HEALTH CRISIS IN THE KINGDOM OF SAUDI ARABIA: A STUDY OF SAUDIS’ KNOWLEDGE OF CORONAVIRUS, ATTITUDES TOWARD THE MINISTRY OF HEALTH’S CORONAVIRUS PREVENTIVE CAMPAIGNS, AND TRUST IN CORONAVIRUS MESSAGES IN THE MEDIA
Saud Abdulaziz Alsulaiman
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillments of the requirements for the degree of
DOCTOR OF PHILOSOPHY
May 2018
Committee:
Terry Rentner, Advisor Per F. Broman Graduate Faculty Representative
Lara Lengel Lisa Hanasono
© 2018 Saud Alsulaiman All Rights Reserved
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ABSTRACT
Terry Rentner, Advisor
As of September 2017, more than 600 people died in the Kingdom of Saudi Arabia
(KSA) since the Coronavirus outbreak in 2012. The Ministry of Health (MOH), in cooperation with international health organizations such as the World Health Organization (WHO), launched a public health campaign to increase awareness of preventive measures. Initial responses from this campaign left people confused by the mixed messages disseminated and led to distrust of the
MOH and its website, the primary source for communication to the public. A new minister launched a comprehensive campaign that incorporated key messages, trustworthy sources, and specific actions.
The purpose of the study was to explore whether the MOH in Saudi Arabia has implemented best public relations practices during a major health crisis or not. The study adapted
Champion’s Health Belief Model (HBM) and Meyer’s Media Credibility Scale to formulate an online survey of 875 students from King Saud University in Riyadh, Saudi Arabia administered in summer 2016. The survey addressed HBM preventive behaviors, effectiveness of the We Can
Stop It campaign on behavioral changes, and the credibility of Coronavirus messages.
Results show that Saudis with higher susceptibility, severity, cues to actions, and self- efficacy scores are more likely to adhere to the MOH’s Coronavirus preventive measures than those with lower scores. Respondents with high perceived barriers are less likely to adhere to
Coronavirus preventive measures. The MOH’s website is the most credible source of
Coronavirus information followed by the WHO and MOH’s Twitter account. Internet search iv engines followed by the MOH’s communication channels, like their website, Twitter, and
Facebook, are the first places Saudis visit when seeking Coronavirus information.
The increasing adherent practices of the MOH’s Coronavirus preventive measures, like washing hands frequently, show how the MOH was successful of regaining trust through effective communication strategies and health interventions. Nonetheless, some Coronavirus preventive measures, such as following a healthy and balanced diet, have not been adopted by the Saudi people.
Principles of crisis communication and Grunig’s two-way communication model served as foundations for comparing and contrasting its current “We Can Stop It” campaign. Lessons learned and recommendations are provided.
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I would not be Dr. Saud without the full support and encouragement from my precious parents,
beloved wife, and special advisor. Thank you all for being in my life.
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ACKNOWLEDGMENTS
First and foremost, I am thankful to my God who gives me the strength and patience to achieve my goals so far in this life. This dissertation would not have been possible without the support of amazing people in my life. Thanks to my advisor Dr. Terry L. Rentner who guided me throughout my study and provided me with support and encouragement. It has been an honor to work with Dr. Rentner during this challenging yet beautiful journey. I really appreciate her contributions of constructive ideas, feedback, and time that have made me not only a better researcher but also a better person. If there is only one thing to say about Dr. Rentner, I would say she is the best of the best. She never underestimates any ideas or any research projects I have in mind; instead, she always encourages me to advance my ideas and provides me with excellent resources to help me achieve my goals. I will not forget how she dedicated her time to make me present in prestigious conferences and publish in respected journals. I am sure my journey with
Dr. Rentner will not end here, and I hope to cooperate in more research projects in the future.
I am also so thankful to have Dr. Lara Lengel and Dr. Lisa Hanasono in my committee, whose knowledge and experience in the health communication field served at best in this study.
Both Dr. Lengel and Dr. Hanasono have provided very excellent and valuable feedback that thrived this study with new and different perspectives. Big thanks to Dr. Per Broman who was very supportive, enthusiastic, and provided different and unique points of view. I am also grateful to Dr. Sadik Khuder from the University of Toledo for his efforts, guidance, and support in analyzing the statistical data.
I am also grateful to my lovely wife, Dr. Fatimah, who has supported and encouraged me to success in my life. She has lived and experienced every challenge, happiness, and joy I have had during my journey of pursuing higher education. Without her, I would not be writing these vii acknowledgments right now. Also, big thanks to my lovely daughters, Reem and Dania, who endured all the challenges and difficulties that took me from their times. Thanks also to my parents and my family for their endless supports and prayers. I am so thankful to have these loving and nurturing people in my life.
Finally, I would like to thank the Department of Mass Communication, College of Arts, at King Saud University for their support during my study.
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TABLE OF CONTENTS
Page
INTRODUCTION………………………………………………………………………..... 1
CHAPTER I. REVIEW OF LITERATURE ...... ……………………… 6
Coronaviruses Middle East Respiratory Syndrome (MERS) in KSA ...... 6
The Ministry of Health’s Efforts to Reduce Coronavirus ...... 9
Coronavirus preventive measures ...... 13
Public Relations Practitioners & Public Campaigns ...... 17
Phases of campaign development ...... 20
Public Relations & Health Campaigns ...... 22
Crisis Communication ...... 28
Crisis Communication and Social Media ...... 32
Using Social Media in Health Organizations ...... 36
Media Credibility ...... 43
The credibility of news organizations ...... 44
CHAPTER II. THEORY ...……………………………………………………………….. 47
Grunig’s Four Models of Public Relations …………………………………………. 47
Health Belief Model (HBM) ...... 54
Elaboration Likelihood Model (ELM) ...... 59
CHAPTER III. METHODOLOGY ...... ………………………. 65
Survey Research ...... ……………………………………………………………….. 65
Online survey ...... 66
Research Design, Population, and Sample ...... 69 ix
King Saud University (KSU) ...... 69
Instrumentation ...... 71
Procedures……………………………………………………...... 74
Validity of HBM coronavirus scale ...... 74
IRB approval …………………………………...... 75
Data collection ...... 76
Data analysis ...... 76
CHAPTER IV. RESULTS ...... ……………………………. 77
Characteristics of Subjects ...... 78
Instrument Reliability ...... 80
Frequency of HBM’s Five Dimensions ...... 81
Perceived susceptibility ...... 81
Perceived severity ...... 81
Perceived barriers...... 81
Perceived benefits ...... 82
Cues to action ...... 82
Self- efficacy ...... 82
Frequency Distributions of Media Credibility ...... 83
Believability ...... 83
Accuracy ...... 83
Trustworthy ...... 83
Biasness...... 83
Completeness ...... 84 x
Results of Research Questions ...... 84
Results of Research Hypotheses ...... 94
Social Media Analytics ...... 106
Limitations of the Study...... 111
CHAPTER V. DISCUSSION ..…………………………………………………………… 112
Information Seeking Behaviors ...... 113
Credibility of Coronavirus Information ...... 114
The Likelihood of Using Different Communication Channels to
Seek Coronavirus Information ...... 115
Health Belief Model and Adherence to Coronavirus
Preventative Measures ...... 116
The Credibility of Coronavirus Messages among Students
in Health Fields ...... 120
Mediation of Self-Efficacy to HBM and Coronavirus
Preventive Measures ...... 123
Best Practices ...... 123
Conclusions… ...... 126
REFERENCES……………………………………………………………………………… 135
APPENDIX A. FREQUENCY DISTRIBUTIONS FOR THE HEALTH
BELIEF MODEL …………………… ...... ……………………………………… 153
APPENDIX B. FREQUENCY DISTRIBUTIONS FOR THE MEDIA
CREDIBILITY ……………………………………………………… ...... 159
APPENDIX C. TABLES ...... 164 xi
APPENDIX D. HUMAN SUBJECTS REVIEW BOARD
CONSENT FORM ...... 168
Arabic Version of Consent Form...... 170
APPENDIX E. SURVEY INSTRUMENT...... 172
Arabic Version of Survey Instrument ...... 191 xii
LIST OF FIGURES
Figure Page
1 A Daily Report by the Command and Control Center on the MOH’s
Website Shows Coronavirus Status in KSA ...... 14
2 A Poster Distributed by the MOH to Increase Awareness of
Coronavirus Among the public ...... 15
3 A Poster Distributed in Workplaces by the MOH Aiming to
Educate the Public and Minimize Coronavirus Cases ...... 16
4 The First Place Where Saudis Go to Seek Coronavirus Information ...... 86
5 Indirect Effect of Perceived Barriers on Following a Healthy
and Balanced Diet through Perceived Self-Efficacy ...... 102
6 Indirect Effect of Perceived Barriers on Staying Away From
Camels through Perceived Self-Efficacy ...... 103
7 Content Sources ...... 106
8 Tweets by Numbers ...... 107
9 Top Mentions in Twitter ...... 108
10 Coronavirus Posts in Details ...... 109
11 Coronavirus’ Word Cloud...... 110
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LIST OF TABLES
Table Page
1 Empirical Validity, Goodness of Fit, and Reliability for
Meyer’s Credibility Scale ...... 72
2 Champion’s Subscales Mean, Standard Deviation,
and Reliability ...... 74
3 Sample Characteristics of Current Study ...... 79
4 Mean and Standard Deviation of the Health Belief Model...... 80
5 Reliability for the Health Belief Model ...... 80
6 Meyer’s Media Credibility Scale ...... 81
7 The First Place Saudis Go to Seek Coronavirus
Crisis Information ...... 85
8 The Most Credible Sources of Information When Seeking
Coronavirus Information among Saudis ...... 87
9 Sub-Scales Correlations ...... 95
10 Median Scores ...... 96
11 Sub-Scales Correlations ...... 97
12 Self- Efficacy as a Mediator between Perceived Barriers
and Following a Healthy and Balanced Diet ...... 101
13 Self-Efficacy as a Mediator between Perceived Barriers
and Staying Away from Camels ...... 102
14 Frequency Distributions for Perceived Susceptibility ...... 153
15 Frequency Distributions for Perceived Severity ...... 154 xiv
16 Frequency Distributions for Perceived Barriers ...... 155
17 Frequency Distributions for Perceived Benefits ...... 156
18 Frequency Distributions for Cues to Actions...... 157
19 Frequency Distributions for Self- Efficacy ...... 158
20 Frequency Distributions for Believability ...... 159
21 Frequency Distributions for Accuracy ...... 160
22 Frequency Distributions for Trustworthiness ...... 161
23 Frequency Distributions for Biasness ...... 162
24 Frequency Distributions for Completeness ...... 163
25 Comparison between the Credibility of MOH’s Website,
Traditional Media, and Social Media...... 164
26 Likelihood of Using Different Communication Channels
to Seek Coronavirus Information ...... 166
27 Adherence of Coronavirus Preventive Measures
Among Participants ...... 167
1
INTRODUCTION
The Ministry of Health (MOH) in the Kingdom of Saudi Arabia (KSA) was established in 1951 to carry out all health affairs in the kingdom. The MOH is in charge of developing all regulations, laws, and legislation to all governmental and private health sectors in KSA. It monitors and regulates health institutions’ performance and offers health training to all health practitioners. According to the MOH (2015a), there are more than 260 hospitals and more than
1,980 outpatient clinics in KSA. The health of Saudi people is given high priority by the government, and around 6% to 7% of the country’s budget goes annually to the MOH to develop and enhance all health services provided to residents of KSA (MOH, 2017). Many new enterprises, such as building new hospitals and establishing new research centers, have been developed by the MOH to provide high quality of health services for all residents. Residents of
KSA have access to many excellent health facilities and services free of charge. In an effort to educate and increase awareness among people, many health campaigns have been developed by the ministry to educate, increase awareness, and prevent diseases among people in KSA. The
MOH has also utilized many communication channels to engage with the public and communicate with them regarding all health issues, including both traditional and new media.
However, in September of 2012, the KSA witnessed the first case of coronaviruses, or what is known as Middle East Respiratory Syndrome (MERS), that caused significant concern, fears, and outrage among Saudi people since many individuals have died from the virus, which placed substantial pressure on the MOH in how to handle such crisis and stop the spread of the disease.
This created a mega-crisis for KSA who faced a significant threat to the health of its people without knowing why or how to stop the virus from spreading. 2
A mega-crisis is defined as “a set of interacting crises that are severe in impact, complex in nature, and global in fallout, with no seeming end in sight” (Yen & Salmon, 2017, p. 1). The impact of Coronavirus on not only KSA but also the world, define Coronavirus as a mega crisis.
The World Health Organization (WHO) states that other countries, such as South Korea, are on high states of emergencies, with fears that the outbreak could cause severe harm to health, economic and social services of countries where health systems continue to be unprepared
(2016). Furthermore, the MOH warns that hospital outbreaks of Coronavirus in KSA could escalate both nationally and internationally into a perpetual global health threat (2016). The number of deaths, the absence of vaccines to treat it, and the complexity of the disease and how it transmits further constitute Coronavirus as a mega crisis.
Tremendous waves of critiques by Saudis on social media erupted in which many individuals attacked how the MOH was handling the crisis. Some researchers and research centers from different countries around the world also accused the MOH in Reuter’s report
(2014b) of lacking transparency, mismanagement, and poor communication between government departments and hospitals in which it hindered the MOH’s ability to manage the crisis. Another report by Reuters (2014a) stated that KSA could have ceased Coronavirus from spreading within the first two years if it was more open to accept the help offered by scientists from around the world. Those scientists could bring broad experience of scientific studies, particularly in how to eradicate epidemic diseases and implement advanced technology to address the issue in a timely manner (Reuters, 2014a).
However, the deputy health minister, Dr. Ziad Memish, rejected all the allegations made by some researchers. He, in fact, stated that the MOH has taken great scientific efforts with international health organizations to control the virus (Aljazeera, 2014). Dr. Memish was a key 3 player in fighting MERS in KSA and was well known among international health organizations.
Yet, he was accused by many international researchers of making slow progress in regard to implementing health policies to combat Coronavirus, which resulted in sacking him from his position (Aljazeera, 2014).
At the beginning of the crisis the MOH did not reveal clear and updated information about the cases of Coronavirus and did not communicate properly with the public regarding
MERS cases. As a result, Saudi people started to exchange information on social media, particularly Twitter, and to have dialogues about Coronavirus cases as well as acquiring hospitals names that treat these cases in order to avoid being infected with Coronavirus. The lack of transparency as well as the absence of information and key messages at the beginning of
Coronavirus crisis led people to seek information from alternative sources that possibly were unreliable. For instance, during a news conference, the minister Abdullah al Rabeeah told the public he had no idea why MERS was spreading across KSA. He also stated that there is no medical reasons nor clinical measures were needed during pilgrim season despite the fact that
KSA hosts millions of people every year from all around the world for the Muslim pilgrimage
(Alomran, Knickmeyer, & Mckay, 2014). As a result of mishandling and mismanaging the
Coronavirus crisis that led to a death toll of around 80 individuals (BBC, 2014), the health minister was fired from his position and the MOH witnessed a new change of command that resulted in dramatic changes, especially in how the MOH communicates with the public. The
MOH under Dr. Adel- Fagih, the new designated minister, used more inclusive communication strategies to inform the public about Coronavirus cases, including using social media like Twitter and other means. The MOH also established the Command and Control Center (CCC) that monitors all Coronavirus cases across the country and provides significant and updated 4 information regarding Coronavirus crisis (MOH, 2017). Despite the use of many communication channels to reach large audiences and educate them about Coronavirus, the MOH endorses its official website as well as press releases to be the primary sources of information when residents need any information related to Coronavirus in KSA (MOH, 2017).
Therefore, since the MOH in KSA has included different communication channels, like social media, to communicate with the public during the Coronavirus crisis, the impact of utilizing these communication channels during a critical crisis time should be examined.
Specifically, in question is whether the dissemination of health messages via social media, like
Twitter and Facebook for instance, has brought significant cognitive and behavior changes among the public. Through the adaption of the Health Belief Model scale, this study tries to predict and assess the broad picture of Saudis beliefs and behaviors regarding Coronavirus. It intends to measure the level of adherence of Coronavirus preventive measures through focusing on the main factors that trigger Saudis to adhere or not to Coronavirus preventive measures. This study explores whether social media, traditional media, or other sources are most often used by
Saudis to obtain information about Coronavirus during this crisis and measures the believability and credibility of each medium used to deliver health messages. This study further explores the type of medium Saudi people trust the most when seeking health information related to
Coronavirus, and examines how the MOH has managed, embraced, and combated the virus from the beginning with its communication strategies. This examination includes an analysis of the current MOH campaign and impact on preventative behaviors. Consequently, the purpose of this study is to explore whether the MOH in KSA has implemented best public relations practices during a major health crisis or not. Particularly, it tries to shed light on the strategies and actions that have been applied by the MOH to minimize the damage of such a risky crisis as well as to 5 see whether these implemented strategies have increased the effectiveness of the ministry’s efforts to change the public’s awareness, knowledge, attitudes, and behaviors.
Examining how and when individuals, particularly Saudis, seek information about
Coronavirus will help gain a better understanding of how Saudi society acts during a health crisis, henceforth, helping lawmakers in KSA to communicate more effectively with the public during a future health crisis. Accordingly, completion of this study will provide comprehensive health insights of how and when individuals in KSA seek information during a health crisis. It will help healthcare providers and public relations practitioners in KSA to deliver key health messages through proper and effective communication channels. Finally, this study will identify the best public relations practices of how to communicate with Saudis and deliver crucial health messages during a major crisis. Understanding how other nations, like KSA, manages and fights health crises, like Coronavirus, may have some implications for both health and communication researchers and add to the health communication body of knowledge.
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CHAPTER I. REVIEW OF LITERATURE
Coronaviruses Middle East Respiratory Syndrome (MERS) in KSA
The World Health Organization (WHO) defines the Middle East Respiratory Syndrome
(MERS) as a "viral respiratory disease caused by a novel coronavirus" or MERS-CoV (WHO,
2015a, para. 1). Individuals who have Coronavirus typically develop a severe acute respiratory illness with symptoms like fever, cough, shortness of breath, congestion in the nose or throat, or diarrhea (Centers for Disease Control and Prevention (CDC), 2016d; MOH, 2017). The virus was first reported in September 2012 in KSA causing a serious crisis in the country (CDC,
2016a; WHO, 2015a). According to the CDC, however, retrospective investigations indicated that health officials discovered the first case of Coronavirus in Jordan in April 2012 (CDC,
2016a). The virus could have been transmitted to KSA through traveling, migrants, or tourists.
As a result, many people in KSA have died from the virus, which led the MOH, as well as the
CDC and the WHO, to take immediate actions and establish new guidelines to preclude the spread of the virus and reduce the number of deaths (MOH, 2014). As the WHO (2015) states, the virus circulated mainly in countries inside the Arabian Peninsula, like KSA, the United Arab
Emirates, Kuwait, and Qatar as well as some Middle Eastern countries, such as Turkey and
Egypt. Although the majority of individuals with Coronavirus cases are attributed to human-to human infections, camels are believed to play a significant role in transmitting the disease among human beings. However, researchers have not yet determined the exact role and route of the transmission (WHO, 2015b). The majority of individuals infected with Coronavirus have weak immune systems and pre-existing health issues, such as cancer, diabetes, chronic heart, lung, and kidney disease (WHO, 2015a; CDC, 2016d). 7
Furthermore, Coronavirus has spread to many Western countries, including the United
States, Italy, France, Greece, and Germany (WHO, 2015a). For instance, in May 2014, two cases of Coronavirus reported in Indiana and Florida came from two healthcare providers who worked as physicians in KSA. The two workers believed they were infected in KSA, and they were later hospitalized in the U.S and discharged after their recovery, according to health officials (CDC,
2016b). South Korea also witnessed Coronavirus outbreak in many health facilities after an elderly businessman returned to South Korea from his visit in the Middle East. The spread of
MERS in South Korea is considered the largest outbreak outside KSA in which thousands of people have been put into isolation (Aljazeera, 2015; 2015; BBC, 2015a). South Korean’s
Minister of Health and Welfare was criticized for mismanaging the crisis when she did not proclaim the name of hospitals that had patients with Coronavirus. As a result, more than 180 people have been infected by the virus and around 35 of those people have died in South Korea
(Kim, 2015) The president of South Korea fired the Minister of Health from her position after the failure to manage the Coronavirus crisis (Kim, 2015).
Additionally, Coronavirus in South Korea is at a high alert level to monitor all suspicious cases and to manage and combat the virus. As a strategy to prevent Coronavirus from spreading,
Samsung Medical Center was shut down temporarily after being identified as the source of half of Coronavirus cases in South Korea (BBC, 2015a; BBC, 2015b). The president of the Samsung
Medical Center apologized to the public by stating, "We apologise for causing great concern as
Samsung Medical Center became the centre of the spread of Mers" (BBC, 2015b, para. 7).
Visitors and patients were banned access to the hospital as a measure to ensure the safety of people. In addition, nearly 2,000 schools nationwide have been shut down to prevent the spread 8 of Coronavirus following criticism of the government’s lack of transparency and failure to respond properly to MERS cases (Aljazeera, 2015).
In spite that Coronavirus has hit many countries around the world, KSA has the highest
Coronavirus cases among all countries around the world (CDC, 2016a; CDC, 2015a; MOH,
2017). The death toll caused by Coronavirus, which exceeded 80 cases in April 2014 placed the country at a high emergency level in which officials sought immediate and effective solutions to stop the spread of Coronavirus. At the beginning of the crisis, however, there was mismanagement as well as nontransparent communication in which the MOH was not able to manage and take clear actions to overcome the crisis (Reuters, 2014b). Many people lost their hope and trust as the crisis became out of the MOH’s control. The MOH failed to provide sufficient, accurate, and timely information to the public in regard to the number of Coronavirus cases as well as how and what to do during such crisis. Many people, therefore, showed their frustration and anger toward the MOH in social media, particularly Twitter, asking for immediate actions and transparency regarding MERS. For instance, the lack of communication, as well as mismanagement between hospitals, government departments, and laboratories, caused some delay in reporting and recording MERS cases, which intensified the issue, according to some Saudi physicians (Reuters, 2014b). However, after appointing a new minister, Dr. Adel M.
