Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists
Identifieur interne : 000813 ( Pmc/Corpus ); précédent : 000812; suivant : 000814Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists
Auteurs : Reema Karasneh ; Sayer Al-Azzam ; Suhaib Muflih ; Ola Soudah ; Sahar Hawamdeh ; Yousef KhaderSource :
- Research in Social & Administrative Pharmacy [ 1551-7411 ] ; 2020.
Abstract
Coronavirus disease (COVID-19), an infection of the zoonotic coronavirus, is presenting a healthcare challenge around the globe. This study aims to assess the levels of disease knowledge and risk perception among pharmacists. We also recognize predictors of risk perception and perceived media roles.
Url:
DOI: 10.1016/j.sapharm.2020.04.027
PubMed: 32340892
PubMed Central: 7179508
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists</title><author><name sortKey="Karasneh, Reema" sort="Karasneh, Reema" uniqKey="Karasneh R" first="Reema" last="Karasneh">Reema Karasneh</name><affiliation><nlm:aff id="aff1">Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Jordan</nlm:aff></affiliation></author><author><name sortKey="Al Azzam, Sayer" sort="Al Azzam, Sayer" uniqKey="Al Azzam S" first="Sayer" last="Al-Azzam">Sayer Al-Azzam</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Muflih, Suhaib" sort="Muflih, Suhaib" uniqKey="Muflih S" first="Suhaib" last="Muflih">Suhaib Muflih</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Soudah, Ola" sort="Soudah, Ola" uniqKey="Soudah O" first="Ola" last="Soudah">Ola Soudah</name><affiliation><nlm:aff id="aff1">Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Jordan</nlm:aff></affiliation></author><author><name sortKey="Hawamdeh, Sahar" sort="Hawamdeh, Sahar" uniqKey="Hawamdeh S" first="Sahar" last="Hawamdeh">Sahar Hawamdeh</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Khader, Yousef" sort="Khader, Yousef" uniqKey="Khader Y" first="Yousef" last="Khader">Yousef Khader</name><affiliation><nlm:aff id="aff3">Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32340892</idno><idno type="pmc">7179508</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179508</idno><idno type="RBID">PMC:7179508</idno><idno type="doi">10.1016/j.sapharm.2020.04.027</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000813</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000813</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists</title><author><name sortKey="Karasneh, Reema" sort="Karasneh, Reema" uniqKey="Karasneh R" first="Reema" last="Karasneh">Reema Karasneh</name><affiliation><nlm:aff id="aff1">Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Jordan</nlm:aff></affiliation></author><author><name sortKey="Al Azzam, Sayer" sort="Al Azzam, Sayer" uniqKey="Al Azzam S" first="Sayer" last="Al-Azzam">Sayer Al-Azzam</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Muflih, Suhaib" sort="Muflih, Suhaib" uniqKey="Muflih S" first="Suhaib" last="Muflih">Suhaib Muflih</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Soudah, Ola" sort="Soudah, Ola" uniqKey="Soudah O" first="Ola" last="Soudah">Ola Soudah</name><affiliation><nlm:aff id="aff1">Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Jordan</nlm:aff></affiliation></author><author><name sortKey="Hawamdeh, Sahar" sort="Hawamdeh, Sahar" uniqKey="Hawamdeh S" first="Sahar" last="Hawamdeh">Sahar Hawamdeh</name><affiliation><nlm:aff id="aff2">Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author><author><name sortKey="Khader, Yousef" sort="Khader, Yousef" uniqKey="Khader Y" first="Yousef" last="Khader">Yousef Khader</name><affiliation><nlm:aff id="aff3">Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Jordan</nlm:aff></affiliation></author></analytic><series><title level="j">Research in Social & Administrative Pharmacy</title><idno type="ISSN">1551-7411</idno><idno type="eISSN">1934-8150</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Background</title><p>Coronavirus disease (COVID-19), an infection of the zoonotic coronavirus, is presenting a healthcare challenge around the globe. This study aims to assess the levels of disease knowledge and risk perception among pharmacists. We also recognize predictors of risk perception and perceived media roles. <italic>Methods</italic> This is a questionnaire-base cross-sectional study. The questionnaire was developed on a web-based platform and invitations were sent to pharmacists nationwide to participate in the study using social media applications. <italic>Results</italic> A total of 486 pharmacists participated in this study, where females were dominant (78.6%, n = 382). Most (40.4%, n = 198) pharmacists scored 4 out of 5 in basic disease knowledge, and more than half were able to recognize common methods of spread. Risk was highly perceived among participants, and was predicted by gender, living area, and having children (p < 0,05). Frequency of watching the media and sources of information also influenced both risk perception and perceived media roles. <italic>Conclusion</italic> Disease awareness among pharmacists, as well as risk perception must be considered for effective risk communication planning. The role of media in shaping perceptions should also be carefully studied to encourage compliance with government containment measures and engagement in preventive behaviors.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="World Health Organisation Who" uniqKey="World Health Organisation Who">World Health Organisation (WHO)</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Huang, C" uniqKey="Huang C">C. Huang</name></author><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y. Wang</name></author><author><name sortKey="Li, X" uniqKey="Li X">X. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Res Social Adm Pharm</journal-id><journal-id journal-id-type="iso-abbrev">Res Social Adm Pharm</journal-id><journal-title-group><journal-title>Research in Social & Administrative Pharmacy</journal-title></journal-title-group><issn pub-type="ppub">1551-7411</issn><issn pub-type="epub">1934-8150</issn><publisher><publisher-name>Elsevier Inc.