienic and preventive measures nearly matching the same percentage by study in China, and another conducted in Jordan among medical students, study among the public in Iraq, and another among the public in Nigeria [4,11,17,18]. A similar trend among respondents in terms of similar gender and education were reported by the study in China [17].
This high and excellent knowledge can be explained by two main reasons: the excellent education programs and campaigns, and action taken by the authorities to contain the COVID-19 spread among the UAE community. Also it can be explained by the media coverage including all media outlets and the impact of the pandemic on social life mandating that people read, listen and get educated about it. However, with all the misconceptions that have been spreading around the virus, our respondents had correct information which indicates that the right message is being spread and it could be again explained by the health authorities 'actions and education campaigns as well respondents' education level and access to the right information platforms such as WHO. In contrast to the Jordanian study and Iraq [17,18], our results showed that the UAE population may depend more on social media, and search engines to get their information about COVID-19, although official websites of health authorities (MOHAP) was the main source of their information on COVID-19 (75.2%) Our results were in the line of other study conducted among students in UAE, as 53.8% and 46.7% were using social media to get the information on COVID-19 [19]. Moreover, this study shows similar findings to that of the Saudi Arabian study [12] in terms of knowledge, practices, and correlated factors such as gender, age, marital status, place of residents, education level, and employment status as being mediators for better knowledge and practices. Comparing the socio-cultural context of both countries, the similar findings and results are very reasonable and are considered normal. Moreover, the efforts of the Ministry of health in both countries were highly intensive in terms of testing and in terms of educating the public and to contain the virus which explains the findings and the similarity in results.
Our study has shown that there was better knowledge and better practices associated with younger ages (below 30), gender (Females), education (higher education), and residing in the capital city of UAE (Abu Dhabi) indicating that more education efforts and more intense health education should be directed toward certain populations like men, lower educated levels and people residing outside AD. The higher significance in terms of the emirate can be explained by the fact that more cases were present in Abu Dhabi lately directing authorities to intensify their education campaigns. Being a female and a mother is expected to show better knowledge and practices in terms of the COVID-19 precautions and preventions, similar to our results, several studies reported that the females had more knowledge and better practices than males [4,18,19].
Our results showed, when tested through logistic regression analysis, that, gender, age and marital status were significantly correlated with better knowledge a while being married for married was negatively associated with good practice. Being females, with better education level, and being employed were significantly correlated with higher knowledge and correct practices. Our results were compatible with many studies that showed similar significance in terms of better knowledge among the educated. Better knowledge with higher scores may lead to better practices as shown in this study and as indicated by other studies [10][11][12]. However, our results did not show any significance when we employed the same factors in our regression. We believe that the significance was not really strong due to the fact again of the intensive education by the authorities and the mandatory hygienic and preventive practices such as washing the hands, using sanitizers, wearing masks, keeping distance, and avoiding touching the face [3]. The findings indicate strongly that awareness campaigns especially social media campaigns and strong health promotions approaches and policies that ensure equity through societies can improve people's adherence to healthy practices and can induce a positive behavioral change no matter what is their educational background, employment or their social status and gender especially in crisis and in sudden public health events [12,20,21]. Health literacy is an important factor in improving people's adherence to precautions, preventions, and screening. However, with the emerging of this pandemic and during crisis management, improving health literacy will depend mainly on people's access to knowledge, reading, and the ability to reflect critically on complex health issues [10]. Therefore, the efforts on improving awareness and keep spreading the right message are highly mandatory to ensure healthy practices among the community. The COVID-19 crisis is creating a burden on individuals, communities, and authorities that needs a complex integration of efforts to overcome and to manage this crisis. Studies on COVID-19 have pointed strongly to the mental health impacts and the burden the COVID-19 is creating on public health [22,23]. In fact, when asked our participants whether they got tested for COVID-19 18.9% stated that they were tested which indicated again the influence of the UAE government efforts of screening [3]. However, what was not surprising that out of the 11.9% that were not positive some declined to declare their results which indicated that there is a new trend of stigma and stereotype that is emerging with the pandemic spread and that needs to be addressed. In fact, studies have shown that COVID-19 is causing anxiety and affecting mental health due to many factors including the COVID-19 positive result stigma [24][25][26].

Limitations
This study was done in a very short time and used convenience samples through an online platform that expected that the people with a higher level of education would access and respond to the survey, moreover, it doesn't give privilege to the uneducated population. Also, the largest percentage of respondents were residents of Sharjah, UAE; thus, the results of this manuscript are not a representation of the total population of the United Arab Emirates. The study dataset was also self-reported, and this practice is subject to courtesy bias or social desirability bias. In addition, knowledge questions are not validated. Another limitation includes the high number of females than males, the possibility of bias being a cross-sectional study, and the possibility of participants looking for answers online.

Conclusions
This study provided a full screening of the knowledge and practices among a sample of residents in the UAE about COVID-19. Overall, UAE residents showed high levels of knowledge and expected practices, similar to most reports around the world. Obtaining information depends on official news of MOHAP, WHO, and social media. Strategies to keep the community updated and vigilant about precautions should continue and more focus on specific groups like males and people with limited education.