Fakeih, people started to regain hope for changing and improving the policy of how the MOH handles the crisis (Reuters, 2014b). During the first days of his appointment, the new minister stated that the MOH would fight Coronavirus until the country is free from the virus (Al-
Arabiya, 2014).
9
The Ministry of Health’s Efforts to Reduce Coronavirus
The role of public relations practitioners in Coronavirus proved vital when the MOH took significant steps to change and reform its policies by implementing new communication strategies and guidelines to reduce Coronavirus. After changing its communication strategies, the
MOH stated that it "put in place measures to ensure best practices of data gathering, reporting
(and) transparency are strictly observed," and "to ensure that from now on, case information will be accurate, reliable and timely" (Reuters, 2014b, para. 5). The MOH has been in direct contact with the WHO and provides detailed information in every MERS case, so it becomes available to scientists to study and investigate as well as to the public (MOH, 2014). As an effort to gain the public’s trust and regulate the situation, the MOH established a new Command and Control
Center (CCC) in June 2014 that consists of many physicians, scientists, and experts in cooperation with international organizations, such as the WHO and the CDC, to conduct research, control infection, manage clinical operations, and conduct data analysis in regard to
MERS (MOH, 2017; Reuters, 2014b). The CCC aims to monitor developing health issues across the kingdom, to ensure that all these issues are managed with a systemic and comprehensive approach, and to provide up- to- date information to the public (Figure 1). The MOH began implementing public relations strategies and tactics to provide accurate, reliable, and updated information about MERS cases, leading people in KSA to witness drastic changes and improvements in how the MOH manages MERS and communicates with the public. Particularly, the MOH has become more open and prompt with releasing vital information to the public through utilizing multiple communication channels, including social media in different languages. People, therefore, are starting to be more engaged in Coronavirus preventative measures that the MOH recommends, especially on social media. For instance, more than eight 10 million people participated in the MOH’s twitter campaign to distribute preventive Coronavirus measures (MOH, 2017).
These efforts culminated in the launch of an educational public campaign by the MOH called “We Can Stop it” on March 4, 2015. The aim of the campaign is to increase awareness of all residents of KSA about Coronavirus and to inform them about the best ways and practices to prevent the spread of Coronavirus disease (MOH, 2017). The MOH is using radio, television, newspapers, and social media to reach different segments of society members. Delivering health messages through posters, brochures, and interviews with health experts are also taking place in various parts of the country (Figures 2 & 3). The campaign includes dissemination of short videos via social media to deliver preventive and instructional health messages to stop
Coronavirus from spreading, such as using scrutinizers, encouraging individuals to wash their hands with soap for at least 20 seconds, following a healthy diet to boost the immune system, avoiding camels, wearing masks, and demonstrating the appropriate way to sneeze. The MOH disseminates information in two languages, Arabic and English; however, residents who speak other languages can obtain more information through browsing the MOH’s website (MOH,
2017).
Additionally, to increase the engagement and individuals’ involvement in fighting
Coronavirus from spreading, the campaign asks all people to link their Twitter accounts to the health campaign in which the MOH tweets updated Coronavirus health messages once a week on behalf of all participants. The number of people who participated in this activity has reached more than 8,480,718 people (MOH, 2017). To increase the awareness of students about
Coronavirus, the MOH is cooperating with the Ministry of Education to educate students about some preventive measures that can reduce the spread of Coronavirus. The MOH has established 11 school guidelines that educate parents, teachers, and students the proper ways of containing
Coronavirus and how to prevent it. Health experts across the country provide lectures to educate children and teachers about the disease. Many galleries and social events are taking place in schools, shopping malls, and across the country to educate the public regarding the preventive measures and the proper ways of fighting Coronavirus (MOH, 2017).
Likewise, as a way to increase the safety of all individuals in KSA, the MOH has established strict guidelines and standards for all hospitals to follow in order to manage
Coronavirus. The MOH has designated several teams in the region to inspect all private and public hospitals to ensure high quality of health services provided to patients. As a result, a private hospital in Riyadh was shut down in February 2015 for ignoring the MOH’s standards of how to contain Coronavirus. In an effort to combat health and medical issues in KSA, the MOH established a 24-hour hotline (937) to help residents and to receive any complaints (Rasooldeen,
2015; MOH, 2017). The MOH also enacted tough measures for all health facilities and clinics by issuing strict laws. Any health clinic, for instance, that does not report cases of Coronavirus will be shut down and their licenses will be revoked. Fines up to $26,000 will be imposed on any health facility that does not report MERS cases to the MOH (Toumi, 2015). On April 8, 2014,
King Fahad’s emergency department in Jeddah city, for instance, was temporarily closed for one day for disinfection (Ross, 2014). Moreover, the MOH has imposed strict measures on all physicians and health professionals who have been in contact with MERS patients and has banned them from traveling outside the country until two weeks from their last contact with
Coronavirus patients (Sophia, 2015). The MOH also designated certain hospitals in each region to treat patients with Coronavirus as a way to limit the spread of the virus. 12
Despite the huge efforts that have been taken by MOH in KSA to reduce Coronavirus,
Coronavirus is still present in the country with new cases emerging from time to time. In the summer of 2015, particularly from June 1 to September 30, a sharp spike of Coronavirus hit the country with 233 confirmed cases (MOH, 2017). In summer of 2016, KSA witnessed around 52
Coronavirus cases that occurred mainly in Riyadh. It is believed that around 25 cases occurred due to a direct contact with a woman admitted to the emergency room on June 10, 2016 in critical condition to a hospital in Riyadh. The woman showed some signs of inconsistent symptoms of Coronavirus upon her admission to the emergency room. Following her admission, the woman started to show signs of Coronavirus symptoms and the case was diagnosed and confirmed as MERS on June 12, 2016, within 48 hours of the initial admission. A rapid response team was immediately dispatched by the MOH to the hospital to conduct active screening and contact tracing to detect patients, health care workers, visitors, household contacts, or anyone who may have been contacted directly or indirectly with the woman. The MOH also implemented other public health measures to contain the virus and prevent it from spreading
(WHO, 2016a). After conducting contact tracing, the MOH reported 24 new confirmed MERS cases on June 22, 2016, in which 20 cases were health workers and 4 were household contacts and patients. According to the MOH, 20 people out of the 24 did not show any Coronavirus symptoms but tested positive for MERS. The woman died on June 22, 2016 (WHO, 2016a). As of August 09, 2017, the number of Coronavirus cases in KSA has reached 1,668 in which 686 people died, 995 people recovered, and 13 people remain under treatment (MOH, 2017). Despite vigorous efforts that have been taken by the MOH in KSA to reduce Coronavirus, it is still present in the country with new cases emerging from time to time which makes it an ongoing crisis. The MOH’s website and press releases remain the main communication channels for the 13 public to know and obtain updated information about Coronavirus (MOH, 2017). Consequently, understanding the role of public relations in delivering health messages, managing crises, designing proper public campaigns, and increasing the effectiveness of an organization is essential to gain a better understanding of the managerial and communicative roles that have been taken to overcome the Coronavirus crisis.
Coronavirus preventive measures. The MOH in cooperation with the WHO has called individuals in KSA to follow simple yet essential steps to combat Coronavirus in the kingdom.
These recommendations are:
1. Washing hands frequently with soap and water.
2. Avoiding close contact with sick people, if necessary wearing a mask.
3. Avoiding touching eyes and nose as possible.
4. Using a tissue when coughing or sneezing.
5. Maintaining a good hygiene.
6. Maintaining healthy habits, such as exercising, eating a healthy diet, and getting
enough sleep.
7. Avoiding close contact with camels.
These and other important preventive measures have been disseminated as part of the MOH’s public health campaign to raise awareness and eradicate Coronavirus across KSA.
14
Figure 1. A daily report by the Command and Control Center on the MOH’s website shows
Coronavirus status in KSA. From “Command and Control Center: Statistics”, by the Ministry of
Health, 2017. Retrieved January 01 2018, from https://www.moh.gov.sa/en/CCC/PressReleases/Pages/statistics-2018-01-01-001.aspx.
Copyright 2014 by Ministry of Health in Saudi Arabia. 15
Figure 2. A poster distributed by the MOH to increase awareness of Coronavirus among the public. From “Awareness Publications- Coronavirus (MERS-COV)”, by the Ministry of Health,
2017. Retrieved January 01 2018, from https://www.moh.gov.sa/en/CCC/PublicationsAwareness/Corona/Pages/Infographis.aspx.
Copyright 2014 by Ministry of Health in Saudi Arabia. 16
Figure 3. A poster distributed in workplaces by the MOH aiming to educate the public and minimize
Coronavirus cases. From “Awareness Publications- Coronavirus (MERS-COV)”, by the Ministry of
Health, 2017. Retrieved January 01 2018, from https://www.moh.gov.sa/en/CCC/PublicationsAwareness/Corona/Pages/Infographis.aspx. Copyright
2014 by Ministry of Health in Saudi Arabia. 17
Public Relations Practitioners & Public Campaigns
Scholarly research has addressed the types of activities that public relations practitioners perform, which are considered the basic components of the public relations profession.
According to Wilcox & Cameron (2009) and Swann (2010), these are:
1. Conduct research to determine behaviors and attitudes of the public to plan for a public
relations strategy.
2. Provide consultation to an organization’s management regarding policies,
communication, and relationships.
3. Build relationships with mass media to expand an organization’s interests.
4. Gain publicity in which public relations practitioners seek more publicity for their
organizations through disseminating accurate and interesting information.
5. Build relationships with employees by answering their concerns and facilitating internal
communication.
6. Provide community relations where public relations practitioners are responsible to plan
and maintain some social activities with the community in order to serve public interests.
7. Incorporate public affairs in which public relations practitioners help organizations to be
involved in public policy to adapt to public expectations.
8. Work in government affairs in which public relations practitioners deal with legislatures
as a part of their activities.
9. Incorporate issues management in which public relations practitioners, through scanning
the environment, identify issues and public concern that might affect the organization.
10. Build financial relations in which public relations practitioners try to build good
relationships with the financial community to attract investors. 18
11. Establish strong relationships with other firms in the industry and trade association.
12. Fundraise and gain public support.
13. Reinforce diversity inside organizations and promote social activities to sell ideas and
products (Wilcox & Cameron, 2009; Swann, 2010).
Furthermore, public relations practitioners also play significant roles in designing public campaigns. Conducting research, establishing goals and objectives, defining audience segmentation, formulating key messages, building proper strategies and actions, planning programs, implementing strategic plans, and evaluating campaigns are some of the responsibilities that fall on public relations practitioners’ shoulders (Wilcox & Cameron, 2009;
Smith, 2009; Beard, 2001). Public relations practitioners have been involved throughout history in designing many successful public campaigns in the political, social, health, and educational fields. During 1913 and 1914, Ivy Lee, the first public relations counsel who worked in management level and considered one of the founding fathers of public relations, was recruited by Pennsylvania Railroad to design a public campaign about raising freight rates. There were huge oppositions toward the company’s plan from the public as well as the Interstate Commerce
Commission (ICC) since the Pennsylvania Railroad needed a 5% raise in tickets prices to remain in the business. Lee believed in the importance of disseminating truthful and accurate information to persuade the public and ICC and make them aware of the situation. Thus, the central message of the campaign was that the railroads provided essential services to the whole nation, but the government did not allow them to charge reasonable and fair rates. Although most large corporations did not even talk with the media regarding their policies during that era, Lee was able to convince the railroads company to release accurate information and engage the public in the issue by releasing truthful information to the press, congressmen, legislators, and 19 the ICC. Lee was also able to distribute the railroad’s testimony after each ICC hearing to the press, railroad employees, congressmen, college presidents, and other opinion leaders to persuade them and make them aware of the issue. Astonishingly, the public opposition declined, and chambers of commerce around all the United States showed their support to the railroad company. Consequently, ICC accepted the proposal and approved the raise of 5% of railroad freight rate (Wilcox & Cameron, 2009).
Edward Bernays, considered the father of modern public relations, also designed and conducted many remarkable public campaigns that aimed to change public opinions and behaviors about various issues. In 1920 for instance, Bernays was approached by bacon industries who were facing a huge decline in meat sales, especially bacon. They contacted
Bernays to help increase bacon sales across the nation. Bernays came up with the idea of contacting doctors across the U.S and asked them if a hearty breakfast is beneficial or not without even mentioning bacon. A survey was disseminated to doctors that asked them one single question, "Do you support a hearty breakfast?" As a result, many doctors endorsed the idea of traditional breakfast of bacon and eggs. An educational campaign was launched to persuade all Americans to eat a healthy breakfast, including bacon and eggs. Until today, many
Americans still have bacon and eggs for breakfast (Wilcox & Cameron, 2009; Spiegel, 2005).
Therefore, designing a public campaign that aims to change the public’s behaviors and influence their opinions requires using proper tools, such as research, to understand the public and persuade them with effective and persuasive messages.
20
Phases of campaign development. Scholars suggest that there are four phases when planning to design a public campaign; each phase has steps that must be taken to help impending effective communication (Wilson & Ogden, 2008; Smith, 2009). The first phase is called formative research, which has three steps. The first step toward launching a campaign or a program is to analyze the situation. Analyzing the situation is crucial to understand what must be done, what the challenges and opportunities are, and what the importance is of that situation to an organization. The second step is analyzing the organization internally and externally by following the traditional method SWOT (strengths, weaknesses, opportunities, threats). By doing so, an organization would have vital information to understand the whole situation to guide them in taking proper actions. The third step is analyzing the public and collecting background information about the audience by using statistical database and surveys. Analyzing the public is essential to understand the main characteristics of the target audience, including their behaviors and attitudes. Understanding the characteristics of each audience will help to create appropriate forms of communication, messages, and goals. It will help also to choose opinion leaders who can play significant roles in persuading certain groups of people about certain messages during any campaign and program. Thus, understanding the public interests and needs will facilitate how key messages are formed during any campaign.
The second phase of launching a campaign is called strategy. This phase also includes three steps. The first step is to establish the goals of the campaign and how to achieve it. The second step is to establish the objectives of the campaign. The objectives should be specific and measurable, such as increasing awareness of breast cancer by 40% among American women.
Having accurate goals and objectives will help to measure both the inputs and outcomes of the campaign. The third step is creating action and response strategies. Creating action includes 21 organizing special events that trigger the key public to take actions, such as an open house.
Likewise, getting sponsorships can increase any campaign’s visibility among publics. For instance, an organization that aims to launch a health campaign to increase women’s awareness about breast cancer would be better sponsored by the American Breast Cancer Foundation to increase its visibility as well as its effectiveness among the public. Creating action also includes communication processes, such as increasing the campaign’s publicity in the news and media outlets, releasing transparent communication to the public, and using third- party endorsement
(e.g. Michelle Obama advocating a nutrition campaign) to increase the credibility of the campaign. The second step of formulating action is to develop a message strategy. This step mainly focuses on the information flow, persuasive messages, and how to engage the public.
Hence, establishing effective messages that can persuade a target audience to engage in the campaign and to take action is an essential part of any campaign. The credibility of the messages’ sources, such as spokespeople and their experience, are some of the important factors that should be considered when delivering key messages.
The third phase of launching a campaign is called tactics. Tactics are "the visible elements of a strategic plan" (Smith, 2009, p. 185). These include what people see and read about the campaign in the media, website, social media, blogs, social events, etc. Therefore, it is important to utilize appropriate ways of communication (e.g. interpersonal communication, mass media, and advertising) to reach the target audience as well as to exchange information. The third step is implementing the strategic plan or the campaign plan. Smith (2009) defines a campaign plan as "[T]he formal written presentation of your research findings and program recommendations for strategy, tactics, and evaluation" (p.255). The campaign plan should be written in a concise and professional way that includes a title page, executive summary, table of 22 contents (e.g. major segments of the campaign), philosophy statement, situation analysis, recommendations, budget and timeline, and evaluation plan. The fourth phase of designing a public campaign is to conduct evaluative research about the campaign. It is important to use appropriate methods and criteria to evaluate the success of any campaign. Criteria, like evaluation of awareness objectives (e.g. media impression), evaluation of acceptance objectives
(e.g. post-campaign opinion survey), or evaluation of action objectives (e.g. ticket sales, attendance, or donation), can help to measure the success of any campaign. It is also noteworthy to address and assess any unplanned outcomes that resulted from the campaign, either positive or negative, in order to gain a better understanding of people’s reaction for future campaigns.
Formative evaluation should be taken place before a campaign starts (e.g. addressing some defects that might affect the plan, pretesting feedback prior disseminating messages by using focus groups), during the campaign (e.g. making some modifications), and after the campaign
(e.g. how well the tactics are being achieved) (Wilson & Ogden, 2008; Smith, 2009).
Public Relations & Health Campaigns
Public relations practitioners working in health organizations and medical sectors have played significant roles in designing and conducting public health campaigns to raise awareness, promote healthy behaviors, and prevent unhealthy practices (Riggulsford, 2013). Strategic public relations is an indispensable pillar for profit and non-profit health organizations, for large health organizations like the CDC and the WHO, and for small and local health community departments (Springston & Weaver Lariscy, 2003; Springston & Weaver Lariscy, 2005). As a result, the role of public relations in health organizations has been rapidly increasing since public relations provides significant values to both health organizations and its publics. The growing demands for both health news and information has placed public relations in many large public 23 health organizations (Springston & Weaver Lariscy, 2005). As Springston & Weaver Lariscy
(2005) said about the role of public relations in health organizations:
Not surprisingly, as public relations becomes widely practiced in public health
agencies where it has been previously absent or under-utilized, it is hugely
popular when it produces highly desirable outcomes: public relations is
enthusiastically embraced when it generates impressive news coverage for a flood
evacuation plan; when it contributes to raising millions of dollar for a disease-
advocacy support group; and when it stabilizes the image of a government health
agency under media siege. (p.220)
For that reason, designing public health campaigns to promote healthy behaviors and prevent unhealthy practices is one of the basic roles that public relations practitioners can do in health organizations. Public health campaigns have shown a significant impact on changing individuals’ health behaviors in many important areas, such as condom use, smoking, cholesterol consumption, and blood pressure control (Hornik, 2002). Throughout history, many health campaigns and education programs have successfully made changes of individuals’ behaviors, such as the Swiss and Dutch AIDS program and the Philippines national immunization program
(Hornik, 2002). Although some studies have shown that public health campaigns have minimal or no effects on changing health behaviors (Winkleby, Taylor, Jatulis, & Fortmann, 1996;
Magura, 2012), there is enough evidence to suggest that positive changes in health behaviors are associated with health campaigns and programs (Hornik, 2002).
A health campaign aims to enhance public health, promote healthy practices, or prevent unhealthy behaviors (Salmon & Atkin, 2003). According to Berthold, Skinner, & Turner (2016), the WHO defined public health as: 24
[A]ll organized measures (whether public or private) to prevent disease, promote
health, and prolong life among the population as a whole. Its activities aim to
provide conditions in which people can be healthy and focus on entire
populations, not on individual patients or diseases. Thus, public health is
concerned with the total system and not only the eradication of a particular
disease. (p. 65)
Public health is also defined by the CDC Foundation (2015) as "the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases" (para.
1).
Rogers & Storey (1987) stated that a campaign aims to "generate specific outcomes or effects 2) in a relatively large number of individuals 3) usually within a specified period of time, and 4) through an organized set of communication activities" (p.821). Rice & Atkin (1989) adapted and expanded Rogers & Storey’s (1987) definition by defining a public communication campaign as:
(1) Purposive attempts (2) to inform, persuade, or motivate behavior changes (3)
in a relatively well-defined and large audience, (4) generally for noncommercial
benefits to the individuals and/or society at large, (5) typically within a given time
period, (6) by means or organized communication activities involving mass
media, and (7) often complemented by interpersonal support. (p. 7)
Health campaigns, accordingly, aim to raise awareness and promote healthy behaviors through an organized set of communication activities among a target population (CDC, 2016b).
Designing a public campaign, including a public health campaign, involves following the four 25 phases mentioned above (formative research, strategy, communication, and evaluation) (Smith,
2009; Wilson & Ogden, 2008; Salmon & Atkin, 2003). Nonetheless, campaigns differ in the amount of information disseminated, time and duration, type of media used (e.g., radio, TV, social media etc.), type of communication channels (e.g., interpersonal or organizational communication), employment of approaches to make social changes (e.g., education), and the level of analysis (e.g., focusing on community level) (Salmon & Atkin, 2003; CDC, 2015b).
Planning for health campaigns, henceforth, requires comprehensive understanding and careful planning for the type of message (e.g., persuasive, instructional, or awareness messages), exposure and attention given to the campaign, number of messages (e.g., how many messages attack the unhealthy behavior, how many messages promote the healthy behavior), intended audiences (e.g., youth), intended responses (e.g., change behaviors), and communication channels to make changes for individuals’ behaviors (Salmon & Atkin, 2003; CDC, 2015b).
Additionally, audience segmentation is an important factor in any campaign, including health campaigns in which the population is divided into subgroups (e.g., age, ethnicity, social class, religion, state of change, self-efficacy etc.). Subdividing the audience helps to increase the message efficiency in which planners can target the intended population (O`Sullivan, Yonkler,
Morgan & Merrit, 2003; Atkin, 2001). It also helps to form proper messages that are tailored to the target audience’s abilities and skills (Atkin & Freimuth, 2001; Slater, 1996). According to
Salmon & Atkin (2003), during a health campaign there are three ways to approach the target audience. The first is through directly targeting the main audience or the target population whose behavior is to be changed. The second is through targeting opinion leaders or influential people who in turn can influence the target population. The third is through altering environment by reaching the lawmakers that shape the public opinion and influence their health decisions. 26
Through triggering and reinforcing messages, health campaigns aim to make a strong impact on individuals who are ready to take action (e.g., adoption of eating vegetables by individuals inclined to eat a nutritional diet) or individuals who are at risk of adopting unhealthy behaviors (e.g., preventive antismoking campaign for teenagers) (Salmon & Atkin, 2001). There are two main approaches that are commonly used in the health field when designing and conducting a health campaign. The first approach is to promote healthy practices and encourage individuals to follow these practices (e.g., encouraging people to engage in physical activity for
30 minutes per day), and the second approach is to reduce or prevent unhealthy behaviors (e.g., don’t smoke). While the preventive approach usually relies on the negative consequences and harmful effects of the unhealthy behavior, promoting healthy practices relies mainly on promoting positive aspects of a certain behavior. In addition, health messages about smoking cigarettes and alcohol use disseminated in health campaigns, for instance, are usually demonstrated in health threatening ways (Salmon & Atkin, 2003; Kline, 2003).
