Perception of the COVID-19 Pandemic Among Members of Saudi Society: Solidarity, Humility, and Connectivity

Background and purpose The magnitude of the coronavirus disease 2019 (COVID-19) pandemic on the healthcare system, economy, education, and social networking is dreadful, the least to say. Surprisingly, and unlike previous epidemics, the impact has been universal, and even top-ranking countries with solid economies were not immune. The purpose of this study is to develop a better understanding of the Saudi community's response and reaction to the preventative measures implemented by the government to combat the COVID-19 pandemic. Methodology A cross-sectional study using a self-administered online-based questionnaire was conducted among 920 participants from March 2020 to February 2021 among the Saudi community across the Kingdom. Results Among the studied participants, the majority (60%) are always committed to washing their hands according to the Ministry of Health (MoH) instructions, and 74% indicated that they were always compliant with the sneezing etiquette outlined by the MoH. Studied participants were affected through different influencers of life aspects. Moreover, 63% of them gained new skills and behaviors during the pandemic curfew. Additionally, many studied participants assumed that "life will not return to what it used to be" as a future perception. Conclusion In conclusion, the present findings proved the importance and power of the Saudi Vision (2030) represented by the National Transformation Program on enhancing the healthcare system, facilitating access to healthcare, and integrating technology among government parties addressed during the COVID-19 pandemic.


Introduction
The new coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an extremely infectious disease that was declared a pandemic on March 11, 2020. Since then, the world has become a completely different place as COVID-19 brought nations to a standstill, drove hospital systems to the brink, and dragged the global economy to stagnation [1][2]. An explosive rise in the number of cases and associated mortality in addition to the lack of definitive treatment and vaccine options urged many governments and health authorities to implement strict precautionary measures to combat the pandemic. These measures included travel and movement restrictions, community lockdown, and cancelation of events and non-essential gatherings [3]. Such measures may help postpone the exponential spread of the disease until a vaccine becomes available. Trust and transparency are critical to preserving a calm and compliant response to mitigation advice among the public [4]. Data suggest that countries that implemented early and resolute interventions may have assisted in flattening their epidemic curves and reducing the rapid spread of the disease [4][5]. The Saudi government equipped itself with decisive, yet culturally tailored, precautionary measures and undertook various health policies to curb the pandemic before its beginning in the Kingdom on March 2, 2020, when the first case of COVID-19 was documented in Saudi Arabia [6][7]. A study done in April 2020 indicated that Saudi Arabia has taken bold measures to combat COVID-19, but the consequences of these actions are yet to be studied [7]. However, the success of these interventions and the compliance of the public with them is undoubtedly linked to efficient risk communication with the public to convey the reasoning behind the decisive actions.
Soon after, on March 8, the Saudi Ministry of Education declared the closure of schools, universities, and other institutions until further notice, to avoid the spread of the disease through these congregated settings [8]. The decision covered all educational institutions, including public and private schools and technical and vocational training establishments [7]. This caused an abrupt shift and a transition to alternative online teaching methods [9].
While cooperation is a crucial element to combat the COVID-19 pandemic across the world, solidarity is too.
There are examples of solidarity among different countries globally, which are gathering the world's leading experts for discussions on top research and innovation and working to promote knowledge and empower communities with state members. These plans were developed by the WHO based on solidarity [10]. The successful COVID-19 pandemic response in Vietnam emphasized the care and solidarity among its population through compliance with precautionary measures under the care ethics [11].
Locally, Saudi Arabia has approached the facilitation of free healthcare access for everyone in its community, especially for the vulnerable migrant population residing illegally [12]. Social media helped spread solidarity in the Saudi population and has kept their response positive towards the pandemic since the beginning. However, this effect began to decline over time. A recent study showed how people supported each other during the pandemic through social media by raising trendy hashtags on the Twitter platform [13]. Furthermore, the Saudi government designated March 2 of every year as "Health Martyr Day" as a sign of solidarity and appreciation to all healthcare workers who have lost their lives on the frontline against COVID-19 [14]. Saudi Arabia has also declared that free COVID-19 vaccines will be provided to all its residents and nationals and will make them available in pharmacies [15].
The purpose of this study was to assess the Saudi community's perception of the precautionary measures and explore the community's solidarity towards the implementation of these measures during the COVID-19 pandemic.