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32340892</article-id><article-id pub-id-type="pmc">7179508</article-id><article-id pub-id-type="publisher-id">S1551-7411(20)30430-7</article-id><article-id pub-id-type="doi">10.1016/j.sapharm.2020.04.027</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Media's effect on shaping knowledge, awareness risk perceptions and communication practices of pandemic COVID-19 among pharmacists</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Karasneh</surname><given-names>Reema</given-names></name><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Al-Azzam</surname><given-names>Sayer</given-names></name><email>salazzam@just.edu.jo</email><xref rid="aff2" ref-type="aff">b</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Muflih</surname><given-names>Suhaib</given-names></name><xref rid="aff2" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Soudah</surname><given-names>Ola</given-names></name><xref rid="aff1" ref-type="aff">a</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Hawamdeh</surname><given-names>Sahar</given-names></name><xref rid="aff2" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Khader</surname><given-names>Yousef</given-names></name><xref rid="aff3" ref-type="aff">c</xref></contrib><aff id="aff1"><label>a</label>Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Jordan</aff><aff id="aff2"><label>b</label>Department of Clinical Pharmacy. Faculty of Pharmacy, Jordan University of Science and Technology, Jordan</aff><aff id="aff3"><label>c</label>Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Jordan</aff></contrib-group><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan. <email>salazzam@just.edu.jo</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>23</day><month>4</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>23</day><month>4</month><year>2020</year></pub-date><history><date date-type="received"><day>22</day><month>4</month><year>2020</year></date><date date-type="accepted"><day>22</day><month>4</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Elsevier Inc. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>Elsevier Inc.</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><title>Background</title><p>Coronavirus disease (COVID-19), an infection of the zoonotic coronavirus, is presenting a healthcare challenge around the globe. This study aims to assess the levels of disease knowledge and risk perception among pharmacists. We also recognize predictors of risk perception and perceived media roles. <italic>Methods</italic> This is a questionnaire-base cross-sectional study. The questionnaire was developed on a web-based platform and invitations were sent to pharmacists nationwide to participate in the study using social media applications. <italic>Results</italic> A total of 486 pharmacists participated in this study, where females were dominant (78.6%, n = 382). Most (40.4%, n = 198) pharmacists scored 4 out of 5 in basic disease knowledge, and more than half were able to recognize common methods of spread. Risk was highly perceived among participants, and was predicted by gender, living area, and having children (p < 0,05). Frequency of watching the media and sources of information also influenced both risk perception and perceived media roles. <italic>Conclusion</italic> Disease awareness among pharmacists, as well as risk perception must be considered for effective risk communication planning. The role of media in shaping perceptions should also be carefully studied to encourage compliance with government containment measures and engagement in preventive behaviors.</p></abstract><kwd-group id="kwrds0010"><title>Keywords</title><kwd>Coronavirus</kwd><kwd>COVID-19</kwd><kwd>Pandemics</kwd><kwd>Pharmacists</kwd><kwd>Social media</kwd><kwd>Risk</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">After the pandemic of two human pathogenic respiratory coronavirus; the severe acute respiratory syndrome coronavirus (SARS-CoV)<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> and the Middle East respiratory syndrome coronavirus (MERS-CoV),<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> a third novel zoonotic human coronavirus (COVID-19) has emerged in December 2019. Through its crossing species, it was found to cause a cluster of frequently severe respiratory infection cases in human population that greatly resemble the clinical manifestation of viral pneumonia.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref> While first reports from initial investigations of this outbreak in Wuhan, China indicated that most cases are associated with wildlife animals and a seafood market where these patients had worked or visited, and the nonexistent of COVID-19 transmission between humans and if so, it could not spread easily between them.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> However, now it is clear that such spreading occurs<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> and many confirmed cases were identified among contacts with patients with COVID-19 and among healthcare professionals, and most of these cases lack direct contact with this animal's market. Thus, transmission between human populations has been confirmed in china<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref> and many other countries<xref rid="bib8" ref-type="bibr"><sup>8</sup></xref><sup>,</sup><xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> and has rapidly evolved into a global health emergency as declared by World health Organization (WHO).<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref> As April 21st<sup>,</sup> 2020, the confirmed number of cases was 2,555,760 with about 75,254 new cases globally, and these numbers are increasing continuously around the world, with the USA emerging as the new COVID-19 hotspot.