Choosing proper channels to disseminate and promote health information is also crucial during a health campaign. Campaigners can utilize many communication channels to deliver health messages, such as television, radio, newspapers, blogs, social media, or interpersonal communication. Yet, it is important to take into consideration both the nature of the message as well as the audience’s characteristics before selecting the medium. Although using traditional media is considered an effective way of communication, utilizing a variety of channels or multichannel approach might lead to better and more effective results (O`Sullivan et al., 2003;
2003; Salmon & Atkin, 2003). According to O`Sullivan et al. (2003), using multiple channels approach helps health campaigners to reach their objectives more quickly, reach larger audiences with more frequency, and increase the exposure of the campaign among the public. When using 27 the multiple channels approach to disseminate key messages, it is imperative to select a lead channel that reaches a vast majority of audience and supporting channels that reinforce the campaign’s messages (O`Sullivan et al., 2003). Public relations techniques, therefore, are indispensable to use during any health campaign to raise the publicity and visibility of the campaign, to achieve greater media acceptance, and to increase the credibility of the distributed messages (Weaver Lariscy, 2005; Salmon & Atkin, 2003). Salmon & Atkin (2003), however, believed that health campaigners usually underestimate the power of public relations. They stated, "Health campaigners have traditionally underutilized public relations techniques for generating public relations news and features story coverage in the mass media" (p.463). In fact, public relations messages can make a greater impact on influential audiences than prepackaged stimuli that are usually used by health campaigners (Salmon & Atkin, 2003).
From all around the world, health campaigns are organized to educate individuals about healthy behaviors and to promote preventive measures to stop diseases and infections.
Throughout history, many organizations, like the WHO and United Nations (UNAIDS campaign), for instance, launched many health campaigns and programs to end the AIDs virus
(HIV) in sub-Saharan Africa. Because more than 70% of global HIV infections are located in
Sub-Saharan Africa (WHO, 2016c), numerous efforts have been taken, such as preventative measures and promotion of healthy behaviors among Africans to fight HIV infection. Raising awareness of preventive measures and encouraging individuals to follow healthy sexual behaviors, like using condoms for males and females, is one of the strategies to fight HIV in
Africa. The UNADIS campaign, for example, utilized large electronic screens in stadiums during the Orange Africa Cup of Nations, Africa’s most prestigious soccer event, to disseminate preventive health messages about HIV. South Africa, in cooperation with UN, also launched a 28 massive campaign in 2010 to fight the HIV infection and to increase individuals’ awareness of
AIDS. The campaign aimed to test around 15 million people for HIV. Upon taking the HIV test, each individual received 100 condoms, HIV counseling, and some informational materials about
HIV and safer sex practices. The campaign also included a decrease in AIDs treatment
(antiretroviral treatment) prices by 30% to encourage all individuals to take the test and fight the infection (UNAIDS, 2015).
Crisis Communication
Crisis communication scholars provide a variety of important definitions of a crisis.
Coombs (2014a) defined a crisis as "a significant threat to operations or reputations that can have negative consequences if not handled properly" (para.3). Pearson and Mitroff (1993) defined an organizational crisis as "an incident or event that poses a threat to the organization's reputation and viability" (p.49). A crisis is also described by Fearn-Banks (2007) as "a major occurrence with a potential negative outcome affecting the organization, company, or industry, as well as its publics, products, services, or good name" (p. 8). As Fearn- Banks (2007) indicated, a crisis could hit large corporations, small businesses, cities, countries and even individuals. A crisis could occur at any time and in many different forms, like a fire, terrorist attack, boycott, product failures, or other events that might damage the image of an organization or interrupt the businesses’ functions (Fearn-Banks, 2007). According to Fink (2000), a crisis is a turning point that poses some degree of risk and uncertainty. A crisis may escalate the intensity of business operations, attract media or government scrutiny, jeopardize the public image, or damage a company’s bottom line (Fink, 2000). Therefore, three evident threats can be created by a crisis, which are: “(1) public safety, (2) financial loss, and (3) reputation loss” (Coombs, 2014a, para.
3). 29
Crisis management, on the other hand, is defined by Fearn Banks as "a process of strategic planning for a crisis or negative turning point, a process that removes some of the risk and uncertainty from the negative occurrence and thereby allows the organization to be in greater control of its own destiny" (p. 9). Coombs (2014a) defines crisis management as a "process designed to prevent or lessen the damage a crisis can inflict on an organization and its stakeholders" (para. 5). Coombs (2014b) also suggests that an organization’s crisis is divided into two types, operational and reputational. Operational crises, such as fires, explosions, workplace violence, accidents, product harm, etc., can cause interruption to organizational operations. Reputational crises, such as irresponsible behaviors by an organization’s management, can harm the organization’s reputation. While operational crises can have some serious threat to public safety, reputational crises usually are less likely to create a public safety threat (Coombs, 2014b). However, during a time of crisis, it is imperative to address public safety first; otherwise, a crisis is more likely to intensify. After remedy of public safety, organizations are encouraged to consider managing financial and reputation loss (Coombs,
2014a). There are three phases of crisis management, which are pre-crisis, crisis response, and post-crisis. Prevention and preparation are conducted in the pre-crisis phase. Prevention aims to reduce any potential risk that could hit an organization, such as looking for warning signs or rumors on social media. On the other hand, preparation includes creating a crisis management plan (CMP), choosing the crisis management team, providing training to the crisis management team, conducting regular drills and exercises to test both the plan and the team, and crafting crisis messages (Coombs, 2014a). The second phase is called a crisis response. A crisis response is defined as "[W]hat the top management does and says after the crisis strikes" (Coombs, 2007, para.13). Crisis response is divided into two types: 1- initial response, and 2- reputation repair 30 and behavioral intentions (Coombs, 2014a). An organization must provide quick, accurate, and consistent information and messages about the incident during the initial response to a crisis, especially when the crisis is related to public safety issue (Coombs, 2014a). However, during the post-crisis phase, an organization must fulfill its promises to both the media and the public
(Coombs, 2006; Coombs, 2007). One of the best practices suggested by most scholars in the crisis communication field is to work with the media as a partner to overcome any type of crisis
(Reynolds, 2002; Seeger, 2006). Working with the media during a crisis offers many benefits to an organization, including building a mutual relationship and lessening the damage of the crisis
(Veil & Ojeda, 2010; Seeger, 2006).
In most crisis situations, the public wants to understand and obtain some information in order to take some actions, like precocious actions regarding the crisis. Hence, it is essential to provide the public with truthful and accurate information during a crisis in order to reduce peoples’ frustrations and concerns (David, 2011; Fearn-Banks, 2007; Coombs, 2014b). Scholars recommend organizations to follow some important strategies to better manage a crisis. As
Coombs (2006) stated after analyzing the crisis communication and management literature, three lessons are evident: be open, be quick, and be consistent. "Being quick" was the most recited lesson of crisis communication (p. 172). Coombs (2006) found that most crisis experts emphasized the significance of releasing information to the public within the first hour of a crisis. Releasing information within the first hour allows both stakeholders and the media to know what type of information an organization has about a crisis. As Flynn (2009) stated, it is not only about the first 24 hours that an organization should worry about; instead, in some cases, it is about the first 24 minutes and even the first 24 seconds. A crisis creates a demand for information, where journalists, the media, and the public need to know exactly what happened. A 31 delay in getting information out to the public might lead to confusion among both the media and the public. Therefore, it is vital to provide a quick response to any type of crisis. A quick response is crucial because it tries to fill the vacuum with facts. Otherwise, others will fill the vacuum with inaccurate information and speculations (Coombs, 2007). Even though an organization has no new information about the crisis, it must position itself as a main source of information and tells its side of the story (Coombs, 2014a).
The existence of the Internet as well as the emergence of social media make it much easier for organizations to communicate with large numbers of people within a short period of time. A longitudinal study of public relations practitioners conducted by Wright & Hinson
(2008) found that social media has changed and enhanced the practice of public relations, particularly when communicating with external audiences. Social media helps organizations to effectively respond to criticism quickly and in a timely manner. The study also suggests that social media is perceived to be complementary to traditional media (Wright & Hinson, 2008).
In some situations, however, Coombs (2014b) suggests that an organization should use social media before traditional media to release information about the crisis. Before the emergence of social media, organizations relied on newspapers, radio, and TV to release information to the public during a crisis. Social media, like Twitter and Facebook, has empowered many organizations to respond properly to a crisis, reach a large number of people within a short period of time, and engage the public in a mutual dialogue (Veil & Ojeda, 2010;
David, 2011, Coombs, 2011; Goldfine, 2011; Lerbinger, 2011; Baron, & Philbin, 2009; Coombs,
2014b; Fearn-Banks, 2007; Coombs, 2007).
32
Crisis Communication and Social Media
The use of social media during a time of crisis can provide rapid and clear communication, which increases the quality of decisions that are made by organizations to respond to a crisis (Coombs, 2011). Social media also provides an interactive space in which all parties, such as victims, lawmakers, and the general public, can participate and interact during a crisis (Palen, 2008). It also allows an organization to control the type of information provided to the public and choose the appropriate time to release it (Driedger, 2008).
A study by Austin, Liu, & Jin (2012) found that people use social media for four main reasons -- entertainment, education, relationship maintenance, and networking. The study indicated that utilizing social media during a crisis not only offers some advantages to an organization, but also offers huge benefits for people. The study suggested that people who use social media during a crisis to check insider information get information about a crisis more quickly than traditional media does. Austin, Liu, & Jin (2012) suggested that people use social media during a crisis to check up on family and friends since the information provided by social media is free to access and download. Sometimes a crisis, like an earthquake, could happen in another country, so people use social media to communicate with their family and friends to make sure they are safe. The main reason why people use social media to obtain some information about a certain crisis is that it is easy and convenient (Austin et al., 2012). Many organizations, as a result, have joined social media to interact with the public and provide them with accurate and truthful information. However, organizations must be prepared in advance to implement a strategic and comprehensive plan before, during, and after a crisis through multiple communication channels, including social media (Fern-Banks, 2007; Veil & Ojeda, 2010; David,
2011). Additionally, with the emergence of social media, scholars suggested that organizations 33 should regularly monitor social media relevant to their industry and look for any signs that might turn into a crisis, such as monitoring YouTube or blogs, to detect any warning signs of a crisis that might hit their organizations (Coombs, 2011). Many people use YouTube videos as well as blogs to express their opinions or frustrations about a service or product, so it is crucial to catch these signs and respond to them before they go viral and cause financial or reputational damages.
A study by Ruggiero & Vos (2014) analyzed current knowledge on social media and crisis communication between 2009-2012 to understand the most recommended methods suggested by crisis communication scholars in regard to utilizing social media during a time of crisis. The study revealed that monitoring and scanning social media environments during a time of crisis is considered one of the most important steps in managing a crisis. In fact, most public relations practitioners and crisis communication scholars recommend monitoring citizens’ interactions before, during, and after a crisis. Information exchanged on social media can build or destroy an organization’s reputation (Lerbinger, 2011); thus, it is important to pay attention and monitor these platforms and respond properly, especially during a crisis.
Scholars suggest using a content analysis method during the environmental scanning process, particularly textual analysis for social media platforms that is relevant to an organization’s industry. Scanning the environment will help organizations to get a better understanding of people’s perceptions and opinions, which in turn can help organizations be more equipped to identify any sign of a crisis (Ruggiero & Vos, 2014; Veil, et al., 2011). Using computer software that is capable of tracking a large number of data, as well as using experts who have some skills in dealing with collecting and analyzing the data, will also help organizations to better understand the public, especially in the time of crisis (Ruggiero & Vos,
2014). Thus, an organization must participate in social media sites, like Twitter and Facebook, 34 and try to engage with the public to gain a better understanding of their needs and demands
(Coombs, 2011; Ruggiero & Vos, 2014 Lerbinger, 2011).
Other studies suggest that incorporating social media during a crisis offers many advantages to organizations. A study of 251 who members of the Public Relations Society of
America (PRSA) found that 82% of public relations practitioners utilize social media on a daily basis (Wigley & Zhang, 2011). However, only around 48% of public relations practitioners have incorporated social media into their crisis plans. The study also suggested that public relations practitioners have used Twitter as a primary tool to release information during a time of crisis.
The study concluded that public relations practitioners whose organizations use social media in their crisis planning are more likely to have more confidence in their organization’s ability to handle a crisis (Wigley & Zhang, 2011).
The use of social media, like using a hashtag on Twitter during a crisis, helps an organization to be more engaged with the public and interact with them during a crisis (Deveney,
2011). Yet, it is more important to be transparent with the public to reach effective results from using social media. As Flynn (2009) illustrated, "To be effective with social media, you must be entirely transparent----putting yourself and your company in the public eye in a direct, authentic way" (p.13). Thus, incorporating social media in a transparent way during a time of crisis is essential to engage the audience. An organization could use social media to open a dialogue with the public and educate them regarding the risks of the crisis. Organizations could also use social media during a crisis to post video, audio, and images because most people prefer interactive media as a source of information. Utilization of an organization’s website and blogs is also crucial to be used during a crisis to communicate with the public and to send effective messages
(Coombs, 2011). 35
Twitter and other social media platforms have been widely used during many major crises and incidents to communicate with the media and the public. For instance, during the
Boston Marathon bombing incident that killed three people and injured 282 others in 2013, the
Boston Police Department (BPD) incorporated Twitter as a primary communication channel to communicate with both mass media and the public in order to disseminate updated information related to the suspects and the incident (Swann, 2013). Twitter was used to announce the first response of BPD to the incident, and around 90 tweets were distributed within the first hour after the incident (Swann, 2013). The public also turned to the BPD’s twitter account to get accurate information regarding the incident as the most updated and reliable media source to communicate with Boston residents, according to the bureau chief of public information for the
BDP, Cherly Fiandaca (Swann, 2013). During the five days of searching for the suspects, the
BPD tweeted 148 tweets that engaged the public and resulted in capturing the suspect (Swann,
2013). Five days after the incident, the BPD’s twitter account followers jumped from 54, 000 followers to more than 49 million followers, thanks to the efficient and accurate information that
BPD provided via Twitter during the crisis, Fiandaca stated (Swann, 2013). Although traditional media tried to compete with the BPD’s twitter account during the crisis by providing some exciting and yet misinforming news, BPD won the competition by providing the most reliable and up-to-date information (Swann, 2013). Moreover, twitter provided a safe environment for the BPD officers to distribute any information without jeopardizing their lives. For instance, during search operations, BPD tweeted alert massages to the media to refrain from localizing the search areas to ensure the safety of the police officers. BPD also tried to maintain the calmness and serenity of Bostonians by providing them with significant and accurate information to refute any rumors distributed by other websites. Cheryl Fiandaca, bureau chief of public information 36 for the BDP, stated, "Twitter proved to be the quickest and most reliable way to communicate with Boston residents, marathon runners, friends and family members, the news media, BPD employees and other law enforcement agencies" (Swann, 2013. para. 5).
Twitter also was utilized in 2007 and 2008 during California wildfires to release initial information and updates to the public (Veil, Buehner, & Palenchar, 2011; Briones, Kuch, Liu, &
Jin, 2011), during the US Airways flight 1549 crash in 2009, the Haiti earthquake in 2010, and other incidents (Veil et al., 2011).
Using Social Media in Health Organizations
The use of social media by health organizations to communicate with the public, especially during crises, becomes necessary and indispensable to reach larger populations who utilize social media on a daily basis. According to the Pew Research Center report, 72% of
Internet users in the United States use the Internet to seek health information (Fox & Duggan,
2013). The same report indicated that 77% of individuals who seek health information on the
Internet indicated that they use Internet search engines first, like Google, Bing, and Yahoo, when they looked for health topics (Fox & Duggan, 2013). In fact, using search engines, emails, and looking for health information online, are the most common online activities across different generations (Zickhur, 2010). Social media has also been significantly used to obtain and share health information (Zickhur, 2010). While individuals can only use search engines to search for health information, social media, particularly Twitter, is found to allow individuals to search and share health information (Choudhury, Morris, & White, 2014).
A study by Fox (2011) found that around 15% of the Internet users utilize social media to seek and obtain health information, 23% of social media users follow their friends’ personal health experiences, and 17% have used social media to commemorate people with specific health 37 conditions. Consequently, many researchers recommend health organizations to adopt and develop effective communication methods to communicate with their patients, including the use of social media to deliver information, build relationships, and to be more oriented to patients
(Gravili, 2013). As Gravili (2013) states, the use of social media in health organizations has many benefits, including enhancing and organization’s reputation and improving the prevention of diseases. In social media, the flow of information between doctors and patients or patients and patients can be very helpful in preventing many diseases. The interaction between doctors and patients or patients and patients on social media enable patients to have both social and emotional support, which are considered important factors for curing many diseases (Gravili,
2013).
According to Pan American Health Organization (2009), communication is used prior to health crises to educate, inform, and prevent diseases from spreading. During health crises, communication focuses on containment activities, public safety, and dissemination of health messages and recommendations via mass media and other channels to the public as well as to prepare health practitioners to act during a crisis. According Lindsay (2011), an analyst in
American National Government, organizations have been using social media enormously during disasters and emergencies situations in two main ways. The first approach is using social media passively. That means organizations send and receive information from audiences, make wall posts, and polls. This type of social media use is followed by most emergency management organizations, such as the Federal Emergency Management Agency (FEMA). The second approach is utilizing social media systemically. That means organizations utilize social media to issue emergency communication, send warnings, look for victims’ help requests and provide 38 assistance, and post information and images to establish awareness and damage estimate
(Lindsay, 2011).
Many international health organizations have utilized social media during crises, like the
WHO, the International Federation of Red Cross and Red Crescent Societies (IFRC), and the
CDC to disseminate health information and communicate with local and external stakeholders
(Harris, Mueller, & Snider, 2013; IFRC, 2015). The WHO adopted Twitter in April 2008 and
Facebook in 2009 to disseminate health messages during health crises; the CDC adopted Twitter in October 2009 and Facebook in April 2009; and the IFRC joined Twitter in August 2008 and
Facebook in September 2008. Health organizations mostly use social media to communicate, inform, educate, and create awareness about various health issues. Many local health departments in the United States (LHDs) also emphasize the importance of educating and informing individuals about health issues through utilizing social media, such as Twitter and
Facebook (Harris et al., 2013). The Public Health Accreditation Board, in fact, has included communication with residents about health issues as a requirement for health organizations to gain accreditation (Harris et al., 2013). Both the CDC and the WHO have utilized social media platforms, such as Twitter and Facebook, during a critical and pandemic time (Biswas, 2013).
During the H1N1 flu that occurred in Mexico and the United States in April 2009, more than 470 people died, many of them children, as a result of the H1N1 infection (Walton, Seitz, &
Ragsdale, 2012). This generated an effort to design a strategic response plan by the CDC to overcome the crisis. The CDC implemented a new social media strategic communication plan as a complement to traditional media strategies. Different social media platforms, including podcasts, YouTube, Twitter, and Facebook, were utilized during the crisis. The CDC used
YouTube in response to the H1N1 crisis with a video that generated more than two million 39 views. Integrating both traditional media and social media allowed the CDC to reach a diverse audience in different geographic areas across multiple platforms. The CDC used social media due to its popularity as well as its ability to deliver credible information in a timely manner.
Social media also provided a better tool to distribute complex health messages via videos on
YouTube, such as preventive behavior messages to stop the spread of H1NI that could not be accomplished via print media (Walton et al., 2012). Allowing the public to have 24 hours access to social media benefitted the CDC in disseminating their health messages. To increase the trustworthiness and credibility of the CDC, names and positions of speakers were included on all
YouTube videos to identify their roles on preventing the H1N1 epidemic. Also, as a part of the
CDC’s H1N1 social media campaign, pre-existing epidemic flu messages as well as seasonal flu messages were distributed on social media. The CDC established regular focus groups with target audiences to test the effectiveness of health messages among the public (Walton et al.,
2012).
In a study by Biswas (2013) that examined both the CDC and the WHO’s Twitter and
Facebook accounts during the H1N1 crisis, Biswas (2013) found that these social media platforms were mainly used to send messages related to the H1NI flu investigation, prevention, safety, news updates, and promotion of both Twitter and Facebook. The study also found that both the CDC and the WHO did not interact with Facebook and Twitter users; instead, they just sent information and monitored the platform. In other words, both the CDC and the WHO used a one- way communication strategy during the H1N1 crisis (Biswas, 2013).
Furthermore, as part of demonstrating the importance of utilizing social media during a time of crisis, the American Red Cross, a humanitarian organization, opened a new social media- based operation in cooperation with Dell to respond to a crisis situation and to provide 40 humanitarian aids during times of disaster. The American Red Cross also launched a Digital
Volunteer program to answer questions and offer critical information to the public during a crisis. The Red Cross aims to engage with the public through social media during a crisis by providing updated information and answering individuals’ questions. A survey by the Red Cross indicated that individuals use social media mainly to seek information, ask for or offer help, and connect with family and friends (The American Red Cross, 2010).