Materials And Methods
A cross-sectional study was conducted from March 2020 to February 2021 among Saudi individuals across the Kingdom. Study participants were selected, and probability sampling was applied according to the reported population size in the Saudi Arabia national census in 2019, which was 34,218,169 [16]. This sampling technique helps us generalize our sampling in the Kingdom.
OpenEpi software version 3 (www.OpenEpi.com) was used to calculate the sample size with a maximum possible variability at the 50% and 99% confidence interval level [17]. However, all individuals living in Saudi Arabia and individuals 15 years old and above were included. Nevertheless, all Saudi and non-Saudi individuals not currently living in Saudi Arabia and individuals below 15 years of age were excluded.
The self-administered online-based questionnaire was disseminated to Saudi community individuals through social media in May 2020 before the curfew unblock. As the study tool was generated by the study researcher, a pilot test was done on 20 participants, 10 persons for each language, before disseminating the questionnaire to the public. Lately, Saudi society has become more accustomed to technology and the internet, yet a low response rate might be anticipated. Low and non-response are due to people's willingness to answer the questionnaire and not a mean sample bias [18].
Participants were invited to enter a prize draw of up to 10 gift vouchers chosen randomly to overcome this anticipated barrier. Prizes were selected based on their phone numbers and email address to ensure any repetition within the participants using the Wheel of Names website [19].
The SurveyMonkey website was used for generating the questionnaire [20]. It comprised four sections, with 23 (open and close-ended) questions: demographic characteristics, questions towards the crisis influence on religion, income, health, and future perception and expectations. These questions included branching logics to minimize the length of a questionnaire and provided in both the Arabic and English languages, as shown in the Appendix.
Informed consent was written as an introduction at the beginning of the questionnaire, explaining the research purpose and ethical considerations. The information taken was kept confidential and will not be used for purposes other than the study. Those who did not meet the inclusion criteria were excluded. This study was approved by Alfaisal University's Institutional Review Board with the number IRB-20035.
Data were cleaned using Microsoft Excel (version 2016; Microsoft Corporation, Redmond, WA) and then analyzed using SPSS (version 26; IBM Corp., Armonk, NY) [21 -22]. Estimates were reported using frequencies and proportions while significance was tested using the chi-square test. Statistical significance was determined based on a p-value of <0.05, and results were determined as highly statistically significant for a p-value of less than <0.01. This study's dependent variable is combating COVID-19 preventive measures while the independent variables include demographic characteristics, prevention practices, and behaviors from the COVID-19 pandemic crisis effect.

Results
This study included 920 participants who fully completed the questionnaire as shown in Table 1  Furthermore, when comparing gender with the participants' commitment to washing their hands according to the MoH instructions, males reported a higher percentage than females (66% and 58%, respectively) and was statistically significant (p-value .03). When going outside the home, 75% of females committed to using gloves compared to only 61% of males and was also statistically significant (p-value <.001). At the same time, 71% of males used face masks compared to 62% of females, which was highly statically significant (pvalue .005). Only 49% of males washed their hands at the workplace compared to 41% of females, which was statically significant (p-value .012). Further, only 6% of females indicated they never leave home during the pandemic, which was statically significant (p-value <.001).  As presented in Table 2, postgraduates were more likely to always commit to hand-washing compared to preuniversity-educated participants (68% to 55%). Furthermore, postgraduates were more likely to indicate always/usually commit to sneezing etiquette compared with pre-university educated participants (77% to 71%). Thus, 59% of postgraduates used gloves, 43% used face masks, and 64% kept a safe distance from other people when going outside the home compared with other educational groups while 73% of the university group were more likely to sterilize their outside home orders compared with other pre-university and postgraduates' groups (64% to 58%). The associations were highly statically significant for using a face mask, keeping a safe distance, and sterilizing orders.