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref></p><p id="p0015">It is observed that suspected COVID-19 cases are usually seeking medical help from available healthcare facilities near to them such as emergency department, pharmacies, and other health organizations. Therefore, health care professionals and front-line staff available in hospitals and other health organizations should be ready and well-prepared with the best available information and protocols to treat any patient with suspected COVID-19 infection even if presenting with minimal notice.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> Pharmacists have been a first point of contact for healthcare provision and have historically performed major roles during pandemics and viral outbreaks. Those include vaccine administration, such as during the H1N1 outbreak, drug distribution, health education, and providing direct patient care under exceptional conditions.<xref rid="bib13" ref-type="bibr"><sup>13</sup></xref><sup>,</sup><xref rid="bib14" ref-type="bibr"><sup>14</sup></xref> Therefore, ensuring sufficient knowledge and awareness of pandemics among pharmacists, in addition to recognizing factors shaping their risk perceptions and communication practices, are vital for the prevention and control of disease.</p><p id="p0020">Media was found to facilitate obtaining of up to date available information improving knowledge, awareness, and practices of both healthcare workers and general public.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> Also, it plays a key role in communication between researchers, scientists, public health experts and funding agencies, for effective and rapid global response.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref><sup>,</sup><xref rid="bib16" ref-type="bibr"><sup>16</sup></xref> The emergence of the COVID-19 outbreak grabbed the attention of media news, press, and social media pages. However, there are too many sources and sites through which any one can obtain information, and many of them are not credible which resulted in misinformation and difficulties to distinguish between rumors and reality. Thus, health care workers and the public must refer to trustworthy sources and information regarding COVID-19 such as WHO which provided social media teams and technical risk communication to respond and track rumors and myths.<xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> Additionally, government and health care facilities should provide transparent and clear communication with health care workers, staff, and public regarding COVID-19 outbreak. This study aimed to assess media role on shaping pharmacists’ knowledge, perceptions and attitudes during the pandemic of COVID-19.</p></sec><sec id="sec2"><title>Methods</title><sec id="sec2.1"><title>Study design</title><p id="p0025">This is a cross-sectional study based on self-reported questionnaire. The questionnaire was developed on a web-based platform to facilitate completion and collection of data during the quarantine period. Invitations were sent to pharmacists nationwide to participate in the study using social media applications. The link to the survey questionnaire was included in the sent invitations. Pharmacists were informed prior to their participation that their participation is anonymised, voluntary, and that their data will be treated as confidential. Also, a brief description about the study purpose was provided. The average completion time of the survey was 10 min. Ethical approval for conducting the study was obtained from the Institutional Review Board (IRB) (reference number: 21/132/2020).</p></sec><sec id="sec2.2"><title>Questionnaire development</title><p id="p0030">Scales for measuring perceived risk towards COVID19 and perceived role of media have been developed, for the most part, in studies relating perceived role of media to the perceived risk of acute infectious diseases. We developed a set of main ideas and primary items directly relevant to our topic were based on current scientific literature. The primary items were reviewed by seven experts in the field of clinical pharmacy and public health who were required to provide feedback and suggest necessary changes in order to establish both face and content validity of the survey questionnaire. Afterwards, the reliability of the questionnaire was established using a pilot test by collecting data from 20 pharmacists not included in the study sample. They were asked to fill in the questionnaire individually and were encouraged to think loudly and to speak what they meant by each answer and how they understood each question. Responses were voice recorded and questions were adjusted accordingly.</p><p id="p0035">The final survey contained 29 items including closed ended questions with responses based on Likert scale and multiple-choice formats. It consisted of five parts: demographics, knowledge, and perceived risks and media role. Demographic information included gender, age, experience (years), level of education, work setting, monthly income, and marital status. Knowledge about COVID -19 was assessed using questions on basic knowledge and factual knowledge. Basic knowledge part consisted of 5 questions that included name, origin (place and vector), incubation period, and diagnosis. These were scored by assigning one point for each correct answer. Factual knowledge included questions on mode of transmission, signs and symptoms, and risk factors. The 3-point Likert scale was used to measure pharmacists perceived risk towards COVID19 by giving each item of the questionnaire one point (Disagree = 1, Neutral = 3, and Agree = 4) to analyze the results as follows: low score (1.00–1.66), medium score (1.67–2.33), and high score (2.34–3). These were ranked as “Third”, “Second”, and “First” respectively.