Sharing information with friends, family, government agencies and aid organizations on social media, such as Twitter and Facebook, during a time of crisis has been increasing among the public (Blanchard et al., 2012). Hence, responding authorities must be aware of any change and must provide proper assistance, if needed, during a time of crisis. On the other hand, many people use social media during a time of crisis to ask for help and assistance. Responding authorities, public safety officials, government agencies, and first responders, therefore, are all responsible to make sure that they monitor social media on a daily basis and collect data during a time of crisis. For instance, two Australian girls aged 10 and 12 were trapped in a storm drain and used their Facebook status to ask for help. A schoolmate, luckily, saw their Facebook status update and called for help (Blanchard et al., 2012). A simulated study by Simon, Adini, El-
Hadid, Goldberg, & Aharonson-Daniel (2014) shows that first responders who utilized social media to help earthquake victims were more likely to find the victims than the first responders who do not use social media in a rescue operation. The study found that first responders who utilized social media were faster in reaching the victims and providing assistance than first responders who do not use social media. The study suggests that the use of social media during a time of crisis helps first responders to evacuate individuals quickly and effectively during a time of crisis. Thus, social media is one of the most important tools that health organizations can use 41 during a time of crisis to communicate with the public and provide them with updated information in a timely manner.
Recently, the world has witnessed a major health outbreak when the WHO declared that
Zika virus is considered a global public health emergency in February of 2016 (WHO, 2016b).
Zika virus can be transmitted to humans by the bite of an Aedes mosquito. Many people infected with Zika virus have shown no symptoms or mild symptoms that could last for a week, such as fever, headache, skin rash, and joint pain. The virus is believed to transmit primarily to human via mosquito bites, pregnant women to their fetus, sex, and maybe blood transfusion (WHO,
2016b; CDC, 2016c). The WHO initiates a global response plan to Zika virus by allocating around $122.1 million that includes detection, prevention, care and support, and research. Until
August 3 of 2016, around 68 countries and territories have reported Zika virus cases, mostly in
South America (WHO, 2016b). Both the WHO and the CDC have issued preventive measures to help people avoid getting infected with Zika virus. Prevention measures, such as using insect repellent, using screens on windows and doors, wearing light and long- sleeved shirts and trousers, and sleeping under a bed net, and other educational materials about Zika virus, have been promulgated through multiple communication channels, including social media (WHO,
2016b; CDC, 2016c). The CDC, for instance, has been using its multiple Twitter and Facebook accounts, the CDC Travel Health and the CDC Emergency, to distribute Zika preventive measures among the public (CDC, 2016c). Additionally, the Ministry of Public Health in
Guyana, for example, has embraced social media platforms to increase awareness of Zika virus by distributing video, audio, and other visual materials and advance its campaign efforts to reduce the number of Zika cases across the country (Kaieteur News, 2016). Thus, social media 42 as an effective tool has been recognized by many organizations worldwide to be one of the primary channels to use during a time of crisis.
Although social media provides numerous benefits for organizations during crises, social media has its disadvantages. One of these disadvantages is spreading and accelerating negative information about an organization which might break geographic boundaries and impact the organization’s reputation (Alfonso & Suzanne, 2008). The use of social media during crises can also trigger a crisis and complicate the situation by different forms, like rumors, cyber-terrorism, hacking, and privacy issues (Alfonso & Suzanne, 2008), making it very difficult for crisis communication teams to manage and control the situation or lessen the negative impact of the crisis (Holmes, 2011). Lindsay (2011) also addressed other social media drawbacks, like technological limitations. During hurricanes that hit different parts of the world, many residents of impacted areas experienced power outages lasting for more than two days which resulted in issues with charging their smartphones’ batteries. Hence, crisis managers should take into consideration these types of limitations and seek alternative options when facing such a situation.
Another pitfall of social media is the uncertainty of cost to operate social media during crises and emergency situations, particularly the number of skilled and trained staff needed to maintain social media, monitor platforms, verify the accuracy of information, and respond to messages (Lindsay, 2011). The potential of disseminating false and inaccurate information during a crisis is another drawback. Because of the nature of social media and the number of people involved in disseminating information, rumors and false information could occur during a crisis and complicate the situation (Lindsay, 2011). For example, a recent study published by
Dredze, Broniatowski, & Hilyard, (2016) analyzed 138,513 tweets that contained both vaccines and Zika virus keywords during the period of January 1 and April 29, 2016 and found that due to 43 uncertainty and lack of knowledge the public had about Zika virus, people on social media became more susceptible to conspiracy theories and pseudo-scientific claims about Zika virus.
The study showed that people exchanged false information and misconceptions about Zika virus that could undermine and hinder any future solutions, like having a Zika vaccine. The researchers urged public health authorities to intensify the use of social media to counter and refute all speculations and misinformation during the Zika virus crisis that might hinder health authorities’ efforts.
Invasion of personal privacy is also a social media limitation in which potential personal data collection and retention might occur during crises. Many scholars have questioned how personal information on social media is used, especially during disasters and terrorist attacks
(Lindsay, 2011).
Media Credibility
According to Meyer (1988), despite the great interest in the concept of credibility, there is no precise definition or operationalization of the concept. For almost five decades, scholars in mass communication research have produced different operationalization, measurements, and definitions of credibility, raising more concern about the concept of credibility (Gaziano &
McGrath, 1986; West, 1994). Early work, such Hovland & Weiss’s (1951) study, tried to understand the structural factor of credibility and found that individuals’ judgments of credibility is based on several components, such as trustworthiness and expertise. Various factors were found to influence individuals’ judgments of credibility, such as type of messages, sources, personal opinions, and the pre-existing knowledge about the messages. Additionally, individuals perceived information as more credible when the information is attributed to “high prestige” sources than low prestige sources (Hovland & Weiss, 1951). Individuals also perceived low 44 credible sources as less fair and less justified than high credible sources. The study of Hovland &
Weiss (1951) found that when a message is attributed to a high credibility source, individuals are more likely to change their opinions about certain issues than low credibility sources. Although scholars have different dimensions to measure media credibility, the most comprehensive and consistent dimensions of media credibility are believability, trustworthiness, completeness, bias, and accuracy of information (Meyer, 1988; Austin & Dong, 1994). Meyer (1988) tested many dimensions to examine individuals’ believability and attitudes towards newspapers by using a
Likert scale of five points and found that these five dimensions are more significant and reliable measures of media credibility than other dimensions.
The credibility of news organizations. According to the Pew Research Center’s study from 2012, media credibility in most major news organizations in the United States have generally witnessed a dramatic decline during the past two decades. The study measured believability ratings or how much people trust the media when getting their news from newspapers, cable and local TV news, and network news by using a 4-point scale (4= believe in all or all most what the media says, 1= believe almost nothing). The study indicated a significant decrease in believability ratings among most major news organizations, such as the New York
Times, USA Today, MSNBC, CNN, and NPR. Across 13 news organizations, the study found that the average positive believability has fallen from 71% in 2002 to 56% in 2012. However, people rated both local TV news and 60 Minutes program in CBS News with positive believability, 65% and 64% respectively. Another Pew research study in 2011 tracked individuals’ perceptions of newspapers’ performance between 1985 and 2011, and the researchers found that press credibility has negative ratings among individuals in general.
Around 66% of individuals indicated that news stories are inaccurate, 77% stated that the news 45 organizations usually favor one side, and around 80% believed that powerful people and organizations have significant influence on news organizations.
In the Middle East, a recent study done by Dennis, Martin, & Wood (2015), who worked for the Northwestern University in Qatar, found that people in Arab countries generally trust their media. People in Arab countries believe that the news organizations strive to provide accurate and fair news. The study indicated that 61% of people in the Arab world who follow the news closely are more likely to believe that the media is credible; 63% believe the media in their countries report news independently and without interferences from governments; and 69% said that the quality of news reporting has improved in the last two years compared to those who follow the media somewhat closely or those who do not follow the media at all. The study also found that 82% of people who perceive the media as a credible source are more likely to trust the media, while 45% who do not perceive the media as a credible source are less likely to trust the media. Additionally, among people who believe that the media is independent in their countries,
78% are more likely to have more trust on the accuracy and objectivity of their media than those who do not. The study also found that people in Gulf countries view their media positively, such as the Kingdom of Saudi Arabia (KSA) (69%), the United Arab Emirates (87%), and Qatar
(61%), compared to other people in Arab countries, like Egypt (26%), Tunisia (39%), and
Lebanon (33%). The study suggested that people in Gulf countries are more likely to believe that the media is independent and can report without interference from governments, like KSA
(57%), Qatar (57%), and the United Arab Emirates (72%) than other Arab countries, like Egypt
(25%), Lebanon (33%), and Tunisia (46%). Although the majority of people in the Arab world rely on their national media to get news, around 50% of people in KSA get their news from news organization that is located in another Arab country. Around 50% of people in KSA also believe 46 in the importance and benefits of getting news information from foreign news channels (Dennis et al., 2015).
The study further examined how people in the Arab world view the information they get from different sources as reliable. The study found that people in KSA consider the Internet and television as the most reliable sources of information, 76% and 75% respectively. Other sources, however, have been perceived to have less reliability when it comes to getting information among Saudis, such as social media (67%), interpersonal sources (69%), radio (51%), and newspapers (53%) (Dennis et al., 2015).
47
CHAPTER II. THEORY
Grunig’s Four Models of Public Relations
Public relations research started between the 1950s and 1960s as a part of mass communication research and was mainly focused on influencing mass media organizations
(Grunig, Grunig, & Dozier, 2006). During the period of the 1950s, many textbooks that had been introduced in public relations, like the first edition of Cutlip and Center’s (1952), claimed that public relations is a two-way communication and that public relations professionals should be involved in managerial functions (Gruing & Grunig, 1992; Grunig et al., 2006). However, there was no clear definition of the two- way communication process and managerial function until J. Grunig came up with the idea of organizational theory in
1976 and advanced the concept of two-way communication. The development of the public relations manager role by Broom and Smith between 1978 and 1979 also helped many scholars to perceive the public relations discipline as a field that was based on both two-way communication and as a management function between an organization and its public
(Grunig et al., 2006). Since public relations practitioners play critical roles in an organization, such as managerial and communicative roles, it becomes quite difficult to define public relations in only a single definition (Grunig & Hunt, 1984). Yet, Grunig &
Hunt (1984) tried to develop a comprehensive definition that describes public relations. They defined public relations as "the management of communication between an organization and its publics" (p.6). Since 1982, the PRSA embraced the following definition of public relations: "Public relations helps an organization and its publics adapt mutually to each other"
(PRSA, 2012, para. 2). However, in 2012 the PRSA came up with a new and more modernized public relations definition, and it defined it as a "strategic communication 48 process that builds mutually beneficial relationships between organizations and their publics"
(PRSA, 2012, para. 4). Hence, public relations departments are responsible for managing all communication and information flow inside and outside an organization and building mutual relationships between an organization and its publics. According the PRSA Code of Ethics
(2015), there are several core values that present public relations profession, like advocacy, honesty, expertise, independence, loyalty, and fairness. Public relations practitioners should adhere to these core values to serve the public interests in their public relations practice.
Ensuring free flow of information, promoting health and fair competition, delivering accurate and clear information, and safeguarding confidential and privacy information are also some of the public relations core principles that should be adhered to in the public relations profession. The adherence to such values, thus, is essential in the public relations profession to better serve the public interests as well as to practice excellent and ethical public relations
(PRSA, 2016).
For around 15 years, specifically between 1985 and 2000, Grunig & Grunig (2000) invested their time and effort in conducting extensive research with four researchers to understand the characteristics of excellent public relations departments in organizations. The project was funded by the International Association of Business Communicators Research
Foundation (IRBC) in order to gain a better understanding of how public relations departments can make an organization more effective and more valued to an organization
(Grunig & Grunig, 2000; Grunig et al., 2006). Grunig & Grunig (2000) examined more than
300 organizations in the United States, Britain, and Canada to see whether public relations departments follow excellent practices described by Grunig & Grunig’s Theory of
Excellence as well as to see what value public relations can bring to an organization. The 49 researchers searched literature in public relations, political science, psychology, feminist culture, and other disciplines to find an answer for their questions, particularly how public relations can increase the effectiveness of an organization and to what extent (Grunig, et al.,
2006).
The result of this extensive and comprehensive research was the establishment of a theory that provides generic principles that can be applied worldwide and in different organizational settings, such as governments and profit and non-profit organizations (Grunig
& Grunig, 2000). As Grunig et al. (2006) stated, "The result was a comprehensive, general theory of public relations. That general theory began with a premise of why public relations has value to an organization" (p.26). The theory offers a solid framework for public relations departments, particularly in how public relations can lead an organization to have an effective management (Grunig & Grunig, 2000). This theory is known as Excellence Theory, which describes the main characteristics of excellence in both management and communication processes of an organization by asking how public relations departments can make an organization more effective. Hence, public relations as a discipline is about organizing the communication process between an organization and its publics as well as how to make an organization more effective (Grunig et al., 2006). Grunig, Grunig, & Dozier
(2002) described excellent public relations as "managerial, strategic, symmetrical, diverse, and ethical" (p.306). Furthermore, Grunig & Grunig (2000) found that considering public relations departments as indispensable components of organizations’ management process is crucial for effective organizations. They found that public relations departments involved in management processes, in fact, are the best predictor of excellent public relations. Botan &
Hazleton (2006) articulated that "over those 20 years, a leading body of work has developed 50 around symmetry/ Excellence Theory, which has probably done more to develop public relations theory and scholarship than any other single school of thought" (p.6). Grunig &
Hunt (1984) constructed four models of public relations that help to get a better understanding of most public relations departments’ practices. Grunig & Hunt (1984) used the term ‘model’ in order to describe the four models of public relations that have developed throughout history in a scientific way, as it is used in science. As Grunig & Hunt (1984) stated, "A model is representation of reality" (p.21) and that humans cannot grasp all reality; instead, the human mind can grasp reality partially. The term ‘model’ was defined by Grunig
& Grunig (1992) as a "set of values and a pattern of behaviors that characterize the approach taken by public relations department or individual practitioner to all programs or, in some cases, to specific programs or campaigns. Thus, ‘model’ describes a broader pattern of behavior than does the concept of roles" (p.286).
The four models of public relations, therefore, are based on the most essential components and behaviors of public relations departments. The four models of public relations help to understand how public relations was practiced in the past and how it is practiced currently. As Grunig et al. (2002) stated, research shows that the four models of public relations describe many public relations practices in different countries, cultures, and political systems. The four models of public relations, in fact, have been embraced by many scholars since they fit very well with reality and explain most significant practices of most public relations practitioners (Gruing, et al., 2002). Furthermore, the four models of public relations have different purposes and functions that can be provided to an organization. Even though, as a discipline, public relations began focusing mainly on persuasive communication, not all the four models of public relations use the same purpose (Grunig & Hunt, 1984). The 51 first model of Grunig’s four models is known as press agent or publicity model. In this model, public relations departments render a propaganda function through disseminating inaccurate information in favor of an organization in order to persuade the public. The second model is known as the public-information model in which public relations departments are only concerned about disseminating information to the public. The third model is called the two-way asymmetrical model. In this model, public relations departments have more functions than in the press agent and information models, which focused mainly on scientific persuasion. The fourth model is known as the two-way symmetrical model in which public relations practitioners aim to build mutual relationships with an organization’s public in a balanced way (Grunig & Hunt, 1984). Hence, the first two models, the press agent and public information models, are a one-way communication model, while the third and fourth model, the two-way asymmetrical and symmetrical models, are two-way communication (Grunig, et al., 2002). The four models are further described here:
The press agent/ publicity model: This model was established between the period of
1850 and 1900. In this model, public relations departments use one-way
communication where information moves from an organization to its publics. An
organization aims to persuade its public through sending persuasive messages as well
as to gain more publicity in the media. Public relations departments in this model do
not conduct research about their publics and do not listen to them; instead they just
“Count the house” and see if their public relations activities led individuals to buy
their products or attend their events. Public relations practitioners in this model also
do not provide a comprehensive picture of their organizations or its products. One of 52
the prominent names who advocated press agency was P. T. Barnum (Grunig & Hunt,
1984; Grunig & Grunig, 1992; Wilcox & Cameron, 2009).
The public information model: This model emerged in 1900 and was used until the
1920s. In this model, public relations departments aim to disseminate information
objectively to the public rather than gaining publicity in the media as the press agent
model does. It is one-way communication where accurate and truthful information
moves from an organization to its publics. The main goal of public relations
practitioners is not to persuade the public, but to send objective information about the
organization. Public relations practitioners in this model are obligated to provide a
complete picture of their organizations and its products. In this model, public
relations departments do little research to send information to an unknown audience.
The emergence of the public information model occurred as a result of attacks
received by large corporations and governments in which they recruited journalists to
write press handouts. The most prominent figure in this model was Ivy Lee (Grunig
& Hunt, 1984; Grunig & Grunig, 1992; Wilcox & Cameron, 2009).
The two-way asymmetrical model: This model emerged and developed in the 1920s.
Public relations departments in this model rely mainly on scientific persuasion. This
model is two- way communication where communication and information flow in
two directions, from an organization to its public and from publics to an organization.
Public relations departments aim only to change the public’s attitudes and behaviors,
but not an organization’s policies. The two- way communication in this model, thus,
is imbalanced because public relations practitioners are more likely to favor their
organizations’ interests. Communication that comes from the public to an 53
organization is called “feedback.” In this model, research plays a significant role
where public relations practitioners conduct formative research to address what the
public wants and does not want, and conduct evaluative research in which the
public’s attitudes and behaviors are measured before and after an organization’s
campaign (Grunig & Hunt, 1984; Grunig & Grunig, 1992; Wilcox & Cameron,
2009).
The two-way symmetrical model: This model evolved in the 1960s and 1970s and is
based on two-way communication where a mutual dialogue takes place between an
organization and its publics. Public relations departments play a significant role in
changing both the publics’ and the organizations’ attitudes and behaviors, as needed.
In this model, conducting research is indispensable for an organization. Public
relations departments conduct formative research to measure an organization’s image
and how the audience perceives the organization. Formative research in this model
aims to modify an organization’s policies and activities to better serve the public’s
interests. Public relations departments also conduct evaluative research in order to
measure whether public relations activities and campaigns have enhanced the public’s
understanding of an organization’s communication and management (Grunig & Hunt,
1984). Grunig & Grunig (1992) state that two- way symmetrical communication uses
"research to facilitate understanding and communication rather than to identify
messages most likely to motivate or persuade publics" (P.289). While the
asymmetrical communication is imbalanced, the symmetrical communication is
balanced. 54
Grunig et al. (2006) state that excellent public relations departments are more likely to follow the two-way symmetrical model rather than the press agentry, public information, or the two-way asymmetrical model. Public relations departments use the two-way communication to develop an organization’s messages in a way that balances the interest of both an organization and its publics. The Excellence Study by Grunig et al. (2006) "has shown that public relations is a unique management function that helps an organization interact with the social and political components of its environment. This institutional environment consists of publics that affect the ability of the organization to accomplish its goals and that expect organizations to help them accomplish their own goals" (p.55). Research has shown that the implementation of the two- way symmetrical model makes an organization more effective and is the most ethical model in public relations (Grunig & Grunig, 1992). Therefore, the value of public relations relies mainly on building mutual relationships between an organization and its publics, especially when applying the two-way symmetrical communication while designing and developing communication messages (Grunig et al., 2006). An organization, hence, should consider the public as a partner not only during normal situations, but also during times of crisis in which a strategic plan and effective communication is essential to overcome any crisis.
Health Belief Model (HBM)
The Health Belief Model (HBM) is one of the most known theories in health behavior that was developed in the 1950s with the aim of explaining and predicting individuals’ health behaviors (National Cancer Institute, 2003; Champion & Skinner, 2008). The HBM is a psychological model developed by several psychologists, Hochbaum, Kegels, and Rosenstock, who worked for the U.S Public Health Service (Janz & Becker, 1984; Glanz, Rimer, & Lweis,
2002). The model was developed to gain a better understanding of why free tuberculosis (TB) 55 health screening programs were not very successful (Hochbaum, 1958; Janz & Becker, 1984;
Glanz et al., 2002). Particularly, the HBM tries to understand why individuals do not adopt disease strategies and behaviors during health campaigns and refuse to engage in preventive behaviors (Hochbaum, 1958; Janz & Becker, 1984; Thweatt & Query, 2005; Hayden, 2013).
Hochbaum’s study of tuberculosis in 1950s examined why some individuals agreed to have X- rays taken while others did not and found that an individual’s state of psychological readiness was a significant factor that determines an individual’s participation in a health program. An individual’s state of readiness before taking any action requires essential components, such as knowledge, emotions, experiences, and feelings. The results of the study indicated that an individual with a belief that he/she may have tuberculosis at any time were more likely to make actions than those who did not (Hochbaum, 1958).
The HBM encompasses several important dimensions. The first dimension is known as perceived susceptibility in which individuals have different feelings of personal vulnerability to a certain disease. The more an individual perceived the risk of a disease, the more likely he/she will engage in some behaviors to decrease that risk (Hochbaum, 1958; Hayden, 2013; Janz &
Becker, 1984 Glanz et al., 2002). Hence, increasing perceived susceptibility leads individuals to adopt healthier behaviors (Hayden, 2013). Perceived susceptibility also motivates individuals to take protective actions to minimize the risk of their behaviors, such as using condoms to avoid sexual disease, getting vaccines to avoid influenza, and using sunscreen to prevent skin cancer
(Hayden, 2013). The second dimension is known as perceived severity in which individuals carry strong fears and concern of contracting an illness or disease. This dimension includes some evaluation of the consequences of an illness based on medical information and knowledge as well as some beliefs about the negative consequences of a certain behavior or disease that might 56 occur for an individual (Janz & Becker, 1984; Hayden, 2012). The third dimension is called perceived benefits in which individuals perceived the value and usefulness of adopting new behaviors in regard to minimizing the risk of an illness. Thus, individuals will adopt new behaviors based on their perceptions of its benefits in reducing threats (Janz & Becker, 1984;
Hayden, 2013). The fourth dimension is called perceived barriers in which individuals evaluate the obstacles and difficulties they might encounter when adopting a new behavior. This dimension, however, might prevent individuals from adopting a new behavior (Janz & Becker,
1984; Hayden, 2013). In fact, perceived barriers have found to be the most powerful dimension of HBM based on many study designs and behaviors (Janz & Becker, 1984). Perceived barriers could be any challenges, difficulties, or negative aspects that prevent individuals from taking the healthy behaviors, such as time consuming, difficulty, painful, or unpleasant etc. (Janz & Becker,
1984). Individuals usually evaluate the benefits and consequences of a new behavior before overcoming the old one (Hayden, 2013). The HBM also suggests that besides the four perceptions, individuals’ behaviors can be influenced by what is called “cue to action,” including external and internal cues. External cues are events, people, mass media, health providers, and any external factor that can trigger people to change their behaviors (Janz & Becker, 1984;
Hayden, 2013). Internal cues include psychological cues, such as pain and symptoms that trigger individuals to adopt a new behavior (Janz & Becker, 1984). Moreover, the self-efficacy dimension that was integrated by Bandura (1977) was added later to the HBM in 1988. This dimension is concerned about an individual’s own ability and capability to make a change, like adopting new healthier behaviors. Bandura (1994) defines self- efficacy as “people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate 57 themselves and behave” (p.2, para 1). Studies found that individuals who believe in their ability and skills to achieve a certain goal are more likely to attain that goal (Hayden, 2013).