Community Perception on protective measures
Moreover, 97% of female participants advised people to follow and commit to the preventive measures. Which was slightly higher compared to males who indicated 94.7%. No significant association was found between gender and advising others to be committed. When researchers asked the participants why they advise others, the most frequent answer was "I care about/love them" for both males and females (82.4%, and 84.4%), respectively. However, more females (18.3%) blamed people around them for not committing and following the preventive measures compared to males (13.2%), and this difference was statistically significant (p-value = 0.046).
Besides, 75.9% of males and 75.2% of females reported calling the Unified MOH Number (937) when they had early symptoms and wanted to self-screen for possible COVID infection via the Mawid application. Upon development of COVID-related symptoms, females were more likely to surf the internet for COVID-19 symptoms, use the self-assessment service via the Mawid application, and go to the nearest health facility compared to males (34% and 21%, respectively) (p-value <0.001).
Females were keener on taking care of their own health (83.4%), their family's health, and the health of those around them (92.7%) compared to males, with a significant association (p-value = .028 and p-value = .002, respectively). More males than females reported that they could not commit to home quarantine due to the nature of their job (10.0% and 4.7%, respectively), and a statistically significant association was found (p-value = .002). About 94.9% of the total participants aged 59 years and above did not find any difficulty in committing to preventative measures. However, participants aged 15-25 years old indicated that they often forgot to adhere to preventative measures. As shown in Figure 1, 97% of the total assessed population of employers advised their employees to follow the precautionary measures while only 3% of them did not.

FIGURE 1: The extent of employers advising their employees to follow precautionary measures
As presented in Table 3, 20.7% of males were engaged in healthcare-related volunteering platform/service delivery companies during the pandemic, and only 10.1% of females of the total population. The association was highly statically significant (p-value <0.001).

Discussion
The current research presents the Saudi community's perception of the precautionary measures during the COVID-19 pandemic in Saudi Arabia. Most respondents were pre-university and university-level females ( Table 3).
The majority of participants expressed their commitment to continue washing their hands according to MOH instructions. The credit could be given to the Saudi MoH, and Saudi CDC attempts to promote adherence to precautionary measures through conducting several media awareness campaigns and guidelines [23]. However, similar findings were reported in that 72% of the African American population always wash their hands for at least 20 seconds and 21% wash their hands for at least 20 seconds for most of their time [24]. Moreover, this supports the observation that 84% of their study sample knew they had to wash their hands for 20 seconds according to MoH instructions [25].
When comparing gender with the participants' commitment to washing their hands for 40 seconds and sanitizing them for 20 seconds according to the Saudi MOH instructions, males were more likely to always be committed than females (66% to 58%) (p-value = 0.03). This is contrary to findings that showed that females were more likely to commit to precautionary measures during MERS-CoV [26].
Females were more likely to commit to using gloves when going outside the home compared to males (pvalue <.001). In contrast, males were more likely to use face masks than females (p-value = .005). A significant difference between genders in face mask use wasn't reported in other studies [27].
When asked about practices at the workplace, male respondents reported washing their hands at work more than female respondents. This could be explained by the fact that female respondents were less likely to leave home during the pandemic and were more likely to work from home and do online shopping (p-value <.001).
Postgraduate participants were more likely to always commit to washing their hands according to MOH instructions, use hand sanitizer, face masks, and practice social distancing than participants of lesser educational attainment. This is consistent with findings of another study by Baig, which found that higher educated participants were more likely to predict positive knowledge and attitudes towards the COVID-19 pandemic in Saudi Arabia [28].
Furthermore, respondents with pre-university education were found to be statistically significant for never leaving home during the pandemic's curfew. This could be largely attributed to homeschooling through virtual learning. Correspondingly, a study that examined students from a Polish secondary school indicated that females were less likely to leave home, use face masks, wear gloves, wash their hands, and avoid public places compared with males after the implementation of the legal regulations [29].
In this research, we inquired about sneezing etiquette as an important component of precautionary measures. The majority of the studied participants were always committed to the sneezing etiquette outlined by the Saudi MOH (74%), which could be largely attributed to the Saudi Centers for Disease Control and Prevention (CDC) and MOH for raising public awareness through social media platforms and websites about the novel coronavirus even before it reached Saudi Arabia [30][31]. In line with this, the study found that 75% of the participants knew that sneezing etiquette would prevent the COVID-19 virus from spreading [25].
Further, pre-university groups were more likely to answer "I don't know about sneezing etiquette" in comparison to higher educational groups. A similar finding was reported that most university students did not comply with the CDC sneezing standards [32]. With instant access to the latest global and local updates on the pandemic and the news, it seems that being educated could reinforce the implementation of precautionary measures.
Culturally, Saudi society observes strong family ties. This could have a double-edged impact on the perception of precautionary measures. From one end, precautionary measures could be adversely perceived and poorly implemented, as it was limiting the connectivity between members of the society. On the other hand, it could be utilized as an empowerment tool to further strengthen adherence to precautionary measures as people strive to protect members of their community. Participants were inquired about their commitment to advising people in their surroundings to follow preventive measures. Females were more likely to advise those who were not committed to nearby people compared to males.
Likewise, females were more likely to commit to home quarantine and apply preventive measures than males with a statistical association (p-value .028). This could be explained by the fact that females are rather wives and mothers with a strong commitment to look after their family members and an eager desire for the curfew to end so they can resume a normal life. Females were probably more vulnerable to pandemic fatigue due to feeling overwhelmed in adapting to the new norm with multiple responsibilities, including those related to online learning of their children and working from home. The study also mentioned that 32% of fathers who have children below 18 years old experienced or worsened their mental health due to fear of infection during the COVID-19 pandemic compared to 57% of mothers who can handle the disproportionately large burden of tasks [33].
Additionally, difficulties in the application and commitment to the preventive measures ranged from one age group to another. Younger participants, aged 15-25, were more likely to forget adhering to preventative measures (p-value .015) than other age groups. In contrast, participants aged 59 years and older expressed that faith in God is even more protective than adhering to precautionary measures (p-value .015).
Moreover, most participants indicated they would never commit, and only a few participants indicated they will always or usually commit to preventive instructions after lifting the total curfew. This could explain the rise of the precautionary measures violations that reached 31868 violations in March 2021 [34] and the increase of COVID-19 confirmed cases after roughly seven months of curfew lifting by the Saudi authorities [35]. As a result, the local officials needed to contain the second surge of COVID cases by reinforcing restrictions in public places and by limiting social gatherings for about 40 days until a fewer number of new cases was reported [36].
Remarkably, the university group was more likely to indicate they would never be committed after the end of the pandemic, which might be attributed to their excitement to return to their everyday life, including university/work and other entertaining activities, compared to the older age groups, for underestimating the likelihood of the future pandemic waves.

