Knowledge, Attitude, and Training of Health-Care Workers and Preparedness of Hospital Emergency Departments for the Threat of Communicable Diseases at Mass Gathering Events in Qatar: A Cross-Sectional Study

Abstract Objective: This study aimed to assess the knowledge, attitude, and training of health-care workers (HCW), and their perception of the preparedness of hospitals for communicable disease (CD) threats during mass gathering (MG) events. Methods: This was a cross-sectional study conducted from June 1 to July 31, 2019, of doctors and registered nurses working in the emergency departments (EDs) of 5 main hospitals in Qatar. A self-administered online survey was used for data collection. Results: The overall mean knowledge score about CD threat among study participants was 75.0% (SD ± 18.1). The majority of the participants had a favorable attitude toward CD preparedness during MG events. The participants achieved high scores in attending workshops on triaging, first aid, and infection control. Study participants as well had favorable perceptions about the current preparedness of their respective hospitals to respond to CD outbreaks in MG events. Conclusions: The participants were knowledgeable about the risk of CD outbreaks during MG events (eg, Federation of International Football Association (FIFA) World Cup games 2022) and had a favorable attitude and necessary training to respond to such outbreaks. Regular practice drills are necessary to ensure that all members of the workforce are knowledgeable of the necessary actions to take in emergent high-risk situations.

Mass gatherings (MGs) at special events present a potential public health hazard because of the risk of transmission of communicable diseases (CDs). 1 The size of MGs may range from as low as 1000 to more than 25,000 people. 2 The public health hazards associated with such large-scale events can be unpredictable and complicated and may include outbreaks of CDs, travel-related infections, violence, and issues related to sanitation and hygiene. 3 Some reasons for CD outbreaks include crowding, inadequate hygiene and sanitary practices, sociodemographic factors such as age and gender, and pre-event health status. 3,4 The main CDs that may raise a public health concern during MG events include seasonal influenza, cholera, measles, hepatitis A, and meningitis. 5 For instance, during preparations for the Brazil 2014 Federation of International Football Association (FIFA) World Cup, of the 1586 travelers who had participated in the event were examined for CDs, 40% had developed dermatological diseases, 25% diarrheal diseases, and 19% febrile systemic illnesses. 1 Moreover, the 2006 Asian Games held in Doha, Qatar, reported an outbreak of chickenpox among the volleyball team players who had come from the Maldives. 6 The main role of health-care workers (HCWs), as frontline responders in combating and containing the spread of CDs in MG events, depends to a great extent on their knowledge, attitude, and training, especially those working in emergency departments (EDs). 7,8 Effective preparedness and response in pandemic situations by HCWs requires specialized training and knowledge. 7,9 A study in Saudi Arabia reported that health-care professionals' mean knowledge score about disaster and emergency preparedness was satisfactory (77.5%). 10 However, a crosssectional study in Yemen reported that only 32.0% had good knowledge, 53.5% had fair, and 14.5% showed poor knowledge about emergency preparedness. 8 The researchers suggested that educational levels may have been a key factor in the knowledge gap.
Qatar is a country that is characterized by its strategic location in the east of the Arabian Peninsula with an estimated total population around 2.8 million. 11 As Qatar will be hosting the 2022 FIFA World Cup games with thousands of people from all around the world expected to attend, the potential risk of CD outbreaks occurring might be high. Therefore, assessing the preparedness of HCWs for MG events in Qatar is critical for any potential risk of CDs occurring. Thus, this study aimed to assess the knowledge, attitude, and training of HCWs working in EDs, and their perception of the preparedness of their hospitals for CD threats during MG events.

Study Design
This was a cross-sectional study conducted from June 1 to July 31, 2019.

Study Population and Setting
The target study population was 783 physicians and registered nurses working in the EDs of 5 public hospitals operated by the Hamad Medical Corporation in the State of Qatar (Hamad General Hospital, Hazm Mebaireek Hospital, Cuban Hospital, Al Wakrah Hospital, and Al Khor Hospital). Physicians and nurses who were not available at the time of the study (eg, on leave) were excluded.