Throughout history, the HBM was used to assess many preventive health behaviors. For instance, in 1976, the outbreak of swine influenza created a great opportunity to assess the HBM in order to understand the vaccination behavior among the public. Several studies were conducted at that time and findings of these studies suggested that each dimension of the HBM has a significant correlation with the individuals’ vaccination behaviors (Janz & Becker, 1984).
Findings also showed that some of the HBM dimensions, such as susceptibility, efficacy, and safety were able to distinguish participants from non-participants in the inoculation program
(Janz & Becker, 1984).
Recently, the HBM has been widely used in health education campaigns and programs
(Glanz et al., 2002) and has shown significant success in encouraging individuals to take preventive measures and adopt new behaviors in diverse health issues (see Adams, Hall, &
Fulghum’s 2014 study of vaccines among hemodialysis patients; Hoseini, Maleki, Moeini, &
Sharifirad’s 2014 study of reducing hypertension among women by encouraging physical activities; Naghashpour, Shakerinejad, Lourizadeh, Hajinajaf, & Jarvandi’s 2014 study of a nutrition program by increasing calcium intake among females in high schools; and Juan, Yue, &
Mei’s 2014 study of injury prevention among high school students). Additionally, the model has been applied in many health behaviors and campaigns, including many Arab countries, like
Jordan, KSA, Egypt and showed significant results (see Mikhail & Petro- Nustas’ 2001 study of breast cancer in Jordan; Almadi’s et al. 2015 study of colorectal cancer screening in KSA; and
Abolfotouh’s et al. 2015 study in the practice of self- examination of breast cancer among Saudi 58
women).Compared to other models, the HBM expands to support and maintain health behavior change’s interventions (Champion & Skinner, 2008).
Furthermore, adherence of health preventive measures and medications plays a significant role regarding the success of any treatment. Failure to follow health recommendations not only could negatively impact patients’ health, but also the whole healthcare system (Jimmy
& Jose, 2011). Ockene & Orleans (2011) suggest that following preventive therapies lead to a better health condition and less healthcare cost. According to the WHO (2003), adherence is "the extent to which a person’s behaviour-taking medication, following a diet, and/ or executing lifestyle changes, corresponds with agreed recommendations from a health care provider" (para.
3). The American Heart Association (AHA) categorized prevention behaviors to three categories, which are: (1) lifestyle behaviors like following a healthy diet, (2) medication use, like taking aspirin, and (3) screening for blood pressure or diabetes etc. (Ockene, Schneider, Lemon, &
Ockene, 2011). Following health preventive measures, smoking, self-management of diabetes, filling prescriptions, or involving in risky sexual behaviors are also some of the examples of therapeutic behaviors (WHO, 2003). A collaborative relationship between the patient and the health care provider is very important to the adherence process. Adherence of health preventive measures or medication requires patients’ agreement to follow health recommendations (WHO,
2003). However, there are five dimensions that could impact individuals’ adherence, which are:
(1) socioeconomic, (2) health system, (3) condition- related factors, (4) patient- related factors, and (5) therapy-related factors (WHO, 2003). Socioeconomic factors, such as poverty, education level, illiteracy, belief about illness and treatment and cultural beliefs, and race and culture are found to have significant effects on adherence (WHO, 2003). The health system also plays an important role on adherence. Poor health services, poor medication distribution system, and lack 59 of education are some are some factors that can make a significant impact on adherence. Factors related to patients’ condition, such as patient disability and severity of disease, and thereby- related factors, such as duration of treatment or side effects of treatment, and patient-related factors, like patients’ knowledge about their illness, are also found to have a major impact on adherence (WHO, 2003).
Elaboration Likelihood Model (ELM)
The Elaboration Likelihood Model of persuasion (ELM) was developed by Petty and
Cacioppo in 1981. The ELM is concerned about the processes and changes of individuals’ attitudes as well as the variables that trigger these processes. It tries to comprehend the effectiveness of persuasive communication on individuals’ attitudes (Petty & Cacioppo, 1986;
Petty, Rucker, Bizer, & Cacioppo, 2004). Attitude is defined by Petty & Cacioppo (1986) as
“general evaluations people hold in regard to themselves, other people, objects, and issues”
(p.127). These evaluations can be shaped by affective, behavioral, or cognitive experiences and influence an individual’s behavioral and cognitive processes. The ELM, therefore, attempts to understand how internal or external variables can have significant impacts on individuals’ judgments (Petty et al., 2004; Duane, 1999). Unlike previous research, the ELM suggests that a given variable can impact an individual’s attitudes in various ways (Petty & Cacioppo, 1986;
Petty et al., 2004; Petty & Cacioppo, 1986). Depending on the role of a given factor, a factor may result in increasing or decreasing persuasion and elaboration through different mechanisms
(Petty et al., 2004). As Petty et al. (2004) state, the elaboration continuum is the core of the
ELM, which is based on an individual’s motivation and ability to evaluate and assess the quality of information in the persuasion context (Petty et al., 2004; Petty & Cacioppo, 1986). Other factors, like emotional and psychological consistency factors, also influence how people process 60 thinking and impact message elaboration. Consequently, the ELM tries to understand how individuals’ attitudes are shaped and reinforced by persuasive communication. Elaboration occurs when individuals are exposed or presented with some sort of information which leads them to evaluate this information and decide whether they accept or reject the message. The
ELM suggests that persuasion can take two routes or paths, the first is called central route and the second one is called peripheral route (Petty & Cacioppo, 1986; Petty et al., 2004; Duane,
1999). The central route means that individuals are more likely to pay attention and concentrate on the message itself by scrutinizing the qualities of the message or the argument presented.
Therefore, individuals’ attitudes are shaped and changed based on the message’s characteristics, such as the quality or strength of the argument presented by the source. Yet, attitude change requires individuals to take greater efforts and more thoughts in order to make or reach a decision. In the peripheral route, individuals are not influenced by the message itself, but by other factors, such as the credibility of the source, visual appeal, and presentation. Hence, individuals who are persuaded by other factors rather than the message are less likely to endure the message and more likely to make counterarguments (Petty & Cacioppo, 1986; Petty et al.,
2004).
In order to explain how attitudes are formed and shaped, the ELM poses seven postulates.
The first one is known as Seeking Correctness that was proposed by Festinger in 1954. It suggests that individuals are motivated to embrace correct attitudes (Petty & Cacioppo, 1986;
Petty et al., 2004). Individuals want to hold opinions that help them to reach correct judgments
(Petty & Wegener 1999). Embracing correct attitudes, however, does not mean that an individual cannot be biased while making assessment for evidence. The first postulate suggests that individuals are rarely motivated explicitly to be biased. Even if an individual relies on a 61 prejudice view, he/ she can have a justification, such as bringing some legitimacy or merit behind his/her point of view. Being motivated to have a consistent point of view can also increase one’s biases and makes him defend his attitudes (Petty et al., 2004; Petty & Wegener
1999; Wagner & Petty, 2011).
The second postulate proposed by the ELM is called the Elaboration Continuum, which suggests that individuals vary in their efforts and the amount of cognitive processes devoted to a certain message (Petty & Wegener 1999). It also suggests that individuals might carry the same interest toward a persuasive message or think similarly about relative information by engaging in the same qualitative process, such as the quality of the message. Yet, they may hold significant quantitative differences in regard to cognitive processes that lead to differences in shaping their attitudes. Therefore, individuals might use the quality of the message or the number of arguments presented in a certain message to form their attitudes (Petty et al., 2004; Petty & Wegener 1999).
The ELM states that cognitive processing will be in the central end of the continuum when individuals carry a high degree of motivation and ability toward the persuasive message. In contrast, cognitive processing will be closer to the peripheral end of the continuum when individuals have a low degree of motivation and ability toward the persuasive message (Petty et al., 2004). The third ELM postulate is known as the Multiple-Roles, which suggests that variables, like source, message, recipient, channel, and context, can play multiple roles and have significant impacts on persuasion (Petty & Cacioppo, 1986; Petty & Cacioppo, 2012; Petty et al.,
2004; Petty & Wegener, 1999). One purpose of the third ELM postulate is to differentiate between considering information as cues or arguments, such as when individuals are engaged in a low amount of thinking toward a persuasive message, their attitudes are more likely to be influenced by simple cues, like the credibility of the source, whereas individuals who are 62 engaged in a high amount of thinking are more likely to be influenced by the argument or the message itself. Sources with high credibility and expertise have also significant impacts on persuasion in which individuals engage in more scrutinized processes. Preexisting attitudes as well as an individual’s mood can play multiple roles under high and low thought conditions. The
ELM claims that when elaboration is low, an individual’s mood can serve as a simple cue to whether he/she accepts or rejects the message. Individuals also are more likely to have more confidence when information is presented by an expert rather than a non-expert (Wagner &
Petty, 2011).
The fourth ELM postulate is called the Objective- Processing, which proposes that individuals are more likely to engage in objective processing seeking for truth from a message rather than reaching a certain attitude toward the target. It also proposes that variables affect an individual’s motivation and ability to process a persuasive message by increasing or reducing the scrutiny of the message’s arguments, so when individuals follow the evidence, the process is considered objective. The fifth ELM postulate is called Biased-Processing, and it suggests that some variables can influence individuals’ motivation and ability, which leads individuals to produce some sorts of thoughts and therefore trigger individuals to either reject or accept a certain message (Petty et al., 2004; Petty & Wegner, 1999). The sixth ELM postulate is called
The Trade- off, which assumes as individuals move through the elaboration continuum, the effect of peripheral processes on attitudes varies. Low levels of information scrutiny, elaboration strategies, and elaboration judgments and processes have more impact on attitudes than the one with a high level. Thus, a tradeoff between the impact of peripheral and central paths occurs on individuals’ judgments along the elaboration likelihood continuum. While the impact of central route on individuals’ judgments increases, the impact of peripheral route on judgments decreases 63
(Petty & Wegner, 1999; Petty et al., 2004). The seventh ELM postulate is known as The Attitude
Strength, which is concerned about the outcomes of persuasive message processing. More specifically, individuals’ attitudes that are shaped by the central route are more likely to be persistent over time and to have more cognitive and behavioral impacts than the peripheral route.
Also, attitudes that are shaped by the central route will be more resistant to persuasion compared to the peripheral one. Finally, attitudes with high elaboration motivate individuals to defend their attitudes against persuasive messages (Petty & Wegner, 1999; Petty et al., 2004).
Hence, based on evidence from the literature review and justification of the HBM and
ELM as theoretical foundations, the following research questions will be addressed
RQ1: Where do Saudi people go first to obtain information about Coronavirus?
RQ2: What source of information do Saudis believe is most believable, accurate, trustworthy, complete, and fair when seeking Coronavirus information?
RQ3: Do Saudi people consider the MOH’s website more credible in obtaining health information related to Coronavirus than traditional media and social media?
RQ4: To what extent do Saudi people use the MOH’s website as a primary tool to obtain health information related to Coronavirus?
RQ5: To what extent do Saudi people use other communication channels to obtain information about Coronavirus?
RQ6: To what extent do individuals in Saudi Arabia adopt the proper health practices that have been promoted by the MOH to combat Coronavirus?
Based on these research questions, the following hypotheses were developed: 64
H1: Scores on the individual concepts of perceived susceptibility, perceived severity, perceived benefits, self-efficacy, and cues to actions will be positively correlated with the MOH’s
Coronavirus preventive measures, such as washing hands.
H2: Scores on the concepts of perceived barriers will be negatively correlated with the frequency of the practice of MOH’s Coronavirus preventive measures, such as washing hands.
H3: Self-efficacy mediates the relationship between perceived severity, perceived barriers, and/or perceived benefits and participants’ preventative health behaviors.
H4: Students in health-related majors are more likely to follow the MOH's Coronavirus preventative measures than students in other majors.
H5: Students in agriculture-related majors are more likely to follow the MOH's Coronavirus preventative measures than students in other majors.
H6: Students health-related majors will view the credibility of Coronavirus messages differently than students in other majors.
H7: Students agriculture- related majors will view the credibility of Coronavirus messages differently than students in other majors.
65
CHAPTER III. METHODOLOGY
Survey Research
Since the 1930s, survey as a research method has been widely used in many fields aiming to collect data and information about certain populations (Fowler, 2013). Fields such as sociology, psychology, and mass communication use survey methods to gain more information about a target population. Surveys attempt to measure and understand individuals’ knowledge, behaviors, characteristics, opinions, and feelings toward a certain issue (Wimmer & Dominick,
2011). Surveys are usually considered as a quantitative or positivistic type of methodology unlike qualitative methods, such as case studies and unstructured interviews (De Vaus, 2013).
Generally, researchers use surveys to examine two or more variables, seek for relationships or correlations between variables, or to test hypotheses to acquire better understanding of a certain issue or a group of people (Wimmer & Dominick, 2011). Scholars have suggested that there are two major types of survey analysis, descriptive and inferential statistics. Unlike the descriptive statistics that aims to provide an overall descriptive information of a collection of data and to explore the current situation, such as describing behaviors or attitudes of a target population, the inferential statistics aims to provide logical reasons and explanation of why something exists or happens. Inferential statistics are designed to produce statistical data that gives researchers both the ability and confidence to generalize the results of a study about a target population (Fowler,
2013; Wimmer & Dominick, 2011). When conducting a survey, researchers suggest two main categories of sampling, probability and non-probability sampling. The most significant difference between probability and non-probability sampling is that probability sampling involves a random selection of a sample, whereas nonprobability sampling does not involve random selection of the units. Another difference is that probability sampling can represent a 66 population but with some degree of error that can be estimated by a researcher, while non- probability sampling cannot represent a population and a researcher cannot estimate the sampling error (Babbie, 2014; Wimmer & Dominick, 2011).
Scholars suggest five modes of surveys that researchers can use, online surveys, telephone surveys, mail surveys, interview surveys, and mixed- mode surveys (Dillman, Smyth,
& Chritian, 2009; Wimmer & Dominick, 2011).
Online survey. The emergence of the Internet has changed the way researchers and commercial companies conduct their research. The first study that used online surveys was published in 1996. Since then, online surveys have received higher attention from scholars than other survey modes in a similar time period in different fields (Couper & Miller, 2008). Today, researchers from various fields can conduct many types of research via the Internet. Online surveys, in particular, have become very popular among researchers who want to collect data about people’s behaviors, attitudes, and opinions on particular issues (Wimmer & Dominick,
2011). Many research centers, like Gallup Organization and Harris Interactive, shifted from collecting data through telephone surveys to online surveys (Chang & Krosnick, 2009). Scholars suggest that online surveys offer many advantages to researchers. One is that researchers can easily obtain a large sample size and a specific group of people. Another advantage is that online surveys can save both time and money for researchers where subjects’ responses can be automatically transformed into data analysis, unlike other survey modes that require time and effort to enter the data (Perkins& Yuan, 2001; Couper & Miller, 2011). With online surveys, subjects are able to take the survey at any time and any location, which makes it more convenient than other survey modes. At the same time, researchers can include visual or audio materials in the online surveys in order to elaborate certain phenomenon or to ask respondents to provide 67 their opinions about certain issues (Wimmer & Dominick, 2011; Perkins & Yuan, 2001).
Moreover, online surveys allow researchers to design a long questionnaire, whereas other modes, such as telephone surveys, require researchers to limit the length of the questionnaire. Having a long questionnaire in telephone surveys, for instance, will result in some issues where respondents refuse to complete the questionnaire (Wimmer & Dominick, 2011; Dillman et al.,
2009). Studies have also shown that collecting data through online surveys offers significant measurement advantages over data collected by telephone surveys (Chang & Krosnick, 2010;
Yeager et al., 2011). As stated by Ha et al. (2015), respondents in telephone surveys have no time to think deeply to answer questions, and they are expected to provide quick answers, unlike online surveys. However, online surveys have some issues with sampling errors, especially when constructing the frame of a population (Couper, 2000).
In many experimental studies, researchers have assigned participants to two groups, either a computer or oral administration by an interviewer, and asked respondents to fill out a questionnaire. They found that collecting data through computers had higher concurrent validity,
“less survey satisficing,” and “less social desirability response bias” (Chang & Krosnick, 2010, p. 155). Thus, researchers suggest that self-administration computers have some advantages over telephone surveys. Also, the study found that online surveys are much better for people who have low cognitive skills since the telephone surveys require respondents to have good memories to remember and answer the questions. The presence of visual presentations in online surveys also make it easier for people with low cognitive skills to respond and answer the questionnaire
(Chang & Krosnick, 2010). Online surveys, however, assume that the one who takes the survey is capable to read and understand all written and accompanied materials (Chang & Krosnick,
2010). Thus, scholars recommend researchers use face-to-face interviews or telephone surveys 68 with those people who are limited in reading skills. The study also reported that people with high cognitive skills are more likely to manage both online surveys and telephones surveys equally well, whereas people with low cognitive skills are more likely to be challenged by oral presentations or telephone surveys (Chang & Krosnick, 2010). The study suggested that the
“response order effect” also occurred in telephone surveys in which respondents select the latest choices while answering questions in intercom mode, whereas there is no response order effect in the online surveys (Chang & Krosnick, 2010).
Furthermore, online surveys are not only offering significant measurement advantages over telephone surveys, but also over paper-and-pencil surveys. Scholars compared online surveys with paper-and-pencil surveys and found that both modes have “similar responses and/ or similar internal consistency” (Perkins & Yuan, 2001, p.370). Nevertheless, online surveys, like any other survey mode, have some disadvantages and issues. The first issue is that researchers have no control over data gathering procedures, which could produce negative consequences on the quality of data collected. Another issue of online surveys is that researchers may have difficulty in identifying the person who participates in the study. Even though some researchers include some questions to identify the person who participates in the research, it is still difficult to know the participant’s identity with 100% certainty (Wimmer & Dominick,
2011).
In its recent annual report of 2014, the Communications and Information Technology
Commission (CITC) in the Kingdom of Saudi Arabia (KSA) conducted a simple random sample of 3,000 people aged between 12-65 years old across 13 main regions in the kingdom. The results found that 91% of residents use the Internet, while the percentage was higher among
Saudis (96%).The Saudi population is considered as one of the youngest populations in the world 69 in which 75% are under 30 years old (Wilson Center, 2011). Thus, utilizing an online survey would be significantly better in this study since the population of KSA are young and have more capacity to deal with technology than older people.
Research Design, Population, and Sample
This quantitative study used a cross-sectional study that was taken at one point of time
(Babbie, 2014). Quantitative research provides precise information and statistical data that help researchers to find proper solutions for many issues (Beatty, 2009). The data in quantitative research is measured by the process of turning the data into numbers through using specific instruments and tests, which make it more accurate (Beatty, 2009). According to Stacks (2002), data in quantitative research are controlled, objective, and systemically observed.
A convenient online sampling method was used since random or systemic probability sampling is cost prohibitive, and the researcher has access to college students at King Saud
University (KSU) in Riyadh, KSA. The convenience sample is less expensive than other types of sampling and can provide useful information for researchers in a short period of time (Wimmer
& Dominick, 2011). Choosing a university located in Riyadh city is imperative for the purpose of this study. Riyadh is one of the two major cities that has the highest number of Coronavirus cases in KSA, according to the MOH (2017). Also, KSU is considered one of the largest universities in KSA with over 50,000 enrolled students.
King Saud University (KSU)
KSU was the first university founded in KSA in 1953 by King Saud bin Abdulaziz. It is located in the capital city, Riyadh, one of the most populous Saudi cities with more than 6 million residents, according to the General Authority for Statistics (2016). Riyadh is a modern city located in the center of Arabian Peninsula with a very developed infrastructure and center of 70
Saudi Arabia’s finance, diplomacy, commerce, industry, and academia. Riyadh has more than
550 health clinics and 49 hospitals. It has the best healthcare services and most modern facilities,
King Fahad Medical City, in the Middle East, according to Al-Riyadh Development Authority
(2016).
KSU is a public university funded by the Saudi government with the aim of serving the public, community, and the Saudi market with excellent and high quality education. KSU consists of 24 colleges that offer premier academic programs in the Arab region to more than
55,000 students for free of charge taught by around 5,000 academic faculty and staff (KSU,
2016). In 2012/2013, KSU received a global recognition and ranked 197th among top universities in the world according to QS World Universities ranking (QS, 2012). Recently, KSU was globally ranked among the top 150 universities and placed in the top 200 universities worldwide in subjects including engineering and technology, computer science, chemistry, mathematics,
English, and medicine according to the Academic Ranking of World Universities (ARWU)
(2017). Annually, the government of KSA allocates the largest share of the education budget to
KSU to enhance and improve all educational and infrastructure projects as well as to meet the market and societal demands.