Strength
The study gathered interesting findings of the Saudi community, which we were yet to know about. This would be the first study to address the perception of the Saudi community toward precautionary measures to combat COVID-19. Our intention was to understand the main force to drive the community, in general, to adhere to precautionary measures, hoping this will support the planning and implementation of future pandemic-related initiatives, which could be better customized to the local community to ensure full community engagement.

Limitations
As this study was limited to the curfew period, we were required to distribute the questionnaire for a limited time during the lockdown period to ensure the acquisition of accurate responses. Despite offering the survey in the English language, we lacked responses from expat employers. Further, the sampling technique was limited to finding a significant difference in gender, educational levels, and employment categories, which are vital variables to implicate significant results.
Since data was collected through a self-administered questionnaire, recall bias and question misinterpretation may have occurred. The questionnaire was piloted for quality and clarity of questions prior to distribution. The small response rate was another limitation. A high response rate was difficult to achieve, but we enhanced our distribution daily by sending the questionnaire to different groups using different social media channels, including WhatsApp, Twitter, and Snap Chat, over two weeks.

Conclusions
In conclusion, our research intended to measure the Saudi community's perceptions toward preventive measures during the COVID-19 pandemic. The majority of our participants found it challenging to commit to precautionary measures outlined by the Saudi MoH, including handwashing, following a proper sneezing etiquette, and advising others to adhere to precautionary measures. Surprisingly, study respondents, most of whom are university graduates, indicated they would never commit to observing preventive instructions after the pandemic ended.

Appendices
Questionnaire: By agreeing to participate in this questionnaire, means that you are engaged in the study.All of your given information will be kept confidential for research purposes and will be destroyed after we finish the study. 1. I will be used to it 2. I will be afraid that the virus will come back again 3. society will be more cautious, so am I 4. I will maintain social distancing at work 5. I will maintain social distancing on occasions 6. I will not shake hands anymore 9. Others: ….
Have you gained any new skills through the pandemic?

= No
If yes, please mention them?
What is your future prediction after this pandemic?