Since the emergence of the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), in China in December 2019, ¹ the world has been encountering unprecedented challenges and COVID-19 was declared a global pandemic in March 2020. ² Numbers of infected cases have been escalating rapidly worldwide, and the governments across the world have had to impose stringent measures to control the rapid spread of the disease. These measures included lockdown, social distancing, travel limitations, public use of personal protective equipment (PPE) and rearrangement of health administrations. ³

The crisis the world has been facing because of the pandemic is attributed to the fast and vast spread of the disease among the population. ^{4 , 5} This resulted in overloaded healthcare systems and an extensive burden being placed on healthcare workers all over the world. ^{6 – 8} Reports have shown increased stress and anxiety of the healthcare providers due to increased workload and fear of contracting and transmitting the disease to family and friends. ^{9 – 12} This may impact the attitude and performance of the healthcare provider and accordingly, the efficiency of the whole healthcare system. ^{13 , 14}

During such a crisis, it is important to maintain an efficient healthcare system. This could be achieved by providing training to, updating the knowledge of, and protecting the healthcare providers. Unfortunately, some reports revealed a shortage of knowledge in healthcare workers regarding the COVID-19 pandemic in Saudi Arabia, with estimates that only about 45% of healthcare workers have a good awareness of COVID-19 when measured in March and April 2020. ¹⁵ Misleading information and myths about the pandemic have gone viral across the different media channels, contributing further to limiting the knowledge of the healthcare workers. ¹⁶ Furthermore, protection of the healthcare providers should be ensured by sufficient supplies and ease of accessibility to the PPE. Recent reports showed that shortage of the PPE supplies is associated with increased risk of infection and severity of symptoms and elevated anxiety among the healthcare providers. ¹⁷

Physical therapy services are essential for the comprehensive recovery of some COVID-19 patients. Cardiopulmonary rehabilitation in acute and post-acute settings can significantly maintain and improve the pulmonary functions. ^{18 , 19} Physical therapists also manage patients recovering from a COVID-19 infection to help them restore mobility and lung functions. This exposes the physical therapists to a high risk of contracting the infection, considering that the physical therapy practice requires prolonged physical contact with the patients. ²⁰

Therefore, collecting information regarding healthcare workers’ sources of knowledge, their attitude and experience during the COVID-19 pandemic, and accessibility to the PPE is important to assess and maintain the healthcare workers’ efficiency and to protect the health of their workforce and the patients they serve. Findings retrieved from such information could help decision-makers find weaknesses and strengths in order to improve the services provided to the patients. To the authors’ knowledge, no studies have assessed such information among physical therapists working in the Saudi healthcare system. Thus, the purpose of this study is to assess and report the sources of knowledge, attitude, experience and accessibility of PPE for physical therapists working in Saudi Arabia.

During the past year, several studies examined how the healthcare practitioners handled the COVID-19 pandemic. ^{9 , 15 , 25 – 30} However, studies focusing on the physical therapy profession were scarce. ^{24 , 31 – 33} Physical therapists typically spend extended periods of time treating patients through prolonged and direct physical interaction with patients. ²⁰ In the current pandemic, physical therapists play an important role providing respiratory support and active mobilization to COVID-19 patients both inside and out of an acute care setting. ^{18 , 19 , 34 , 35}

The COVID-19 pandemic is an unprecedented medical situation that has been associated with extreme measures imposed worldwide. Accordingly, it was essential to assess the knowledge of physical therapists about the new viral infection. Our results showed that nearly 40% of the physical therapists were responsible enough to seek knowledge about the new pandemic from trusted sources such as the official websites. Meanwhile, more than one quarter (26.7%) of the participants used social media as their main source of information. This may suggest that the physical therapists may have developed misconceptions about the pandemic because of the invalid information about how the virus spreads and any myths about the virus symptoms through the social media. ^{16 , 36} Other studies investigated the community knowledge about the pandemic and found a significant knowledge gap among the public ^{37 , 38} and healthcare providers. ¹⁵

The current results indicate commitment from most of the physical therapists to apply the recommended precautionary measures. More than 80% of the participants reported using hand sanitizers and washing clothes once they return home. Previous reports revealed an increased anxiety among healthcare providers in Saudi Arabia during April 2020 because of the pandemic. ²⁸ One of the main reasons for increased anxiety was the fear of contracting the infection and transmitting it to family and friends. ^{15 , 39} In the current study, women were more inclined than men to apply additional precautionary measures, which reflects a greater protective attitude. This is in accordance with previous studies that showed hygienic practices were positively associated with women, ^{37 , 40} and they were more compliant than men with the imposed public policy measures while dealing with COVID-19 pandemic as mandating the use of face masks, quarantine the infected cases, etc. ⁴¹