</p><p id="p0040">The 5-point Likert scale was used to measure pharmacists perceived role of media, by giving each item of the questionnaire one point (Strongly Disagree = 1, Neutral = 3, and Strongly Agree = 5) to analyze the results as follows: low score (1.00–2.33), medium score (2.34–3.67), and high score (3.68–5.00). These were ranked “Third”, “Second”, and “First” respectively.</p></sec><sec id="sec2.3"><title>Statistical analysis</title><p id="p0045">Data were analyzed using IBM SPSS software version 24. Data were described using frequencies and percentages. Chi-square was used to analyze differences between categorical variables. Student's t-test was used to compare the means between two groups. A p-value of less than 0.05 was considered statistically significant.</p></sec></sec><sec id="sec3"><title>Results</title><sec id="sec3.1"><title>Demographic characteristics</title><p id="p0050">Participants' demographics are shown in <xref rid="tbl1" ref-type="table">Table 1</xref>. A total of 486 pharmacists were enrolled in our study. Females pharmacists were dominant (78.6%) with around 50% holding bachelor's degree of pharmacy and 40.2% working in a community or chain pharmacies. Around half of the participants had a monthly income of less than 700$ and 80% are living in urban areas.<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>Characteristics of participants (N = 486).</p></caption><alt-text id="alttext0010">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th>Variable</th><th>Frequency (%)</th></tr></thead><tbody><tr><td colspan="2" align="left">Gender</td></tr><tr><td align="left">Male</td><td align="left">104 (21.4)</td></tr><tr><td align="left">Female</td><td align="left">382 (78.6)</td></tr><tr><td colspan="2" align="left">Age group</td></tr><tr><td align="left">Up to 25</td><td align="left">179 (36.8)</td></tr><tr><td align="left">26–30</td><td align="left">143 (29.4)</td></tr><tr><td align="left">31–35</td><td align="left">67 (13.8)</td></tr><tr><td align="left">Above 35</td><td align="left">97 (20.0)</td></tr><tr><td colspan="2" align="left">Experience (years)</td></tr><tr><td align="left">≤5</td><td align="left">242 (49.8)</td></tr><tr><td align="left">6–10</td><td align="left">79 (16.3)</td></tr><tr><td align="left">>10</td><td align="left">165 (34)</td></tr><tr><td colspan="2" align="left">Levels of Education</td></tr><tr><td align="left">Diplomate in Pharmacy</td><td align="left">52 (10.7)</td></tr><tr><td align="left">Bachelor of Pharmacy</td><td align="left">253 (52.1)</td></tr><tr><td align="left">PharmD</td><td align="left">106 (21.8)</td></tr><tr><td align="left">Master's Degree in Pharmacy</td><td align="left">75 (15.4)</td></tr><tr><td colspan="2" align="left">Work Setting</td></tr><tr><td align="left">Working Part-time</td><td align="left">133 (27.4)</td></tr><tr><td align="left">Full-time Community Pharmacy</td><td align="left">197 (40.2)</td></tr><tr><td align="left">Full-time Hospital Pharmacy</td><td align="left">156 (31.8)</td></tr><tr><td colspan="2" align="left">Monthly Income (USD$)</td></tr><tr><td align="left">Less than 700</td><td align="left">274 (56.4)</td></tr><tr><td align="left">700–1400</td><td align="left">156 (32.1)</td></tr><tr><td align="left">More than1400</td><td align="left">56 (11.4)</td></tr><tr><td colspan="2" align="left">Marital Status</td></tr><tr><td align="left">Married</td><td align="left">223 (45.5)</td></tr><tr><td align="left">Single</td><td align="left">263 (54.1)</td></tr><tr><td colspan="2" align="left">Have children</td></tr><tr><td align="left">Yes</td><td align="left">188 (38.6)</td></tr><tr><td align="left">No</td><td align="left">298 (61.3)</td></tr><tr><td colspan="2" align="left">Area of living</td></tr><tr><td align="left">Urban</td><td align="left">392 (80.7)</td></tr><tr><td align="left">Rural</td><td align="left">94 (19.3)</td></tr><tr><td colspan="2" align="left">Source of information</td></tr><tr><td align="left">Local Channels and International Channels</td><td align="left">123 (25.3)</td></tr><tr><td align="left">Social Media</td><td align="left">283 (58.2)</td></tr><tr><td align="left">WHO Website and social pages</td><td align="left">28 (5.8)</td></tr><tr><td align="left">Scientific Journals</td><td align="left">16 (3.3)</td></tr><tr><td align="left">Others (e.g., Workplace and Colleagues, and Ministry of Health (MOH) Website)</td><td align="left">36 (7.4)</td></tr><tr><td colspan="2" align="left">Frequency of use of source of information</td></tr><tr><td align="left">Daily</td><td align="left">165 (34.0)</td></tr><tr><td align="left">Weekly</td><td align="left">264 (54.3)</td></tr><tr><td align="left">Monthly</td><td align="left">57 (11.7)</td></tr></tbody></table></table-wrap></p></sec><sec id="sec3.2"><title>Knowledge assessment about COVID-19</title><p id="p0055">Frequency of correct answers of questions that assessed basic knowledge on COVID-19 are shown in <xref rid="tbl2" ref-type="table">Table 2</xref>. Almost all the pharmacists had knowledge related to COVID-19 place of origin and incubation period. Most of the participants (n = 198, 40.4%) scored 4 out of 5 of basic knowledge about COVID-19 pandemic. Almost all of the participants answered that coughing and sneezing is the main mode of transmission, fever and shortness of breath are the most common signs and symptoms and that older patients and patients with chronic diseases and weakened immunity are at higher risk for contacting COVID-19. However, 68.2% (n = 334) of participants answered that the infection can be transmitted from person to person and only 13.5% (n = 66) answered that headache is a common sign of infection.<table-wrap position="float" id="tbl2"><label>Table 2</label><caption><p>Basic and factual knowledge of pharmacists about COVID 19.