Study Tool and Data Collection
A structured, anonymized, self-administered questionnaire was designed and distributed through Survey Monkey, a Web-based application, to all potential participants. The questionnaire was adapted from previous studies 10 and was intended to assess HCWs' knowledge, attitudes, and training and their perception of the preparedness of EDs to respond to CD threats during MG events. The face and content validity of the questionnaire were ensured by conducting an extensive search of the literature, and critical review by an expert panel made up of public health experts and emergency medicine consultants. It comprised 5 sections: (1) background characteristics with 10 items, (2) knowledge questions with 11 items, (3) attitude questions with 10 items, (4) training questions with 4 items, and (5) ED preparedness questions with 10 items. The questionnaire was piloted with 20 individuals to assess its comprehensiveness and clarity.

Measures
Responses to the knowledge questions were assigned a score of 1 for each correct answer and 0 for each incorrect answer. Therefore, the overall knowledge scores computed could range from 0 to 11. The scores were categorized as <40% denoting very low knowledge, 40% -<60% low knowledge, 60% -<80% moderate knowledge, and ≥80% high knowledge. HCWs' attitudes, training, and perception of ED preparedness were expressed as proportions.

Statistical Analysis
Data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 23. Descriptive and inferential statistics were used to analyze the data. For continuous variables, means and standard deviations (±SD) were calculated. For categorical variables, frequencies, and percentages were used. Comparing the distribution of categorical variables was computed using the Chi-squared test. Independent Student t-test was used to test significant differences between 2 independent means, and analysis of variance (ANOVA) was used to test significant differences between more than 2 independent means. A P-value <0.05 was considered significant.

Background Characteristics
As shown in Table 1, 261 of 783 invited doctors and nurses completed the online questionnaires with a response rate of 33%. Their mean age was 36.9 y (SD ± 7.5) and 58.9% were male. The vast majority of respondents were nurses (89%). Professional experience working in EDs ranged from 1 to 5 y (49.6%) and more than 5 y (43.5%). The overall mean knowledge score about preparedness to CD threats during MG events was 75.0% (SD ± 18.1). The mean knowledge score did not vary by age, gender, hospital of work, and duration of work in the EDs. However, doctors' mean knowledge score was significantly higher (85.1%) than nurses' (73.9%) with a P-value of 0.003. The mean knowledge scores of professionals from the UK or the United States were significantly higher compared with those from other countries (P-value <0.01). reported the presence of a system for the reporting of CDs, and 78.1% reported the existence of a CD disaster plan.

Training of HCWs in CD Preparedness During MGs
Overall, 207 (79.3%) of the participants reported ever receiving courses/workshops in disaster planning and in mass casualty responses, 229 (87.8%) in triage, and 231 (88.5%) in first aid/infection control. Figure 1 displays HCWs' training in CD preparedness according to gender and profession. In all training subject categories the proportion of females who received training was higher than males. However, only the proportion of females who received training in disaster planning (89.8% vs 73.5%; P < 0.01) and mass casualty responses (92.4% vs 71.5%; P < 0.01) were significantly higher than the proportion of males. Moreover, the proportion of doctors who received training in disaster planning was significantly higher than nurses (96.4% vs 77.9%; P = 0.01). However, the proportion of those who received training in triage, mass casualty responses, and first aid/infection control did not significantly differ by profession.