In the current study, physical therapists showed a positive attitude towards managing COVID-19 positive cases. Despite of the documented concern and anxiety among healthcare providers regarding the pandemic, ^{15 , 39} more than half of the participants were willing to treat a COVID-19 patient. Physical therapy services by nature require extended and direct physical interaction between the therapist and the patient, which would potentially significantly increase the risk of contracting a highly contagious infection such as COVID-19. Thus, it is expected that physical therapists might be hesitant to manage a positive case, which was reported by almost half of the study participants. Meanwhile, men as well as more experienced therapists, were more motivated to treat COVID-19 patients. This finding is counterintuitive considering the reported fact that older adults and males are more likely to be at greater risk of serious morbidity and higher mortality. ^{42 – 44} However, this interesting finding could be explained by reports of the gender-based differences regarding attitude and risk perception during the COVID-19 pandemic. Women reported greater fear and health-related negative expectations than men. ^{41 , 45} Additionally, experienced therapists are commonly assigned to higher administrative positions that limit direct interaction with patients. Furthermore, they are typically older than less experienced therapists. Therefore, they are considered amongst the high-risk group for contracting infection and experiencing serious health consequences. Thus, they had limited or no interaction with patients, which may explain their positive attitude and limited concern regarding treating patients diagnosed with COVID-19.

Unfortunately, only about one third of the participants (30.9% and 31.6%, respectively) reported being involved in management and planning teams of the pandemic or receiving training to deal with the pandemic. This surprisingly low percentage indicating the need to provide more training programs for rehabilitation professionals by the governing authorities. However, it could be justified by the fact that COVID-19 is a life-threatening disease for which, the first line of treatment is medical rather than rehabilitative. Thus, it is reasonable that physicians and nurses become the focus group for treatment planning and training efforts during the pandemic. This should not underestimate the valuable role physical therapists have in acute settings for treating COVID-19 patients. ¹⁹ Our findings also indicate that involvement in management teams was positively associated with male, older and more experienced therapists working in governmental institutions. This further corroborates the finding discussed here above regarding gender-based differences about worries, fear and negative expectations toward the pandemic that are more associated with women. This could potentially be a barrier for female therapists to participate in management and planning teams. Additionally, the measures imposed by the Saudi Ministry of Health targeted primarily the governmental medical institutions that are more capable to accommodate the increased number of COVID-19 cases. ⁴⁶ This may explain the interesting finding favoring therapists working in governmental institutions. This argument is supported by the reported data regarding actual treatment of positive cases. The majority of therapists who reported treating COVID-19 cases were mostly working in governmental institutions, and male therapists treated higher numbers of patients compared with female therapists.

The results revealed that accessibility to the PPE was not a problem for the majority of the participants. This indicates the preparedness of the Saudi healthcare system to face the pandemic and equip the healthcare providers with the necessary protective equipment. ⁴⁶ This is particularly important considering that more than 60% of the participants work in governmental institutions. Protection of healthcare providers during a pandemic is crucial for the quality and efficiency of the service provided. Reports have shown a significant shortage of PPE in some healthcare systems. In Italy, only 13% of physicians reported to have access to PPE every time they needed to. ⁴⁷ Another study in Ethiopia identified a critical shortage of PPE that is significantly associated with high levels of dissatisfaction amongst healthcare workers. ⁴⁸ This should be a warning to the governing authorities to continuously provide sufficient supplies of PPE and avoid shortage using different resources, ^{49 , 50} given the findings revealing that limited access to or shortage of PPE is significantly associated with increased risk of contracting the COVID-19 infection and increased severity of symptoms among the health care workers. ¹⁷

The current study has some limitations that should be noted. The data collection process was not carried out at the time of the lockdown during the peak of the COVID-19 pandemic during March to June 2020. ⁵¹ Therefore, the data obtained were collected retrospectively. Thus, it may likely suffer the recall bias inherent with retrospective self-reported data. The five geographical regions of Saudi Arabia were not equally represented, which may limit the generalizability of the obtained findings. However, successfully recruiting participants more than the required minimal sample size could provide credible data.

In conclusion, the current study showed that physical therapists were knowledgeable about best hygienic practices. Furthermore, sufficient supplies of PPE were available through the Saudi healthcare system, which indicates appropriate planning by the authorities. Physical therapists showed a positive attitude towards COVID-19 patients. Yet, this could be improved significantly by implementing a stringent plan to educate physical therapy practitioners about misleading information on social media as a source of information and involving them more in management planning teams. Developing better physical therapists’ awareness about the COVID-19 pandemic would help establish more efficient management strategies during pandemics. In doing so, appropriate and immediate responses could be implemented to ensure the continuity of service provision and limit economic burden.