</p></caption><alt-text id="alttext0015">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th>Statements</th><th>n (%)</th></tr></thead><tbody><tr><td colspan="2" align="left">Basic Knowledge</td></tr><tr><td align="left">Name of Corona Virus (COVID19)</td><td align="left">373 (76.6)</td></tr><tr><td align="left">Where Corona Virus Originated (China)</td><td align="left">485 (99.8)</td></tr><tr><td align="left">Corona Virus (Animal Origin)</td><td align="left">305 (62.8)</td></tr><tr><td align="left">Incubation Period (2–14 days)</td><td align="left">437 (89.9)</td></tr><tr><td align="left">Diagnostic Testing (PCR)</td><td align="left">150 (30.9)</td></tr><tr><td colspan="2" align="left">Factual knowledge</td></tr><tr><td align="left">Main method of transmission</td><td></td></tr><tr><td align="left">Coughing and Sneezing</td><td align="left">486 (100)</td></tr><tr><td align="left">One person to another</td><td align="left">334 (68.7)</td></tr><tr><td align="left">Contaminated surfaces</td><td align="left">448 (92.2)</td></tr><tr><td align="left">Faecal-Oral Route</td><td align="left">111 (22.8)</td></tr><tr><td align="left">Air droplets</td><td align="left">201 (41.4)</td></tr><tr><td align="left">Body Fluids</td><td align="left">51 (10.5)</td></tr><tr><td align="left">Unknown</td><td align="left">9 (1.9)</td></tr><tr><td align="left">Raw Food</td><td align="left">76 (15.6)</td></tr><tr><td align="left">Receiving goods from China</td><td align="left">76 (15.6)</td></tr><tr><td align="left">Most common sign and symptoms</td><td></td></tr><tr><td align="left">No Sign and Symptoms</td><td align="left">5 (1)</td></tr><tr><td align="left">Fever</td><td align="left">480 (98.8)</td></tr><tr><td align="left">Dry Cough</td><td align="left">457 (94)</td></tr><tr><td align="left">Shortness of Breath</td><td align="left">469 (96.5)</td></tr><tr><td align="left">Diarrhea</td><td align="left">202 (41.6)</td></tr><tr><td align="left">General Weakness</td><td align="left">405 (83.3)</td></tr><tr><td align="left">Headache</td><td align="left">66 (13.6)</td></tr><tr><td align="left">Nausea and Vomiting</td><td align="left">356 (73.3)</td></tr><tr><td align="left">Sputum Secretion</td><td align="left">42 (8.6)</td></tr><tr><td align="left">Patients at-Risk for contacting COVID19</td><td></td></tr><tr><td align="left">Older Adults</td><td align="left">486 (100.0)</td></tr><tr><td align="left">Chronic Diseases</td><td align="left">486 (100.0)</td></tr><tr><td align="left">Weakened Immunity</td><td align="left">461 (94.9)</td></tr><tr><td align="left">Pregnant</td><td align="left">315 (64.8)</td></tr><tr><td align="left">Smoker</td><td align="left">292 (60.1)</td></tr><tr><td align="left">Children</td><td align="left">83 (17.1)</td></tr><tr><td align="left">Adult Female</td><td align="left">10 (2.1)</td></tr><tr><td align="left">Adult Male</td><td align="left">48 (9.9)</td></tr></tbody></table></table-wrap></p><p id="p0060"><xref rid="tbl3" ref-type="table">Table 3</xref>shows the perceived risk of COVID-19 infection among pharmacists. The average (±SD) risk perception score for participants was high for almost all statements. For example, pharmacists were concerned about the risk of community spread (2.93 ± 0.33) and getting infected during work in healthcare settings (2.56 ± 0.79). They also believed this disease is more dangerous than winter flu (2.64 ± 0.68). However, scores were also high for positive risk perceptions, such as high recovery rates (2.67 ± 0.63) and mildness of the disease for less susceptible patients (2.51 ± 0.79).<table-wrap position="float" id="tbl3"><label>Table 3</label><caption><p>Perceived risk of COVID-19 infection among Pharmacists.</p></caption><alt-text id="alttext0020">Table 3</alt-text><table frame="hsides" rules="groups"><thead><tr><th>Statement</th><th>Mean (SD)</th><th>Rank</th></tr></thead><tbody><tr><td align="left">I feel that it would be extremely dangerous if it began to spread in the community</td><td align="left">2.93 ± 0.33</td><td align="left">First</td></tr><tr><td align="left">The lack of current information about the Corona virus makes it difficult to prepare for each scenario</td><td align="left">2.80 ± 0.56</td><td align="left">First</td></tr><tr><td align="left">The disease recovery rate is high, which is a good thing</td><td align="left">2.67 ± 0.63</td><td align="left">First</td></tr><tr><td align="left">I am concerned about getting sick by dealing with the public</td><td align="left">2.65 ± 0.73</td><td align="left">First</td></tr><tr><td align="left">This disease is more dangerous than winter flu</td><td align="left">2.64 ± 0.68</td><td align="left">First</td></tr><tr><td align="left">I am concerned about getting an infection while working in health care settings</td><td align="left">2.56 ± 0.79</td><td align="left">First</td></tr><tr><td align="left">I feel that the disease will be very dangerous for those who are more likely to develop the disease, and it will be mild to the rest</td><td align="left">2.51 ± 0.79</td><td align="left">First</td></tr><tr><td align="left">All patients with coronavirus will need supportive medical care</td><td align="left">1.78 ± 0.93</td><td align="left">Second</td></tr></tbody></table><table-wrap-foot><fn><p>[Three-point Likert scale, agree with the perceived risk = 3; neutral = 3, disagree = 3].</p></fn></table-wrap-foot></table-wrap></p><p id="p0065">The perceived role of media briefing on COVID-19 was also assessed (<xref rid="tbl4" ref-type="table">Table 4</xref>). Pharmacists scored high in agreement with the following media roles: spreading disease awareness, educating the public on preventive behaviors, caring for ill or suspected ill individuals, and preparing for an outbreak. Meanwhile, they agreed that media increases fear and anxiety among the public (3.79 ± 1.26) and had moderate trust (2.85 ± 1.07) in what is posted on social media.<table-wrap position="float" id="tbl4"><label>Table 4</label><caption><p>Perceived role of media briefing on COVID-19 among Pharmacists.