Discussion
To the best of our knowledge, this study is the first of its kind in Qatar. This study assessed the knowledge, attitude, training of HCWs, and their perception of the preparedness of hospital EDs for CD threats during MG events. Prompt and effective response to CD outbreaks during MG events requires that frontline HCWs have the correct knowledge, adequate training, and proper attitude about CDs and outbreaks and especially those working in EDs. 7,8 It is also necessary for EDs to have the necessary preparedness to effectively and promptly respond to such drastic situations. 7 An essential condition of preparedness to CD outbreaks is a basic understanding of relevant concepts such as disasters, pandemics, and influenza. The results of this study showed a high percentage of correct knowledge of the concepts of pandemic and disaster, but moderate knowledge about influenza. This is consistent with the study by Berhanu et al. (2016) where the majority of their health-care professional participants (85.1%) were able to correctly describe the concept of disaster. 9 On the other hand, in a study in Yemen about the knowledge and attitude of health-care professionals, 68% had poor to fair knowledge. 8 In terms of attitude toward preparedness for CD threats during MG events, the majority of the participants in our study expressed a favorable attitude consistent with the study by Nofal et al. (2018), where only 6.3% of the participants indicated no interest in disaster plans. 10 Almost all of our participants (98.1%) as well as 98.4% in the study by Nofal et al. (2018) agreed that hospitals needed to update their CD disaster plans regularly. In both studies, the participants scored high on the importance of preparedness of managerial staff, 99.2% and 93.7%, respectively. These are all reflective of HCWs' favorable attitudes toward preparedness for responding to CD pandemics arising from MG events.
Regarding training, high scores were obtained for attending workshops in triaging (87.8%) and first aid and infection control (88.5%). This is in contrast to only 21% of health-care professionals who were trained in disaster-related subject in a study in Southwest Ethiopia. 9 Similarly, a study in Saudi Arabia about the preparedness of ED nurses reported that only 3% had received current training. 7 In our study, participants as well had favorable perceptions about the current preparedness of their respective hospitals' EDs to respond to CD disasters in MG events. The majority reported that referral systems were available (96.9%) and systems were in place for reporting of CDs (97.7%). In a study in the United States about the pandemic influenza and major disease outbreak preparedness in hospitals in general and specifically in EDs reported 85% of the health professionals surveyed acknowledged the existence of such plans in their hospitals, while only 68% confirmed that their EDs had such plans. 12 Several strengths were highlighted in this study, including recruiting participants from 5 main public hospitals in the State of Qatar. This contributes to having a representative sample of HCWs working in EDs. This study is a significant step in building a solid foundation towards understanding HCWs' knowledge, attitudes, and training across HMC hospitals to enable building the recommended capacity to effectively respond to CD threats in the upcoming 2022 FIFA World Cup games in the State of Qatar.

Limitations
The study as well had a few limitations. One potential limitation was the probability of having recall bias. We relied on participants' capacity to recall their training about CDs and pandemics. Still, in future studies, such biases may be addressed by searching for alternative sources such as hospital records of training provided. With only 33% of the HCWs responding to the survey may have potentially led to under-coverage bias. However, the target population is not very diverse as it is made up of physicians and nurses who are working in the EDs of the respective 5 hospitals. Sending follow-up reminders to the potential participants may be a useful strategy to increase response rates. Another notable limitation is the applicability of our findings to other hospitals outside Qatar because of diverse organizational mandates. As well, the recent COVID-19 pandemic may have influenced HCWs' knowledge, attitude, and perceptions about preparedness to respond effectively to future MG events.

Recommendations
While the participants in this study showed the necessary knowledge, attitude, and training, as new CDs emerge, it would be necessary to update training programs based on the most current  evidence in the recognition of and response to outbreaks. In addition, regular practice drills are necessary to make sure that all members of the workforce are knowledgeable of the necessary actions to take in emergent high-risk situations.

Conclusions
This study examined the knowledge, attitude, and training of registered nurses and physicians working in hospital EDs. The study also examined their perception of the preparedness of their respective hospitals. This is the first study in Qatar on these subjects. In general, doctors and nurses are knowledgeable about the risk of CD outbreaks during MG events and have the proper attitude and necessary training to respond to such outbreaks. As well, they consider their respective hospitals have the necessary preparedness to respond to such outbreaks promptly and effectively.
Data availability statement. Data are available upon reasonable request.