The university hosts both domestic students who come from different regions in the kingdom and international students who receive scholarship offers to pursue their higher education at KSU. Therefore, the decision to include KSU in this study is based on the university being located in the populated area with the highest number of Coronavirus cases and the diversity of students who come from different parts of KSA and abroad to pursue their education, thus giving the researcher an advantageous position to reach a significant conclusion about the topic under study. Also, the study concentrates on KSU’s students who are in health and 71 agriculture fields to see if students in these fields carry different perspectives of Coronavirus than other students. The researcher assumes that both students in agriculture and health fields have some background about the infectious disease, Coronavirus; thus, focusing on them was imperative for the purpose of the study. Professionals in healthcare and agriculture believed to be at increased risk for Coronavirus since they have close contact to sick people and/or animals
(CDC, 2017b). Thus, it is crucial to examine their adherence to MOH’s Coronavirus preventive measures. The College of Medicine at KSU has more than 2,300 enrolled graduate and undergraduate students who pursue their bachelors, residency, and Ph.D.s, whereas the College of Food & Agriculture Sciences has around 1,300 of undergraduate and graduate students (KSU,
2016).
Instrumentation
To test the media credibility scale, the researcher adapted Meyer’s (1988) scale who modified an existing scale developed by Gaziano & McGrath (1986). The scale includes five dimensions that measure the believability of the media, which are believability, accuracy, trustworthiness, biasness, and completeness (Meyer, 1988). Although Meyer (1988) used the scale to measure the credibility of newspapers, Meyer’s scale of five dimensions is consistently used by many researchers to measure media credibility (Austin & Dong, 1994; McComas &
Trumbo, 2001; Flanagin & Metzger, 2000), and the scale is found to perform very well across many source types and contexts as in McComas and Trumbo’s (2001) study. All questions for the scale used an ordinal Likert scale with 5 points from (1) lower scores to (5) higher scores.
Higher scores in the five dimensions means greater believability, accuracy, trustworthiness, unbiasedness, and completeness. Meyer’s scale (1988) shows high reliability of .92 as well as 72 high validity (West, 1994) (Table 1). The scales in this were constructed using Qualtrics software that offers excellent features and services for researchers.
Table 1
Empirical Validity, Goodness of Fit, and Reliability for Meyer’s Credibility Scale
Chi- Square df GFI AGFI Item Reliability Overall Reliability Empirical Validity
Interval 83.49 13 .796 .765 .699 .921 .831 Standardized 55.69 13 .868 .848 .692 .920 .835
Note. Table adapted from “Validating a scale for the measurement of credibility: a covariance structure modeling approach,” by M. West, 1994, Journalism quarterly, 71(1), p.163. Copyright
1994 by Journalism quarterly.
The researcher also used the Health Belief Model (HBM) scale that was developed in
1993 by Victoria Champion. The researcher modified the scale to make it more suitable for the purpose of this study by substituting the word Coronavirus for breast cancer. For example, the original scale asked respondents to either agree or disagree with the statement, “It is extremely likely I will get breast cancer,” while in this study it is modified to, “It is extremely likely I will get Coronavirus.” The questionnaire consists of 43 items addressing the HBM’s variables.
Seven questions examine perceived severity, five questions examine perceived susceptibility, seven questions for perceived barriers, seven questions for perceived benefits, eight questions for cues to action, and nine questions for perceived self-efficacy (Appendix B). All question for the six scales used an ordinal Likert scale with 5 points from strongly disagree (1) to strongly agree
(5). Higher scores in the six scales means greater perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, and self-efficacy. The scale was used by
Champion in 1993 to prevent breast cancer and to encourage breast self-examination. The scale 73 has high internal consistency with Cronbach alpha reliability coefficients that ranged from .80 to
.93 and can be modified for use with other health behaviors (Table 2). The content validity of this scale was also tested by three well-known judges who were familiar with the HBM
(Champion, 1993).
The questionnaire also included the MOH’s Coronavirus preventive measures to assess the adherence level of proper practices among Saudi people. Questions included were: 1- Do you wear a mask when you visit sick people (Yes, No, I don’t visit sick people); 2- Do you follow a healthy and balanced diet to increase your immune system (Yes, No); 3- Do you get enough sleep every day (Yes, No); 4- Do you cover your mouth or use a tissue when coughing or sneezing
(Yes, No); 5- Do you keep yourself away from camels (Yes, No); and 6- For how many minutes do you exercise weekly (I don't exercise, Less than 75 minutes, Between 75- 140 minutes, 150 minutes or more). Participants of the study were also asked some questions related to information seeking of Coronavirus. These questions include: 6- I seek information about
Coronavirus: (Daily, 1-2 times a week, 1-2 times a month, once a month, once every other month,
1-2 times a year); 7- The first place I seek information about Coronavirus is: (The MOH's
(Website, Twitter, Facebook, YouTube; The Internet (Google, Yahoo, etc.); The World Health
Organization's (Website, Twitter, Facebook, YouTube); Traditional Media (television, newspapers, radio, etc.); Centers for Disease Control and Prevention's (Website, Twitter,
Facebook, YouTube); Family and friends; Doctors or other health providers; I have never sought information about Coronavirus; Other). Participants were also asked about their likelihood (1= very unlikely, 5= very likely) of using various communication channels when seeking information about Coronavirus. Respondents who never sought Coronavirus information were blocked from answering and assessing Coronavirus information credibility (media 74 credibility scale) as well as the likelihood of using different communication channels to seek
Coronavirus information and automatically directed and diverted to demographic questions.
Other demographic questions were asked for the purpose of the study, including age, gender, and level of education. The complete questionnaire can be found in Appendix B.
Table 2 Champion’s Subscales Mean, Standard Deviation, and Reliability.
Sub-scale Mean SD Cronbach’s alpha Test-Retest Susceptibility 2.54 0.81 0.93 0.70 Seriousness 3.25 0.68 0.80 0.45 Barriers 2.02 0.60 0.88 0.65 Benefits 3.88 0.52 0.80 0.45 Cues to actions/ 3.78 0.59 0.83 0.67 Health Motivation
Self- efficacy/ 3.31 0.57 0.88 0.65 Confidence
Note. Table adapted from “Instrument refinement for breast cancer screening behaviors,” by V.
L. Champion, 1993, Nursing Research, 42(3), p. 142. Copyright 1993 by American Journal of
Nursing Co.
Procedures
Validity of HBM coronavirus scale. Prior to the IRB approval, the survey went through a translation and validity process. The English language questionnaire was assessed by three experts from Bowling Green State University who are professors and experts in health communication for content and face validity. Changes were made based on the experts’ recommendations to cover Coronavirus phenomenon. The researcher modified the scale to make it more suitable for the purpose of this study by substituting the word Coronavirus for 75 breast cancer. Additionally, the questionnaire was sent to a doctor and epidemiologist to ensure appropriateness of language used, comprehension, and correctness of terminologies in the subject. Modifications were made based on all experts’ recommendations and notes. After the editing process, cognitive testing was conducted by giving the survey to three other
English speakers. Each one was asked to review the clarity, easiness, and appropriateness of the survey language. Comments and problems led to some revisions to the language and format of the questionnaire. After ensuring the clarity of the language used in the instrument, two native Arabic speakers, who study and hold master’s degrees in the U.S., translated the questionnaire to Arabic. The researcher verified the translation to ensure that the correctness of the translation reflects the study’s aim and scope. Finally, the translation of the questionnaire was reviewed and verified by a faculty member in the Arabic Department at KSU who holds a master’s degree in Linguistic Studies from the United Kingdom. Modifications were made to several items in the Arabic questionnaire, such as choice of words and grammar errors. The researcher then conducted a pilot study by asking five college students both male and female to take the Arabic and the English questionnaires to ensure the clarity of the language. Few items were adjusted based on students’ comments. Participants in this study were allowed to choose the language of the questionnaire, Arabic or English. Additionally, Champion’s Health
Belief Model (CHBM) was previously translated to Arabic and tested for validity and reliability by many researchers and show significant results (Mikhail & Petro- Nustas, 2001).
Reliability for the HBM sub-scales in this study were analyzed using Cronbach’s Alpha.
Results were similar to the original scales obtained in Champion’s work (Table 5).
IRB approval. This study was reviewed and approved prior to its implementation by the
Institutional Review Boards (IRB) at Bowling Green State University (BGSU) in Bowling 76
Green, OH, which is in the United States of America (See appendix D). The study was also reviewed and approved prior to its implementation by the Deanship of Scientific Research at
KSU in Riyadh, KSA. After obtaining the approval from the IRB at BGSU and the Deanship of
Scientific Research at KSU, the researcher contacted the Deanship of e-Transaction and
Communication to disseminate the email invitation with the survey link.
Data collection. Ultimately, data were collected at the end of the spring semester and the beginning of summer of 2016. An invitation letter to participate in an online survey designed through Qualtrics was sent to the Deanship of E-Transactions and Communications at KSU via email after getting approval from the Deanship of Scientific Research at the University to distribute the questionnaire among students. The invitation letter was then sent directly via email from the Deanship of E-Transactions and Communications to all enrolled students in KSU campuses. The invitation letter was sent three times within a period of 45 days asking students for their participation to complete the questionnaire (Appendix E).
Data analysis. A total of 875 students participated in the study, with a completion rate of
63% (N= 551). All data were analyzed via SPSS. Frequency, descriptive, Chi-square test,
Spearman correlation coefficient, Mann-Whitney U test, Kruskal-Wallis test, and Preacher &
Hayes (2008) multiple mediation analyses were all used to analyze the data. Missing data were omitted from the analyses.
Additionally, the researchers included further social media analytics data by using
Crimson Hexagon, a leading social media analytics software, to provide useful data and enrich the topic under study. The statistical results were reviewed and approved by a professor who is specialized in biostatistics and epidemiology in the Department of Medicine at the University of
Toledo, located in Ohio. 77
CHAPTER IV. RESULTS
This chapter presents the results of the current investigation. This study aims to assess
Saudis’ knowledge of a current and acute virus that occurred in September of 2012 in the
Kingdom of Saudi Arabia (KSA), known as Coronavirus. The study assesses the level of adherence of the MOH’s preventive measures that seek to reduce Coronavirus among Saudi people. The study adapted Champions’ HBM scale of six dimensions—susceptibility, severity, barriers, cues to actions, perceived benefits, and self-efficacy—to assess the impact of MOH’s
Coronavirus preventive measures on changing Saudi behaviors. This study also measures Saudis’ trust on Coronavirus information disseminated in different media outlets and their attitudes toward the Coronavirus “We Can Stop It” campaign.
The study posed five significant research questions and five hypotheses. The first research question aimed to know the first communication channel Saudis use when seeking
Coronavirus information. The second research question aimed to know what source of information Saudis believe is most credible when seeking Coronavirus information. The third research question aimed to know to what extent Saudi people use the MOH’s website to get
Coronavirus information. The fourth research question asked to what extent Saudi people use other communication channels, like traditional media or social media, to seek Coronavirus information. The fifth research question aimed to measure the level of adherence to Coronavirus preventive measures and healthy behaviors among Saudis.
Furthermore, the study posed five hypotheses. The first hypothesis aimed to assess individual concepts of perceived susceptibility, perceived severity, perceived benefits, self- efficacy, and cues to actions in relation to adopting healthy behaviors and complying with
Coronavirus preventive measures. The second hypothesis aimed to assess individuals’ concepts 78 of perceived barriers and its relation to the MOH’s Coronavirus preventive measures, such as washing hands or wearing a mask when visiting sick people. The third hypothesis aimed to understand if self-efficacy mediates the relationship between perceived severity, perceived barriers, and/or perceived benefits and participants’ preventative health behaviors. The fourth hypothesis posed that students majoring in health fields are more likely to follow the MOH’s
Coronavirus preventive measures than students in other fields. The fifth hypothesis posed that students majoring in agriculture fields are more likely to follow the MOH’s Coronavirus preventive measure than students in other fields. The sixth hypothesis attempted to understand if the credibility of Coronavirus messages is perceived differently by health students than students in other fields. The seventh hypothesis attempted to understand if the credibility of Coronavirus messages is perceived differently by agriculture students than students in other fields. All research questions and hypotheses are discussed in detail in this chapter
Characteristics of Subjects
Characteristics of participants are presented below. The sample comprised of 875 college students aged between 18 and 45 years of age (M= 7.85, SD= 4.35), with more female students
(65.15%) than male (34.35%). A majority of participants were undergraduate students (74.23%) or graduate students (25.77%). Around 30% of participants were majoring in a health- related field compared to only (1.45%) of participants whose majors were in an agriculture- related field.
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Table 3 Sample Characteristics of Current Study
Sample Characteristics n % Age* 18- 24 years 436 79.13 25- 34 years 99 17.95 35- 44 years 15 2.74 45- 54 years 1 0.18
Education* First year in college 64 11.62 Second year 92 16.70 Third year 95 17.24 Fourth year 88 15.97 Fifth year 45 8.17 Sixth year 25 4.54 Graduate 142 25.77 Gender* Female 359 65.15 Male 192 34.85
Field of study* Health or related major 163 29.58
Agriculture or related major 8 1.45
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Table 4
Mean and Standard Deviation of the Health Belief Model
Sub-scales Mean SD
Susceptibility 2.25 0.74 Severity 2.59 0.77 Barriers 2.43 0.69 Benefits 3.78 0.61 Cues to actions 4.05 0.55 Self-efficacy 3.99 0.58
Instrument Reliability
Reliability for the Health Belief Model (HBM) and the Media Credibility subscales in this study were analyzed using Cronbach’s Alpha. Results were similar to the original scales obtained in Champion’s work and Meyer’s credibility scale and are summarized in Tables 5 and
6.
Table 5
Reliability for the Health Belief Model
Scale Current Data Champion’s Data
*Health Belief Model (HBM) Susceptibility 0.84 0.93 Severity 0.82 0.80 Barriers 0.71 0.88 Benefits 0.77 0.80 Cues to Actions 0.80 0.83 Self-Efficacy 0.82 0.88
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Table 6
Meyer’s Media Credibility Scale
Current Data Meyer’s Data
0.94 0.92
Frequency of HBM’s Five Dimensions
Perceived susceptibility. The distribution of perceived susceptibility shows that the majority of respondents have low susceptibility level to Coronavirus. In all five items in the perceived susceptibility scale, at least 50% of the respondents strongly disagree and disagree with each item showing that Saudis have low susceptibility to Coronavirus. For example, around
63% of respondents strongly disagree and disagree with the statement, “I feel I will get
Coronavirus in the future,” whereas only 10% strongly agree and agree with the same statement
(See Table 14, appendix A).
Perceived severity. In the perceived severity of Coronavirus, respondents vary in their responses to each item. For instance, around 45% of respondents agree and strongly agree that the thought of getting Coronavirus scares them. However, around 75% of respondents strongly disagree and disagree with the idea that when thinking about Coronavirus, their hearts beat fast.
Also, around 70% of respondents strongly disagree and disagree with the statement, “I’m afraid to think about Coronavirus.” Around 45% of respondents state that they strongly agree and agree their life would be changed if they were infected with Coronavirus (See Table 15, appendix A).
Perceived barriers. Respondents show different levels of barriers when it comes to adherence to Coronavirus preventive measures. For example, around 50% of respondents strongly disagree and disagree that handwashing stations and/or antibacterial solutions are not 82 available at the places where they spend most of the day. However, 35% of respondents strongly agree/agree that handwashing stations and/or antibacterial solutions are not available at their places where they spend most of the day. Additionally, 75% of respondents strongly disagree/disagree that washing hands with soap and water is not convenient. Also, 79% of respondents strongly disagree/disagree that washing hands is time consuming. However, around
30% of respondents strongly agree/agree that it is difficult to avoid close contact with sick people, while at the same time, around 50% of respondents strongly agree/agree that they are not comfortable wearing a mask to prevent getting infected with Coronavirus (See Table 16, appendix A).
Perceived benefits. Many respondents indicated the benefits of following the MOH’s
Coronavirus preventive measures to reduce the spread of the disease. For instance, more than
85% of respondents believe that covering a mouth with a tissue when sneezing or coughing is a healthy behavior. In addition, more than 90% of respondents believe that when following the
MOH’s Coronavirus recommendations, they will help in minimizing the spread of Coronavirus.
However, only 35% believe in the benefit of avoiding camels to reduce their risk of getting
Coronavirus (See Table 17, appendix A).
Cues to actions. The distribution of cues to actions to Coronavirus shows that respondents have a high level of cues to actions toward Coronavirus. For example, around 95% of respondents believe that maintaining proper hygiene is important to good health. Also, 90% of respondents believe that getting enough sleep will help them to be in good health (See Table 18, appendix A).
Self-efficacy. The distribution of self- efficacy of the preventive measures of Coronavirus show that the majority of respondents have a high level of self-efficacy. In other words, most 83 respondents have high confidence when performing Coronavirus preventive measures. For instance, around 90% of respondents are capable of staying away from camels. However, respondents show a moderate level of self-efficacy toward their ability to identify Coronavirus symptoms. Only 45% of respondent indicate that they are able to identify Coronavirus symptoms
(See Table 19, appendix A).
Frequency Distributions of Media Credibility (See tables in appendix B):
Believability. When respondents were asked to rate the believability of Coronavirus information derived from each communication channel, 92% of respondents indicated that the
MOH’s website is believable/extremely believable followed by the MOH’s Twitter account at
88%, the WHO at 83%, and MOH’s YouTube channel at 79%. Facebook, however, was viewed as the lowest believable source at 34% (See Table 20, appendix B).
Accuracy. Around 90% of respondents indicated that the MOH’s website is an accurate/very accurate source of Coronavirus information, followed by the MOH’s Twitter account at 83%, the WHO at 80%, and The CDC at 78%. Facebook, however, was viewed as the lowest accurate source of information at 42% (See Table 21, appendix B).
Trustworthy. The majority of respondents (89%) viewed the MOH’s website as the most trustworthy source of Coronavirus information, followed by the MOH’s Twitter account
(85%), and the WHO (80%). Facebook was viewed as the most untrustworthy source of
Coronavirus information at 46% (See Table 22, appendix B).
Biasness. Around 53% of respondents indicated that Coronavirus information derived from the MOH’s website is not biased/not biased at all followed by the WHO 51% and the CDC at 50%, Facebook was viewed as the most biased source of information by 24% (See Table 23, appendix B). 84
Completeness. Around 80% of respondents viewed the MOH’s website as a complete/very complete source of Coronavirus information, followed by the WHO at 70%, and the CDC at 68%. Around 49% of respondents indicated that Facebook provide very incomplete/incomplete Coronavirus information (See Table 24, appendix B).
Results of Research Questions
RQ1: Where do Saudi people go first to obtain information about
Coronavirus?
Participants were asked to choose the first place they go to when seeking information about Coronavirus from a list of nine options (Table 7 and figure 4).
The study found that around 39% of participants go first to the Internet search engines, like Google and Yahoo, to seek Coronavirus information, followed by the
MOH’s website at 29%, the WHO’s communication channels at 7%, and the CDC at
3%%. However, 15% of participants did not seek information about Coronavirus at all while less than 2% turned to traditional media, like TV and radio, to seek information about Coronavirus. Also, fewer than 5% of participants turned to doctors and healthcare providers to seek Coronavirus information, and fewer than
2% seek Coronavirus information from their family and friends.
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Table 7
The First Place Saudis Go to Seek Coronavirus Crisis Information
Items n %
The Ministry of Health’s (Website, Twitter, Facebook, 200 28.69 YouTube). The Internet (Google, Yahoo, etc.) 268 38.45
The World Health Organization’s (Website, Twitter, 46 6.60 Facebook, YouTube). Traditional Media (television, newspaper, radio, etc.) 11 1.58
Centers for Disease Control and Prevention’s (Website, 20 2.87 Twitter, Facebook, YouTube).
Family and friends 12 1.72
Doctors or other health providers 32 4.59
I have never sought information about Coronavirus 103 14.78
Other 5 0.72
Total 697 100%
86
The Internet search engines 0.73% (Google, Yahoo, etc.) 2% 2% The MOH's (Website, Twitter, 5% YouTube, Facebook) 3% I have never sought information about coronavirus 7% The WHO's (Website, Twitter, 38.45% YouTube, Facebook) The CDC's (Website, Twitter, YouTube, Facebook) 15% Family and friends
Traditional media (TV, radio, newspaper) Doctors or other health providers 28.70% Other
Figure 4. The first place where Saudis go to seek Coronavirus information.
RQ2: What source of information do Saudis believe is most believable, accurate, trustworthy, complete, and fair when seeking Coronavirus information?
Participants were asked to what extent the crisis information obtained about Coronavirus from each medium is believable, accurate, trustworthy, biased, and complete (Meyer, 1988). An ordinal-Likert scale with 5 points from (1) lower scores to (5) higher scores was used for all five dimensions. Higher scores in the five dimensions mean greater believability, accuracy, trustworthiness, unbiasedness, and completeness. Participants were given 16 communication channels to rate its credibility in regard to Coronavirus information. Across the five dimensions of media credibility, the MOH’s website was the most credible source of Coronavirus information followed by the WHO, MOH’s Twitter account, and the CDC (Table 8).
RQ3: Do Saudi people consider the MOH’s website more credible in obtaining health information related to Coronavirus than traditional media and social media? 87
The descriptive analysis for media credibility scale testing participants’ perceptions of believability, accuracy, trustworthiness, completeness, and biasness of Coronavirus information participants obtain from various communication channels indicated that Saudi people consider the MOH’s website a more credible source of Coronavirus information than traditional media and social media (Also see Table 8). Participants perceived the MOH’s website to have higher believability (M= 4.56, SD= .76), higher accuracy (M= 4.44, SD= .78), higher trustworthiness
(M= 4.45, SD= .80), higher completeness (M= 4.13, SD= 1.00), and less biasness (M= 3.51,
SD= 1.26) than traditional media and social media. Overall, the MOH’s website has the highest credibility ranking compared to other communication channels in regard to Coronavirus information (M= 4.23, SD= .66).
Table 8 The Most Credible Sources of Information When Seeking Coronavirus Information among Saudis
Medium M SD
MOH Website 4.23 0.66 WHO 4.14 0.74 MOH Twitter 4.12 0.72 CDC 4.07 0.77 MOH YouTube 4.02 0.75 Doctors & Health providers 3.88 0.68 MOH Facebook 3.83 0.82 Internet search engines 3.06 0.74 TV 3.04 0.74 YouTube 2.97 0.73 Newspaper 2.90 0.75 Radio 2.90 0.67 Twitter 2.85 0.78 Blogs 2.79 0.64 Family & Friends 2.76 0.75 Facebook 2.57 0.64 Note. Mean and standard deviation of each communication channel. 88
Results for each media credibility dimension is also presented below (See Table 25 in appendix
C).