</p></caption><alt-text id="alttext0025">Table 4</alt-text><table frame="hsides" rules="groups"><thead><tr><th>Statement</th><th>Frequency (%)</th><th>Rank</th></tr></thead><tbody><tr><td align="left">The role of the media in educating people about the procedures to follow in the event of an outbreak and how to prepare for it</td><td align="left">4.48 ± 0.79</td><td align="left">First</td></tr><tr><td align="left">The role of the media in increasing general preventive behaviours to control the infection</td><td align="left">4.47 ± 0.79</td><td align="left">First</td></tr><tr><td align="left">The role of the media in spreading awareness in the community</td><td align="left">4.44 ± 0.86</td><td align="left">First</td></tr><tr><td align="left">The role of the media in people education on how to protect others if they are ill or suspected of being ill</td><td align="left">4.38 ± 0.86</td><td align="left">First</td></tr><tr><td align="left">The role of the media in increasing fear, anxiety and confusion among people</td><td align="left">3.79 ± 1.26</td><td align="left">First</td></tr><tr><td align="left">Your trust in what is posted on social media</td><td align="left">2.85 ± 1.07</td><td align="left">Second</td></tr></tbody></table><table-wrap-foot><fn><p>[Five-point Likert scale, strongly disagree = 1 to strongly agree with the perceived risk = 5].</p></fn></table-wrap-foot></table-wrap></p><p id="p0070">Several factors predicted an increased risk perception among pharmacists (<xref rid="tbl5" ref-type="table">Table 5</xref>). For example, female gender, living in a city, and having children were all associated with an increased perception of COVID-19 risk (P < 0.05). Those who watched the media weekly, compared to daily or monthly, also had higher risk perceptions. Other predictors included work setting and sources of information. Gender, work setting, frequency of watching the media, sources of information also predicted the perceived media role among pharmacists (p < 0.05).<table-wrap position="float" id="tbl5"><label>Table 5</label><caption><p>Association between pharmacists’ perceived risk of COVID19 and role of media by sociodemographic characteristics, COVID19-related basic knowledge.</p></caption><alt-text id="alttext0030">Table 5</alt-text><table frame="hsides" rules="groups"><thead><tr><th rowspan="2">Variable</th><th rowspan="2">Groups</th><th colspan="2">Perceived Risk<hr></hr></th><th colspan="2">Perceived Media Role<hr></hr></th></tr><tr><th>Mean (SD)</th><th>P value</th><th>Mean (SD)</th><th>P value</th></tr></thead><tbody><tr><td align="left" rowspan="2">Gender</td><td align="left">Male (<italic>n</italic> = 104)</td><td align="left">2.41 (.30</td><td rowspan="2"></td><td align="left">3.94 (.67)</td><td align="left" rowspan="2"><bold><0.05</bold></td></tr><tr><td align="left">Female (<italic>n</italic> = 382)</td><td align="left">2.39 (.29)</td><td align="left">4.2 (.57)</td></tr><tr><td align="left" rowspan="4">Age group</td><td align="left">Up to 25 (<italic>n</italic> = 179)</td><td align="left">2.41 (.29)</td><td rowspan="4"></td><td align="left">4.06 (.58)</td><td rowspan="4"></td></tr><tr><td align="left">26-30 (<italic>n</italic> = 143)</td><td align="left">2.38 (.29)</td><td align="left">4.08 (.59)</td></tr><tr><td align="left">31-35 (<italic>n</italic> = 67)</td><td align="left">2.35 (.29)</td><td align="left">4.01 (.67)</td></tr><tr><td align="left">Above 35 (<italic>n</italic> = 97)</td><td align="left">2.44 (.28)</td><td align="left">4.12 (.56)</td></tr><tr><td align="left" rowspan="2">Area of Living</td><td align="left">City (<italic>n</italic> = 392)</td><td align="left">2.41 (.29)</td><td align="left" rowspan="2"><bold><0.05</bold></td><td align="left">4.08 (.56)</td><td rowspan="2"></td></tr><tr><td align="left">Rural (<italic>n</italic> = 96)</td><td align="left">2.34 (.31)</td><td align="left">4.00 (.69)</td></tr><tr><td align="left" rowspan="3">Work setting</td><td align="left">Hospital Pharmacy (<italic>n</italic> = 183)</td><td align="left">2.47 (.29)</td><td align="left" rowspan="3"><bold><0.05</bold></td><td align="left">4.19 (.59)</td><td align="left" rowspan="3"><bold><0.05</bold></td></tr><tr><td align="left">Community Pharmacy (<italic>n</italic> = 181)</td><td align="left">2.36 (.30)</td><td align="left">3.98 (.61)</td></tr><tr><td align="left">Part-Time (<italic>n</italic> = 122)</td><td align="left">2.35 (.35)</td><td align="left">4.01 (.58)</td></tr><tr><td align="left" rowspan="4">Level of education</td><td align="left">Diplomate in Pharmacy (<italic>n</italic> = 52)</td><td align="left">2.46 (.29)</td><td rowspan="4"></td><td align="left">4.13 (.54)</td><td rowspan="4"></td></tr><tr><td align="left">Bachelor of Pharmacy (<italic>n</italic> = 253)</td><td align="left">2.39 (.31)</td><td align="left">4.08 (.55)</td></tr><tr><td align="left">PharmD (<italic>n</italic> = 106)</td><td align="left">2.41 (.27)</td><td align="left">4.03 (.64)</td></tr><tr><td align="left">Master's Degree in Pharmacy (<italic>n</italic> = 75)</td><td align="left">2.35 (.30)</td><td align="left">4.04 (.69)</td></tr><tr><td align="left" rowspan="3">Frequency of watching media</td><td align="left">Daily (<italic>n</italic> = 165)</td><td align="left">2.29 (.37)</td><td align="left" rowspan="3"><bold><0.05</bold></td><td align="left">4.15 (.59)</td><td align="left" rowspan="3"><bold><0.05</bold></td></tr><tr><td align="left">Weekly (<italic>n</italic> = 264)</td><td align="left">2.45 (.27)</td><td align="left">4.05 (.56)</td></tr><tr><td align="left">Monthly (<italic>n</italic> = 57)</td><td align="left">2.36 (.31)</td><td align="left">3.91 (.61)</td></tr><tr><td align="left" rowspan="5">Sources of information</td><td align="left">Local and International Channels (<italic>n</italic> = 123)</td><td align="left">2.39 (.32)</td><td align="left" rowspan="5"><bold><0.05</bold></td><td align="left">4.06 (.62)</td><td align="left" rowspan="5"><bold><0.05</bold></td></tr><tr><td align="left">Social Media (<italic>n</italic> = 283)</td><td align="left">2.38 (.29)</td><td align="left">4.05 (.55)7</td></tr><tr><td align="left">WHO Website (<italic>n</italic> = 28)</td><td align="left">2.58 (.29)</td><td align="left">4.32 (.55)</td></tr><tr><td align="left">Scientific Journals (<italic>n</italic> = 16)</td><td align="left">2.29 (.24)</td><td align="left">3.70 (.75)</td></tr><tr><td align="left">Others (e.g., Workplace and Colleagues, and Ministry of Health (MOH) Website) (<italic>n</italic> = 36)</td><td align="left">2.45 (.32)</td><td align="left">4.12 (.55)</td></tr><tr><td align="left" rowspan="3">Years of Experience</td><td align="left">Less than 5 years (<italic>n</italic> = 242)</td><td align="left">2.41 (.32)</td><td rowspan="3"></td><td align="left">4.06 (.55)</td><td rowspan="3"></td></tr><tr><td align="left">5–10 years (<italic>n</italic> = 79)</td><td align="left">2.36 (.31)</td><td align="left">4.11 (.61)</td></tr><tr><td align="left">More than 10 years (<italic>n</italic> = 165)</td><td align="left">2.40 (.28)</td><td align="left">4.07 (.62)</td></tr><tr><td align="left" rowspan="2">Having children</td><td align="left">No (<italic>n</italic> = 298)</td><td align="left">2.36 (.30)</td><td align="left" rowspan="2"><bold><0.05</bold></td><td align="left">4.06 (.59)</td><td rowspan="2"></td></tr><tr><td align="left">Yes (<italic>n</italic> = 188)</td><td align="left">2.45 (.29)</td><td align="left">4.06 (.59)</td></tr></tbody></table><table-wrap-foot><fn><p><sup>a</sup>Significant value (p < 0.05).</p></fn></table-wrap-foot></table-wrap></p></sec></sec><sec id="sec4"><title>Discussion</title><p id="p0075">The novel coronavirus (COVID-19) outbreak, originating from Wuhan, China, presents a global healthcare crisis.<xref rid="bib15" ref-type="bibr"><sup>15</sup></xref> In this study, we aimed to assess the knowledge of pharmacists about disease spread, symptoms, and susceptibility. We also identify predictors of the COVID-19 risk perception and perceived media roles during the outbreak.</p><p id="p0080">Generally, social media was the main source for coronavirus-related information in around half of the population. This was followed by local and international channels. Such sources were used daily to weekly by most pharmacists. These results are in accordance with a study that compared knowledge and practices among healthcare workers during the 2012 Middle East Respiratory Syndrome (MERS) outbreak.<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref> Pharmacists compromised 4.6% of the study population, which also included physicians (41.4%), nurses (33.3%), and technicians (20.7%). Social media ranked second among sources of MERS-related information used by healthcare providers (45%), only preceded by seminars and workshops (48%). Other media outlets used were newspapers and magazines (18%), and radio and television (37%). However, among pharmacists, books and articles led the sourced of MERS-related information, followed by workshops and seminars (38%) and posters and pamphlets (38%). Media sources of information among pharmacists included social media (33%), radio and television (27%), and newspapers and magazines (22%). Two other similar studies on MERS had consistent results, as social media and the internet were the most common sources of information among healthcare providers.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref><sup>,</sup><xref rid="bib19" ref-type="bibr"><sup>19</sup></xref></p><p id="p0085">Risk perception of pandemics can predict compliance with preventive measures and tendency to seek treatment or vaccination.<xref rid="bib18" ref-type="bibr"><sup>18</sup></xref><sup>,</sup><xref rid="bib19" ref-type="bibr"><sup>19</sup></xref> Furthermore, identifying how risk is perceived is important for creating risk communication plans.<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref> Unlike other reports, where female gender has been linked to more worry and engagement in preventive and treatment-seeking behaviors,<xref rid="bib21" ref-type="bibr"><sup>21</sup></xref><sup>,</sup><xref rid="bib22" ref-type="bibr"><sup>22</sup></xref> we find males to have higher perception of risk. Additionally, living in city areas, having children, and working in a hospital pharmacy are all associated with a higher perceived risk of the coronavirus pandemic. Other studies also report a strong association between age and risk perception. For example, Jacob et al. found that younger age (16–24) predicted higher disease concern.<xref rid="bib20" ref-type="bibr"><sup>20</sup></xref> In contrast, a study of 1290 US adults showed no association between age and engagement in protective measures during the H1N1 influenza pandemic.<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> In our study, those below 25 and above 35 years had the highest risk perception, but the difference was not significant. This could be due to lower participation of younger age groups (<20 years) in both our study and the study from the US. Distinction between city and rural areas can also be justified by the variation in case numbers between different geographic areas.<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> Therefore, we expect higher concern about viral spread in the more crowded cities. Jacobs also finds no association between having elderly and children in the household and disease concerns. This is however inconsistent with results from a similar study, where more household members predicted increased precautionary activities.<xref rid="bib23" ref-type="bibr"><sup>23</sup></xref> It is justified as children can be more susceptible to viral infections. Nonetheless, it is worth to note the difference in disease vulnerability among children between H1N1 and the novel coronavirus. Whereas morbidity and mortality is increased in the former, COVID-19 appears to take a milder toll on children.