Believability
The study found that participants rate the MOH’s website as the most believable communication channel (M= 4.56, SD= .76), followed by the MOH’s Twitter account (M= 4.46,
SD= .83), the WHO (M= 4.37, SD= .85), the Ministry of Health’s YouTube channel (M= 4.30,
SD= .90), the CDC (M= 4.27, SD= .90), and doctors and other healthcare providers (M= 4.10,
SD= .76). The traditional media, like TV (M= 3.38, SD= .92), newspaper (M= 3.19, SD= .95), and radio (M= 3.18, SD= .84), have similar believability rankings with the Internet (M= 3.29,
SD= .90) and social media platforms, like Twitter (M= 3.12, SD= .99), YouTube (M= 3.23, SD=
.94) among participants. Participants view Facebook as less believable (M= 2.58, SD= .88), followed by blogs (M= 2.86, SD= .89), and family and friends (M= 2.98, SD= .96).
Accuracy
Participants view the MOH’s website as the most accurate source of information regarding the Coronavirus crisis (M= 4.44, M= .78), followed by the MOH’s Twitter account
(M= 4.30, SD= .89), the WHO (M= 4.30, SD= .89), the CDC (M= 4.24, SD= .91), the MOH’s
YouTube channel (M= 4.17, SD= .92), doctors or other health providers (M= 4.02, SD= .84), and the MOH’s Facebook account (M= 3.97, SD= 1.00). The accuracy of Coronavirus information obtained from traditional media, such as TV (M= 3.07, SD= 1.01) and newspaper
(M= 2.86, SD= 1.01) is similar to the information obtained from the Internet (M= 3.02, SD=
1.02), YouTube (M= 2.99, SD= .99), and Twitter (M= 2.85, SD= 1.03). Facebook is seen as the least accurate source of information (M= 2.53, SD= .85), followed by family and friends (M=
2.66, SD= 1.02), and blogs (M= 2.71, SD= .86). 89
Trustworthy
The MOH’s website is seen as the most trustworthy communication channel to obtain
Coronavirus information (M= 4.45, SD= .80), followed by the MOH’s Twitter account (M=
4.37, SD= .85), the WHO (M= 4.32, SD= .88), the CDC (M= 4.24, SD= .93), the MOH’s
YouTube channel (M= 4.24, SD= .91), doctors or other health providers (M= 4.04, SD= .85), and the MOH Facebook’s account (M= 4.01, SD= 1.02). Participants, however, believe that traditional media, like TV (M= 3.10, SD= 1.02), newspaper (M= 2.96, SD= 1.04), and radio (M=
2.94, SD= .96) are more trustworthy in delivering Coronavirus information than Twitter (M=
2.79, SD= .99) and blogs (M= 2.70, SD= .88). Facebook is seen as the least trustworthy source for Coronavirus information (M= 2.49, SD= .88), while the Internet (M= 2.91, SD= .98) is viewed to have similar trustworthiness to traditional media.
Completeness
When asked to what extent participants believe the crisis information obtained about
Coronavirus from each medium below is complete, the MOH’s website ranks first (M= 4.13,
SD= 1.00), followed by the WHO (M= 4.07, SD= 1.02), the CDC (M= 4.02, SD= 1.01), the
MOH’s Twitter account (M= 3.89, SD= 1.09), the MOH’s YouTube channel (M= 3.85, SD=
1.07), doctors or other health providers (M= 3.72, SD= 1.01), and the MOH’s Facebook account
(M= 3.71, SD= 1.11). The Internet is viewed to have more complete information about the
Coronavirus crisis (M= 3.00, SD= 1.10) than traditional media, like TV (M= 2.70, SD= 1.06), radio (M= 2.54, SD= .94), and newspaper (M= 2.62, SD= 1.07), and social media, such as blogs
(M= 2.72, SD= .93) and Twitter (M= 2.53, SD= 1.05). Facebook is the least source to provide complete information about Coronavirus (M= 2.41, SD= .93), followed by family and friends
(M= 2.50, SD= 1.03), and Twitter (M= 2.53, SD= 1.05). 90
Biasness
When respondents were asked to what extent they believe the crisis information obtained about Coronavirus from each medium below is biased, participants indicated they believe that both the WHO (M= 3.57, SD= 1.22) and the CDC (M= 3.56, SD= 1.21) are less biased in regard to delivering Coronavirus information than the MOH’s website (M= 3.51, SD= 1.26), the
MOH’s Twitter account (M=3.49, SD= 1.24), the MOH’s YouTube channel (M= 3.45, SD=
1.18), and doctors or healthcare providers (M= 3.43, SD= 1.10). Respondents believe that newspapers (M= 2.88, SD= .94), and Facebook (M= 2.88, SD= .88) are the most biased sources of Coronavirus followed by television (M= 2.92, SD= .96), blogs (M= 2.91, SD= .82), family and friends (M= 2.93, SD= 1.02), and radio (M= 2.94, SD= .86).
Therefore, when combining the media credibility subscales, the descriptive analysis shows that the MOH’s website is perceived to be more credible (M= 4.23, SD= .66), followed by the WHO (M= 4.14, SD= .74), the MOH’s Twitter account (M= 4.12, SD= .72), the CDC (M=
4.07, SD= .77), and the MOH’s YouTube channel (M= 4.02, SD= .75).
RQ4: To what extent do Saudi people use the MOH’s website to obtain health information related to Coronavirus?
When asked to indicate the likelihood of using communication channels to seek information about Coronavirus ranging from 1= extremely unlikely and 5= extremely likely,
39.93% of respondents (n=236) stated they are extremely likely to use the MOH’s website to seek Coronavirus information, whereas 24.70% (n= 146) are likely to use the MOH’s website.
However, 6.77% (n= 40) indicated they are extremely unlikely to use the MOH’s website to get
Coronavirus information, and 9.64% (n= 57) are unlikely to use the MOH’s website. Around 91
18.95% (n=112) stated they are neutral in using the MOH’s website to obtain Coronavirus information.
RQ5: To what extent do Saudi people use other communication channels to obtain information about Coronavirus?
The Internet search engines
When asked to indicate the likelihood of using communication channels to seek information about Coronavirus ranging from 1= extremely unlikely and 5= extremely likely (see
Table 26 in appendix C), 57.19% (n=338) stated they are extremely likely to use the Internet search engines (Google, Yahoo, etc.) to seek Coronavirus information, whereas 30.12% (n= 178) are likely to use the Internet to obtain Coronavirus information. Only 2.54% (n= 15), however, said they are extremely unlikely to use the Internet to seek Coronavirus information, followed by
2.03% (n=12) who are unlikely to use the Internet to get Coronavirus information. Around
8.12% (n= 48) of respondents stated they are neutral when it comes to using the Internet to seek
Coronavirus information.
Social Media
When asked to indicate the likelihood of using communication channels to seek information about Coronavirus ranging from 1= extremely unlikely and 5= extremely likely, respondents said they are more likely to rely on Twitter in getting Coronavirus information than any other social media platforms. Around 39.09% (n=231) of the respondents stated they are extremely likely to use Twitter to seek Coronavirus information, whereas 34.01% (n=201) are likely to use Twitter. Around 57% of respondents (n= 338), however, are extremely unlikely to use Facebook and 20.81% (n= 123) are unlikely to use Facebook to acquire Coronavirus information. Additionally, 34.52% of respondents (n= 204) are likely to use YouTube to seek 92
Coronavirus information, and 24.03% of respondents (n= 142) are extremely likely to use
YouTube to seek Coronavirus information. When asked about blogs, around 31% of respondents
(n= 183) stated they are neutral, 43% (n= 257) are extremely unlikely and unlikely, and 26% of respondents (n= 151) are extremely likely and likely to use blogs to obtain Coronavirus information.
In regard to the MOH’s social media channels, 42.5% of respondents (n= 250) said they are extremely likely to use MOH’s twitter account to seek Coronavirus information, and 27.41%
(n= 162) are likely to use it. Around 17% of respondents (n=103) are extremely unlikely and unlikely to use MOH’s Twitter account. The majority of respondents, 70% (n=413), are extremely unlikely and unlikely to use the MOH’s Facebook to seek Coronavirus information.
However, only 17% (n= 100) are extremely likely and likely to use the MOH’s Facebook account. Around 45% of respondents (n= 270) are extremely likely and likely to use MOH’s
YouTube channel for Coronavirus information, and 33.5% of respondents (n= 198) are extremely unlikely and unlikely to obtain Coronavirus information from the MOH’s YouTube channel.
Traditional Media
Around 44.50% (n= 263) of respondents indicated they are extremely unlikely to seek
Coronavirus information in newspapers, and 23.01% (n=134) are unlikely to use newspapers to seek Coronavirus information. Only 13% of respondents (n= 79) stated they are extremely likely and likely to use newspapers to seek Coronavirus information. Respondents are also unlikely to use radio to seek Coronavirus information. Around 42.47% of respondents (n= 251) are extremely unlikely to obtain Coronavirus information from radio, and 21.49% (n= 127) of respondents are unlikely to use radio. Only 18% (n= 102) of respondents use radio to get 93
Coronavirus information. However, 40% of respondents (n= 239) rely on television for
Coronavirus information, whereas 30% (n= 177) do not rely on television to obtain Coronavirus information.
Other Communication Channels
Around 45% of respondents (n= 268) stated they are extremely likely and likely to turn to the WHO to seek Coronavirus information compared to 37% of respondents (n= 220) who are extremely likely and likely to turn to the CDC. Nearly 32% of respondents (n= 188) are extremely unlikely and unlikely to obtain Coronavirus information form the WHO compared to
38% of respondents (n= 224) who are extremely unlikely and unlikely to use the CDC. Around
25% of respondents (n= 147) are neutral in using the CDC compared to 23% of respondents (n=
135) who state the same about the WHO. Nearly 55% of respondents (n= 324) are extremely likely and likely to ask friends and family about Coronavirus information compared to 72% of respondents (n= 428) who get Coronavirus information from doctors and health providers.
Nearly 19% of respondents (n= 114) are extremely unlikely and unlikely to obtain Coronavirus information from family and friends compared to 10% (n= 59) who do not seek Coronavirus among doctors and health care providers.
RQ6: To what extent do individuals in Saudi Arabia adopt proper health practices that have been promoted by the MOH to combat Coronavirus?
To answer this question, seven multiple choice questions were included in the questionnaire to measure the adherence of Coronavirus preventive measures recommended by the MOH (See Table 27 in appendix C). First, respondents were asked how many times they wash their hands daily. Around 30% of respondents (n= 170) stated that they wash their hands between 5-7 times, 23.20% of respondents (n= 127) wash their hands 3-5 times, 7-9 times by 94
21.20% (n=117), and10 or more times by 20.65% (n=114). Only 3.99% of respondents (n= 22) wash their hands 1-2 times daily. Second, participants were asked to report whether they use a mask when visiting sick people or not. The majority of participants at 55.25% (n= 305) stated they do not visit sick people, whereas 27.36% of respondents (n= 151) stated they do not wear a mask when visiting sick people. Only 17.39% of respondents (n= 96) use a mask when visiting sick people. Third, respondents were asked if they follow a healthy and balanced diet to increase their immune system. 44.20% of respondents (n= 244) stated they follow a healthy diet while
55.80% of respondents (n= 308) do not. Fourth, respondents were asked whether they cover their mouths or use tissues when coughing and sneezing. Around 87.50% of people (n= 483) say yes and 12.50% (n= 69) say no.
Fifth, participants were asked whether if they get enough sleep every day or not. 68% of respondents (n= 371) said they get enough sleep everyday whereas 32.79% (n= 181) said they do not get enough sleep daily. Sixth, participants were asked whether they keep themselves away from camels or not. Around 90.40% of people (n= 499) said they keep themselves away from camels while only 9.60% of respondents said they do not (n= 53). Seventh, participants were asked for how many minutes they exercise weekly. Around 36.41% (n= 201) of respondents stated they do not exercise at all, 34.24% (n= 189) exercise less than 75minutes weekly, 15.58%
(n= 86) exercise between 75-140 minutes, and 13.77% (n= 76) exercise for 150 minutes or more weekly.
Results of Research Hypotheses
H1: Scores on the individual concepts of perceived susceptibility, perceived severity, perceived benefits, self- efficacy, and cues to actions will be positively correlated with the
MOH’s Coronavirus preventive measures, such as washing hands. 95
To answer H1, different statistical analyses were run to test the correlations between
HBM and the different MOH’s Coronavirus preventive measures.
1.1 Frequency of Washing Hands
The data for the individual’s HMB sub-scales was analyzed using the Spearman correlation coefficient. The findings are summarized in Table 9.
Table 9 Sub-Scales Correlations Sub-Scale Spearman Rho
Susceptibility .078 Severity .085* Benefits .075 Cues to Actions .190** Self- efficacy .145**
* p < .05 ** p <.001. (2 tailed)
Support for H1 was found for three of the six sub-scales of HBM. Perceived severity (p<
.05), cues to actions (p< .001), and self-efficacy (p< .001) were positively correlated with the frequency of washing hands at a statistically significant level. The correlation between perceived susceptibility and benefits and the frequency of washing hands was not significant.
1.2 Wearing Masks when visiting sick people
To test the association between the HBM and the behavior of wearing a mask when visiting sick people, a nonparametric Kruskal-Wallis test was conducted. Support for H1 was found for the HBM and the preventive measure of wearing a mask when visiting sick people (p<
.001), χ2 (2) = 35.863. Respondents with high HBM scores are more likely to wear a mask than respondents with lower HBM scores. Median scores for each group is summarized in Table 10. 96
Table 10 Median Scores
Do you wear a mask when you visit sick HBM
people?
Yes 131.00
NO 122.00 I don’t visit sick people 125.00
Total 125.00
1.3 Staying away from Camels
The Mann-Whitney U test indicated that there is a significant difference between respondents in regard to keeping away from camels (U= 7103.5), (P< .001). Respondents with high HBM scores are more likely to keep themselves away from camels (Mdn= 126) than those with lower HBM scores (Mdn= 117). Thus, H1 is supported.
1.4 Getting enough Sleep
The Mann-Whitney U test indicated that there is a significant relationship between the
HBM and getting enough sleep (U= 29161.0), (p< .05). Respondents with high HBM scores
(Mdn= 126) are more likely to get enough sleep than those with less scores (Mdn= 123).
1.5 Following Healthy and Balanced Diet
The Mann-Whitney U test indicated that there is a significant relationship between the
HBM and the preventive Coronavirus measures of following a healthy and balanced diet (U=
29275.0), (p< .001). Respondents with higher HBM scores (Mdn= 128) are more likely to follow a healthy and balanced diet than those who do not (Mdn= 123).
1.6 Covering a Mouth or Using a Tissue when Coughing or Sneezing 97
The Mann- Whitney U test indicated there is a relationship between high scores of HBM and the Coronavirus preventive measure of covering a mouth or using a tissue when coughing or sneezing (U= 11624.0), (p<.001). People with high scores of HBM are more likely to cover their mouths when coughing or sneezing (Mdn= 126) than respondents with low HBM score (Mdn=
121).
1.7 Time Exercising Weekly
The data for the individual’s HMB sub-scales were analyzed using the Spearman correlation coefficient. Support for H1 was found for three of the six sub-scales of HBM (Table
11). Perceived benefits (p<.01), cues to actions (p<.001), and self-efficacy (p<.01) were positively correlated with the time spent exercising every week. Perceived severity (p< .05) were negatively correlated with the time spent on exercising every week. The correlation between perceived susceptibility (p=.279) and time spent on exercising was not significant.
Table 11
Sub-Scales Correlations Sub-Scale Spearman Rho
Susceptibility -.046
Severity -105*
Benefits .119**
Cues to Actions .240***
Self- efficacy .122**
* p < .05 ** p <.01 ***p <.001. (2 tailed) 98
H2: Scores on the concepts of perceived barriers will be negatively correlated with the frequency of the practice of MOH’s Coronavirus preventive measures, such as washing hands.
2.1 Frequency of Washing Hands
The data for the individuals’ perceived barriers was analyzed using the Spearman correlation coefficient. Respondents with high score barriers are less likely to wash their hands than those with higher frequency. Support for H2 was found (p< .001).
2.2 Wearing Masks When Visiting Sick People
The data for this sub-scale were analyzed using the nonparametric Kruskal-Wallis Test.
Support was found for perceived barriers with wearing masks when visiting sick people (p<
.001), χ2 (2) = 42.996. Respondents with high barriers scores (Mdn= 18) are less likely to wear a mask when visiting sick people than respondents with less barriers scores (Mdn= 14).
2.3 Staying away from Camels
The Mann-Whitney U test indicated that there is a significant difference between respondents in regard to being away from camels (U= 9565.0), (P< .001). Respondents with high perceived barriers scores are less likely to keep themselves away from camels (Mdn= 20) than those with less perceived barriers scores (Mdn= 16). Thus, H2 is supported.
2.4 Getting enough Sleep
The Mann-Whitney U test was used to examine the association between this sub-scale and the preventive Coronavirus measure of getting enough sleep. Support was found for the perceived barriers and getting enough sleep (U= 28597.5), (p< .01). Thus, respondents with high perceived barriers scores (Mdn= 17) are less likely to get enough sleep than respondents with less scores (Mdn= 16). Thus, H2 was supported. 99
2.5 Following a Healthy and Balanced Diet to Increase your Immune System
The Mann-Whitney U test was run to examine the relationship between the perceived barriers and the preventive Coronavirus measures of following a healthy and balanced diet. A significant relationship was found (U= 30888.00), (p< .001). Respondents with higher barriers scores (Mdn= 17) are less likely to follow healthy and balanced diet than those with less scores
(Mdn= 16). Thus, H2 was supported.
2.6 Covering a Mouth or Using a Tissue when Coughing or Sneezing
The Mann-Whitney U test indicated there is a relationship between high scores of perceived barriers and the Coronavirus preventive measure of covering a mouth or using a tissue when coughing or sneezing (U= 11727.0), (p< .001). Respondents with high scores of perceived barriers are less likely to cover their mouths when coughing or sneezing (Mdn= 19) than respondents with low scores (Mdn= 16). Thus, H2 was supported.
2.7 Time Exercising Weekly
The data for the perceived barriers were analyzed using the Spearman correlation coefficient. Support for this sub-scale was found (Spearman’s rho= -.126), (p< .01). Thus, there is a negative relationship between perceived barriers scale and the time spent on exercising every week. H2 is supported.
H3: Self-efficacy mediates the relationship between perceived severity, perceived barriers, and/or perceived benefits and participants’ preventative health behaviors.
Multiple regression analyses, Preacher and Hayes 2008 Multiple Mediation, and bootstrapping analyses were conducted to assess all components and variables of the proposed and hypothesized mediation. Only significant and full mediation results are reported. 100
1- Multiple regression analyses were conducted to investigate the hypothesis that self-
efficacy mediates the relationship between perceived severity, perceived barriers, and/or
perceived benefits and participants’ preventative health behaviors. Results indicated that
perceived barriers were negatively related to self-efficacy (B= -.440, SE= .042, P<. 001)
and that the mediator, self- efficacy, was negatively associated with the preventive health
behavior of following a healthy and balanced diet (B= -.072, SE= .019, P<. 001). Results
found that perceived barriers was positively associated with following a healthy and
balanced diet (B= .065, SE= .018, P<. 001). Because both a and b paths were significant,
mediation analyses were conducted using bootstrapping method with bias-corrected
confidence estimates and that 95% confidence interval of the indirect effect was obtained
with 5000 bootstrap resample (Preacher & Hayes, 2008). The indirect effect was
significant (B= .032, CI= .013 to .056). The direct effect of barriers on the preventive
health behavior of following a healthy and balanced diet was not significant (B= .035,
SE= .020, P=. 08). Thus, the mediation analysis indicates that the mediator, self-efficacy,
mediates the relationship between barriers and the preventive health behavior of
following a healthy and balanced diet to increase the immune system. See Table 12 and
Figure 5.
2- Multiple regression analyses were conducted to investigate the hypothesis that self-
efficacy mediates the relationship between perceived severity, perceived barriers, and/or
perceived benefits and participants’ preventative health behaviors. Results indicated that
barriers was negatively associated to self-efficacy (B= -.440, SE= .042, P<. 001) and that
mediator, self-efficacy, was negatively associated with the preventive health behavior of
staying away from camels (B= -.108, SE= .026, P<. 001). Results also found that barriers 101
was positively associated with being away from camels (B= .091, SE= .028, P<. 001).
Because both a and b paths were significant, mediation analyses were conducted using
bootstrapping method with bias-corrected confidence estimates and that 95% confidence
interval of the indirect effect was obtained with 5000 bootstrap resample (Preacher &
Hayes, 2008). The indirect effect was significant (B= .047, CI= .025 to .080). The direct
effect of benefits on the preventive health behavior of staying away from camels was not
significant (B= .050, SE= .031, P= .105). Thus, the mediation analysis indicates that the
mediator, self-efficacy, mediates the relationship between benefits and the preventive
health behavior of staying away from camels (See Table 13 and figure 6). Hence, H3 is
supported.