<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref><sup>,</sup><xref rid="bib24" ref-type="bibr"><sup>24</sup></xref></p><p id="p0090">Frequency of watching media predicted both risk perception and perceived media roles among pharmacists. This is strongly supported by previous reports from the MERS, SARS, and H1N1 outbreaks. For example, a study from South Korea had shown a positive association between social media exposure and the formation of risk perception during the latest MERS outbreak.<xref rid="bib25" ref-type="bibr"><sup>25</sup></xref> Moreover, Chang et al. reported a correlation between watching H1N1-related television news and formation of public risk perception about the outbreak.<xref rid="bib26" ref-type="bibr"><sup>26</sup></xref> While this may support the role of media in effective risk communication, it is worth noticing the effects media create on mental wellbeing during a pandemic. In its advice for coping with coronavirus stress, WHO recommends limiting news exposure that may cause upset or agitation.<xref rid="bib27" ref-type="bibr"><sup>27</sup></xref></p><p id="p0095">Overall, pharmacists had good basic knowledge about COVID-19, as most (n = 198, 40.4%) has scored 4 out of 5. Almost all recognized the most common methods of disease spread. Like other respiratory viruses<xref rid="bib28" ref-type="bibr">28</xref>, <xref rid="bib29" ref-type="bibr">29</xref>, <xref rid="bib30" ref-type="bibr">30</xref>, <xref rid="bib31" ref-type="bibr">31</xref> transmission of COVID-19 occurs mainly through respiratory droplets and person-to-person contact.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref><sup>,</sup><xref rid="bib32" ref-type="bibr"><sup>32</sup></xref> The most common symptoms, including fever, cough, fatigue or myalgia<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> were also recognized by almost all participants. However, only 13.6% and 41.6% correctly identified headache and diarrhea, respectively, as disease symptoms. Those symptoms, in addition to nausea, may be the early clinical manifestation among coronavirus patients.<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> Reports from earlier pandemics show similar satisfactory levels of disease knowledge among pharmacists. However, they remain inferior compared to other healthcare providers, possibly due to less involvement in hospital patient care. For example, when Albarrak et al. scored knowledge related to MERS, pharmacists (88.9%) ranked third to physicians (95.7%) and technicians (91.4%) in having ‘Good’ disease knowledge.<xref rid="bib17" ref-type="bibr"><sup>17</sup></xref> Highest scores (94.4%) were attained for questions related to vaccine availability in the market and methods of viral transmission. Most (94.4%) pharmacists showed positive attitudes towards the MERS crisis, with all (100%) agreeing that protective masks, gloves, and googles should be used when dealing with patients, and that patients should be kept in isolation. This was in accordance with study results from Saudi and Vietnamese populations where attitudes towards wearing protective gear were also positive.<xref rid="bib33" ref-type="bibr">33</xref>, <xref rid="bib34" ref-type="bibr">34</xref>, <xref rid="bib35" ref-type="bibr">35</xref> The majority of pharmacists have also shown positive MERS practices, including washing hands with soap and water (72.2%), throwing used tissues in the trash (100%), and covering nose and mouth during sneezing and coughing (77.8%). However, only 27.8% reported wearing face masks in the crowds. Another small study of 35 healthcare providers (HCP) in hospitals and community pharmacies was conducted during the H1N1 pandemic.<xref rid="bib36" ref-type="bibr"><sup>36</sup></xref> The study assessed the knowledge of HCP on the transmission, prevention, and management of H1N1. Pharmacists' knowledge was suboptimal among all three aspects. Additionally, most participants (64%) were uninformed about the drug management of H1N1 or the side effects (92.5%) of recommended antivirals.</p></sec><sec id="sec5"><title>Conclusion</title><p id="p0100">Disease knowledge and awareness, in addition to risk perception, are determining factors in how people respond to and engage in preventive behaviors. Pharmacists had good levels of COVID-19 knowledge and have shown high risk perception of the disease. This was significantly affected by social and media-related factors. This must be taken into consideration when planning for effective risk communication. Moreover, future studies should assess the effect of these factors on treatment-seeking and vaccination should a vaccine be available.</p></sec><sec id="sec6"><title>CRediT authorship contribution statement</title><p id="p0105"><bold>Reema Karasneh:</bold> Conceptualization, Methodology, Validation, Formal analysis, Writing - original draft, Supervision, Project administration. <bold>Sayer Al-Azzam:</bold> Conceptualization, Methodology, Supervision, Project administration, Writing - review & editing. <bold>Suhaib Muflih:</bold> Conceptualization, Methodology, Writing - review & editing, Formal analysis. <bold>Ola Soudah:</bold> Conceptualization, Methodology, Supervision, Project administration, Writing - review & editing. <bold>Sahar Hawamdeh:</bold> Conceptualization, Methodology, Writing - review & editing. <bold>Yousef Khader:</bold> Conceptualization, Methodology, Writing - review & editing.</p></sec><sec sec-type="COI-statement"><title>Declaration of competing interest</title><p id="p0110">None.</p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref id="bib1"><label>1</label><element-citation publication-type="book" id="sref1"><person-group person-group-type="author"><name><surname>World Health Organisation (WHO)</surname></name></person-group><chapter-title>Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31</chapter-title><year>July 2003</year></element-citation></ref><ref id="bib2"><label>2</label><mixed-citation publication-type="other" id="sref2">World Health Organisation (WHO). 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