Table 12
Self- Efficacy as a Mediator between Perceived Barriers and Following a Healthy and Balanced
Diet
Coefficient SE T z p
Effects of barriers on self-efficacy (a path) -0.440 0.042 -10.371 0.001 Effects of self-efficacy on Coronavirus’ preventive measure (following a healthy and balanced diet to increase the immune system). (b path) -0.726 0.0197 -3.676 0.001 Direct effects of barriers on following a healthy and balanced diet to increase the immune system (c path) 0.065 0.018 3.536 0.001 Bootstrap results for indirect effects 95% confidence Bootstrap estimate interval Estimate SE Lower Upper Indirect effect of barriers on following a healthy and balanced diet 0.0324 0.011 0.013 0.056 to increase the immune system through self-efficacy (a × b path)
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Self-Efficacy
-.072**
-.44**
-.032** Following a Percieved healthy and Barriers balanced diet
Figure 5. Indirect effect of Perceived Barriers on following a Healthy and Balanced Diet through
Perceived Self-Efficacy. Note. ** p < .001
Table 13 Self-Efficacy as a Mediator between Perceived Barriers and Staying Away from Camels
Coefficient SE T z p
Effects of barriers on self-efficacy (a path) -0.440 0.042 -10.371 0.001
Effects of self-efficacy on Coronavirus’ preventive measure (staying away from camels). (b path) -0.108 0.0269 -4.023 0.001
Direct effects of barriers on staying away from camels (c path) 0.091 0.028 3.211 0.001 Bootstrap results for indirect effects 95% confidence Bootstrap estimate interval Estimate SE Lower Upper Indirect effect of barriers on staying away from camels through 0.0491 0.011 0.023 0.080 self-efficacy (a × b path)
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Self-Efficacy
-.010**
-.044**
.091**
Percieved Staying away Barriers from camels
Figure 6. Indirect effect of Perceived Barriers on staying away from camels through Perceived
Self-Efficacy. Note. ** p < .001
H4: Students in health-related majors are more likely to follow the Ministry of Health's
Coronavirus preventative measures than students in other majors.
Relationships between the HBM of students in health-related majors and the Ministry of
Health’s preventive measures were tested.
1. Frequency of Washing Hands
The Mann- Whitney U test indicated that there is no significant relationship between students in health-related majors and frequency of washing hands. H4 is not supported in this preventive measure (p=.435).
2. Wearing Masks When Visiting Sick People
A Chi-Square test of independence indicated that there is a significant relationship between students in health majors and wearing masks when visiting sick people, χ2 (2, N= 551) =
9.90, P<. 05, meaning students majoring in health fields are more likely to wear a mask when 104 visiting sick people (25.2%) than students in other fields (14.2%). H4 is supported in this preventive measure.
3. Staying away from Camels
A Chi-Square test of independence found that there is a significant relationship between students in health majors and staying away from camels, χ2 (1, N= 551) = 4.47, P<. 05, meaning that students majoring in health fields are more likely to stay away from camels (94.5%) than students in other fields (88.7%). H4 is supported in this preventive measure.
4. Getting enough sleep
A Chi-Square test of independence found that there is a significant relationship between students in health majors and the preventive measure of getting enough sleep, χ2 (1, N= 551) =
5.18, P<. 05, finding that students majoring in health fields are less likely to get enough sleep
(60.1%) than students in other fields (70.1%). H4 is supported in this preventive measure.
5. Following a Healthy and Balanced Diet
A Chi-Square test of independence indicated that there is no significant relationship between students in health majors and following a healthy and balanced diet (P= 057). H4 is not supported in this preventive measure.
6. Covering a Mouth or Using a Tissue when Coughing or Sneezing
A Chi-Square test of independence found that there is a significant relationship between students in health majors and covering a mouth or using a tissue when coughing or sneezing, χ2
(1, N= 551) = 8.62, P<. 05, meaning that students majoring in health fields are more likely to cover their mouths or use a tissue when coughing or sneezing (93.9%) than other students in other fields (84.8%). H4 is supported in this preventive measure.
7. Time Exercising Weekly 105
The nonparametric test, Mann-Whitney U, indicated that there is no significant relationship between students majoring in health fields and time devoted to exercise per week
(P= 152). H4 is not supported in this preventive measure.
H5: Students in agriculture-related majors are more likely to follow the Ministry of
Health's Coronavirus preventative measures than students in other majors.
Relationships between the HBM of students in health-related majors and the Ministry of
Health preventive measures could not be tested due to the small number of agriculture students who participated in this study. The small number would not provide any significant statistical data.
H6: Students in health-related majors will view the credibility of Coronavirus messages differently than students in other majors.
The nonparametric test, Mann-Whitney U, indicated that there is a significant relationship between majoring in health-related fields and the credibility of Coronavirus messages (U= 19343.00), (P<. 0.05). Thus, students in health-related majors (Mdn= 266) viewed
Coronavirus messages as less credible compared to students in other majors (Mdn= 273). H6 is supported.
H7: Students in agriculture-related majors will view the credibility of Coronavirus messages differently than students in other majors.
Because of the small number of students who identified themselves in agricultural-related majors, no test were performed for this hypothesis.
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Social Media Analytics
After analyzing the quantitative data using SPSS, the researcher ran further social media analyses to enrich the topic under study. The researcher used Crimson Hexagon, a leading social media analytics software, to explore more information about Coronavirus. The researcher used key words, like Coronavirus, corona, and MERS when pulling the data. The data collected was from September 01 of 2012 to June 09 of 2017 and yielded the following results:
Figure 7. Content sources. Coronavirus was most mentioned on Twitter followed by news organizations, Facebook, and YouTube.
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Figure 8. Tweets by numbers.
108
Figure 9. Top mentions in Twitter (the most frequently mentioned Twitter handles in posts).
The World Health Organization (WHO) followed by the Ministry of Health in Saudi Arabia are the top mentioned Twitter handles in posts worldwide.
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Figure 10. Coronavirus posts in details.
110
Figure 11. Coronavirus’ word cloud. The Coronavirus’ word cloud shows the most words people exchange about Coronavirus on social media. Hashtags and keywords, like #Coronavirus, #mers,
@Saudimoh, health, respiratory, virus, and syndrome are among the top words when talking about Coronavirus.
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Limitations of the Study
There were six limitations to this study. The first was the use of a convenience sample.
Although a convenience sample is less expensive than other types of sampling, it can provide useful information for researchers in a short period of time (Wimmer & Dominick, 2011). Cost was a prohibitive factor in gaining a sample from a larger population. This led to the second limitation, the use of college students as the unit of analysis. College students may have different characteristics than the general public. It is worth noting, however, that King Saud University is located in Riyadh, the city with the largest number of Coronavirus cases. It is the largest university in the country in terms of student enrollment that hosts both domestic students from various regions in the country and international students. Third, the investigator recognizes that people may have been practicing preventative behaviors before the campaign or are practicing them without having been exposed to the campaign; however, an argument can be made that the
MOH’s strong credibility has positively influenced attitudes and behaviors in following preventative recommendations. As with any health campaign, it is near impossible to claim that the results were directly related to the campaign and not other influences. Non-response bias was a fourth limitation of this study. While the email invitation to participate in this study was sent to all KSU students, only 875 participated in the study, leaving a large number of KSU students who might carry different perspectives about the topic under study. The study also did not include baseline data or a control group to assess the credibility of the MOH’s Coronavirus messages but relied on participants self-reporting after the occurrence of the Coronavirus crisis.
Finally, the study did not explore perspectives of healthcare workers or the MOH officials who may add different and significant perspectives to the topic under study.
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CHAPTER V. DISCUSSION
The purpose of this study was to examine how Saudi people seek information during a major health outbreak, Coronavirus, and credibility factors of the Ministry of Health’s (MOH)
Coronavirus campaigns after the MOH’s initial and improper response to the Coronavirus crisis at an early stage. The study then assessed the relationship of MOH messages to the practice of preventative behaviors and if self-efficacy mediates the relationship between perceived severity, perceived barriers, and/or perceived benefits and participants’ preventative health behaviors.
Finally, the study looks at college students to see if there is a relationship between those in health and agriculture majors and their likeliness to follow MOH recommendations.
The study utilized an online survey disseminated to college students with the aim to assess perceptions of how the MOH in the Kingdom of Saudi Arabia (KSA) handled the crisis.
Although the sample of college students has some limitations, use of this population makes sense in KSA since around 70% of Saudis are under the age of 30 years.
This study used a modified version of Champion’s Health Belief Model (HBM) (1993) scale and Meyer’s (1988) Media Credibility scale to assess the compliance of Coronavirus preventive measures and the credibility of Coronavirus messages in different communication channels. The study found that the MOH did make efforts to raise awareness and educate residents of KSA about the preventive measures of Coronavirus, thus leading to an increased level of adherence to Coronavirus preventive measures among Saudi people. This would not happen without the implementation of the two-way symmetrical communication strategy that was proposed by Gruing’s model. The shift from one-way communication to a two-way symmetrical strategy enabled the MOH to regain people’s trust and hope after its failure in the early stage of the crisis. 113
Information Seeking Behaviors
Participants were asked to select from various communication channels where they would go first to seek Coronavirus information. The study shows that the MOH is considered a second place to obtain Coronavirus among Saudis (29%) after the Internet search engines (38%).
This is relatively consistent with the Fox & Duggan (2013) study that found the majority of
Internet users go first to the Internet search engines, like Google and Yahoo, to seek health information. It is also relative to Bawazir, Al- Mazroo, Jradi, Ahmed, & Badri’s (2017) study that found the majority of Saudis who live in Riyadh receive Coronavirus information from the
Internet. This is also similar with Jradi’s (2016) study which found that the Internet was the first source of Coronavirus information to Saudis. Ranking the MOH as the second place to seek
Coronavirus information after the Internet search engines is also consistent with crisis communication guidelines in which an organization should position itself as a main source of information to tell its side of the story during a crisis (Coombs, 2014a). Being the main source of information during a crisis ensures that an organization is in charge of handling the flow of accurate information (Coombs, 2007). The MOH, in fact, declares that the website is the main hub for Coronavirus information. A Saudi online newspaper, Makkah Online, states that seasonal influenza and Coronavirus are the most searched topics in the MOH’s website (2017). This may indicate that people started to gain trust in the information disseminated by the MOH after its initial response to Coronavirus crisis. The study also revealed that over 50% of participants seek
Coronavirus information once or twice a year while 23% of participants seek Coronavirus information once every other month. Only 5% of participants seek Coronavirus information one to two times weekly, and 10% seek Coronavirus information once or twice a month. This may indicate two possibilities. Either the public campaign initiated by the MOH has reached a large 114 number of people and provided them with sufficient Coronavirus information so there is no reason to search Coronavirus information regularly, which is what we believed according to our assessment of the MOH campaign, or people in KSA did not care that much about the crisis. If it is the second possibility, then a lot of work has to be done by the MOH to address the risk and the impact of Coronavirus on the Saudi society. However, there is some indication that the second possibility is not the case. In this study, the majority of participants showed a high level of confidence on how to properly perform Coronavirus’ preventive measures, such as wearing a mask properly. This is would not happen without having knowledge and exposing a good amount of information.
Credibility of Coronavirus Information
The study found that the MOH’s website is seen as the most credible source of information among the other 15 communication channels, including international organizations.
This is would not happen without the implementation of a strategic and effective policy that emphasizes transparency, accountability, accuracy, and engagement with the public. The credibility of the source of information is imperative to encourage individuals to act upon the intended behaviors. As Hovland & Weiss (1951) stated, when a message comes from a highly credible source, individuals are more likely to change their opinions and take actions than when it comes from low credible source. This indicates the importance of maintaining transparency, accuracy, integrity, and fairness during major crises. Paradoxically, this study found that participants are more likely to trust the information they get from traditional media, particularly television, than social media, like Twitter, Facebook, YouTube, and blogs. They are also more likely to trust information from traditional media than family and friends. More specifically,
Facebook is found to have the least credibility scores among all five dimensions (believability, 115 accuracy, trustworthy, fairness, and completeness) compared to other communication channels.
This is consistent with the Pew Research (2016) report that found people have less confidence and trust in the information they get from social media. This is also quite similar to the Dennis et al. (2015) study that found television is considered the most reliable communication channel among Saudis to get information. Although this study found that television carries more credibility than Twitter and Facebook, respondents of this study stated that social media accounts administrated by health institutions, like the MOH, the WHO, and the CDC, have more credibility than TV. For instance, Saudis perceived the MOH’s Twitter account, the MOH’s website, and the MOH’s YouTube to be more credible in obtaining Coronavirus information than
TV. Also, the study found that Saudis consider YouTube to be more credible than all traditional media. This indicates the importance of employing short videos when addressing public health issue, such as Coronavirus. Finally, the type of messages, sources, and the pre-existing knowledge about the topic play significant roles in how individuals perceive and process
Coronavirus information (Hovland & Weiss, 1951). Thus, focusing on crafting tailored messages along with recruiting famous experts who have high credibility among the Saudi society may be an advantage to further advance the MOH’s plans in regard to Coronavirus.
The Likelihood of Using Different Communication Channels to Seek Coronavirus
Information
The study found that majority of participants are more likely to use social media to obtain information about Coronavirus than traditional media. This is relatively consistent with the Pew
Research (2016) findings that indicate traditional media is witnessing a dramatic decrease in the number of people who use it, especially newspapers. In the U.S., among younger generations between ages 18- 29, the dependency on getting information from traditional media is much less 116 than any other age groups and that younger generations are more likely to use digital media, apps, and social networking sites to get their information compared to older generations, according to the Pew research (2016) report.
Health Belief Model and Adherence to Coronavirus Preventive Measures
The study found that participants have high scores in regard to the Health Belief Model’s
(HBM) five dimensions (susceptibility, severity, benefits, cues to action, and self-efficacy) are more likely to comply with the MOH’s guidelines and instructions. For instance, people with higher self-efficacy, cues to action, and perceived severity are more prone to wash their hands than those with lower scores. Another example is that respondents with high HBM scores are more likely to wear a mask when visiting sick people. Such findings are consistent with
Champion’s (1990) findings of the correlation between high HBM scores and the frequency of breast self-examination. Champion (1985) also found that HBM score is a significant predictor of frequency of breast self- examination. This also indicates that when individuals perceive a source of information to be credible, they are more likely to follow any instructions and adhere to the health preventive measures provided by officials. Also, this proves the imperative and effectiveness of public health campaigns and tailored messages during an epidemic and major crisis on changing people behaviors.
The study found that respondents with high barriers scores are less likely to follow the
MOH’s Coronavirus preventive measures. Specifically, individuals with a high level of barriers
(e.g. cannot avoid close contact with sick people, or do not wear a mask because it is inconvenient) are less likely to adhere to Coronavirus preventive measures, like washing hands, covering mouth with a tissue when coughing or sneezing, wearing a mask when visiting sick people, getting enough sleep and eating healthy food to strengthen the immune system, and 117 staying away from camels. Hence, these findings point to the importance of raising awareness to reduce these barriers through addressing the challenges and obstacles that most Saudis encounter when following Coronavirus guidelines in order to reduce the epidemic in the country and promote healthy practices among the Saudi society. This could happen through further studies, like focus group studies or interviews with a group of Saudis from different ages and backgrounds to better understand the barriers that prevent people from making the behavior change. Campaign messaging could be developed to educate and provide tools to help individuals overcome these barriers. For example, focus group studies or interviews could help campaign planners better understand why some individuals do not exercise or eat healthy to boost the immune system. Understanding this would add to the current study and would explain some complicated issues of why Saudis choose to follow some Coronavirus preventive measures and ignore the others. It would also help the MOH to know if there are some shortcomings of its campaigns so it can overcome it and improve in near future.
Understanding barriers is important in not only comprehending the reasons why people do choose to follow healthier guidelines, but also to understand why they cannot follow these guidelines. Campaign planners must understand the social, economic, religious and cultural reasons why people cannot adopt the recommended behavior. For example, individuals may live in regions of a country that are poorer than others and do not have access to healthy food. Also,
KSA has a large number of expats who may carry different perceptions of preventive measures for Coronavirus and need extra efforts or different approaches to adhere to preventive measures for Coronavirus. For example, many of camel herders are expats; hence, encouraging them to be part of the solutions by offering intensive education and providing them with advanced techniques to determine infected camels and uncomplicated ways of reporting any suspicious 118 cases may increase the effectiveness of the MOH’s Coronavirus campaign. What the MOH has to keep in mind, however, is that many camel herders and people live in tents and may lack some resources, such as tissues, soap and water, and masks; therefore, tackling these impediments is critical to the efforts of eradicating Coronavirus from the country. The MOH could offer tissues, masks, and soaps to those camel herders to ensure safety and proper health practices. Because many of those people live in the desert and away from cities and towns, the lack of resources and access to preventive measures are expected. Therefore, the MOH, in cooperation with other government entities, should create a crowdsource mapping of the number of camel herders and people who live in tents and their geographical locations and movements to better understand, communicate, organize, and mobilize assistance and resources to those people. Having sufficient data about camel herders and people living in the desert could help the MOH to develop and apply healthy interventions efficiently and in a timely manner.
Furthermore, common social and cultural behaviors may be another reason that prevents the MOH from achieving its goals and eradicating Coronavirus from the country. Although
Coronavirus could be easily transmitted from one person to another, it is important to take into consideration that many daily habits and cultural behaviors, such as shaking hands and cheek kissing, in Saudi society could largely contribute to the spread of the disease. Therefore, it would be preferable to specifically address these behaviors and advise people to be more cautious in these regards. This could be tackled by crafting persuasive key messages and short videos to articulate the importance of lifting these behaviors at least during this critical time. The common practice of medicine, like acupuncture, herbs, cupping, faith healing, and light therapy etc., to heal and treat different chronical and even complicated diseases, such as cancer in KSA (Al-
Rowis, Al-Faris, Gad Mohammad, Al-Rukban, Abdulghani, 2010; Mohammed et. al., 2015) may 119 also play a significant role in delaying the extradition of Coronavirus. This is when some people try alternative methods of treatments when feeling ill. A study conducted in Riyadh city and
Riyadh suburbs found that the majority of traditional medicine seekers are elderly people and illiterate (Al-Rowais et al., 2010). This is significant and cannot be ignored as most of
Coronavirus cases are older people with pre-existing conditions (WHO, 2015a; CDC, 2016e).
Thus, designing proper messages with proper communication channels that target older people, such as individual sessions to explain the importance of implementing Coronavirus preventive measures is essential. The MOH could also encourage and educate family members who have older people living in the same household to take extra precautions to minimize unhealthy behaviors, such as being close to sick people or not following a healthy diet, and reduce the spread of Coronavirus among elderly.
Understanding all social determinants of health, such as resources, socio-economic, poverty, level of education, and also all cultural and religious aspects of the society is crucial to any health campaigners (CDC, 2017a). This allows officials and governments to achieve health equity in which all individuals have equal access to health services and no one is disadvantaged because of his/her socioeconomic circumstances (CDC, 2017a). Additionally, having sufficient data and understanding the target audience may help the MOH to tailor key messages effectively and mobilize assistance to the impacted areas in a timely manner. Also, it would help the MOH to understand which group(s) or area(s) underperformed so it can move extra assistance and provide additional support to those areas. Having an updated set of data and comprehensive information about current health practices among target audiences would not only help the MOH to effectively tailor key messages to different audiences and apply healthy interventions during 120 crises, but it also may help to predict and detect future crises that may occur because of certain group behaviors.
The Credibility of Coronavirus Messages among Students in Health Fields
Another interesting finding in this study is that respondents with health field backgrounds hold different attitudes toward the credibility of the MOH’s Coronavirus preventive measures campaigns than those not in health fields of study. Chiefly, respondents in health majors perceived Coronavirus information disseminated by the MOH as less credible than those in different study fields. One likely explanation is that respondents in health fields are more knowledgeable in health topics; thus, they hold more critical thinking and perspectives toward
Coronavirus messages. This finding suggests the importance of audience segmentation and crafting proper massages for different audiences (Wilcox & Cameron, 2009; Smith, 2009; Beard,
2001). While many policymakers and public health professionals intend to create awareness and educate as many people as they can during a major crisis, it is crucial to recognize the differences of society members, such as the level of education, age, social status and etc. Therefore, it is not only about getting information out to the public, but the type of messages sent to each audience.
For instance, during the HINI flu that hit Mexico and the United States in 2009, the CDC integrated social media, especially YouTube, to deliver complex messages to the targeted audience. Names and positions of speakers were included on all YouTube videos to identify their roles on preventing the H1N1 epidemic and to increase the credibility of the messages (Walton et al., 2012). This tactic could be used in the KSA to convey effective messages that persuade the public to follow healthy behaviors. Although best practices are crucial to avoiding catastrophes, mistakes still could happen. This is what happened in one of Texas’ hospitals, Texas Health
Presbyterian Hospital in Dallas, when a Librarian national man, Thomas Eric Duncan, arrived to 121 an emergency room on September 25, 2014 just few days after his trip from Liberia to the U.S.
He arrived in the emergency room with a fever, abdominal pain, and dizziness, but for some reason he was released from the hospital after having some basic tests (Voorhees, 2014;
Shoichet, Fantz, & Yan, 2014). Although the Liberian man told the staff at the hospital he just came from Liberia, this information did not draw the staff’s attention and was not fully communicated to the attending physician and medical team (Voorhees, 2014; Shoichet, Fantz, &
Yan, 2014). On September 28, the same man was rushed to the hospital suffering from diarrhea, vomiting, and dizziness and the case was announced as an Ebola risk after notifying the CDC.
The hospital stated that it follows the CDC and the Texas Department of Health Services but some nurses from the same hospital told a different story (Vooehees, 2014). In fact, the nurses’ union states that there was no protocol and advanced preparedness or system in what to do with the patient (Vooehees, 2014). Additionally, the hospital announced that the patient was immediately isolated after he was confirmed as an Ebola case. However, the nurses’ union stated that it was not true and that the patient stayed for several hours next to other patients (Vooehees,
2014). Also, nurses stated that the hospital allowed them to continue their work without any basic and protective equipment. One of the nurses contracted Ebola and said the hospital lacked proper training, preparedness, and basic equipment (NPR, 2014). As a result, she sued the hospital for damages and recklessness in dealing with infectious and risky diseases. The hospital apologized for mishandling the situation and missing the Ebola diagnosis (NPR, 2014).
This Ebola example shows how lack of preparedness and absence of protocols, training, and reporting systems could serve as a lesson to the MOH in how hospitals need to have protocols in place before a crisis occurs. Therefore, intensive training for all health staff, vivid protocols, and availability of equipment to handle any suspicious Coronavirus cases should exist. 122
Understanding the role of health care workers is crucial to the prevention and spread of viruses and diseases and one reason why this study focused on KSA. The results found that students in health care fields are more likely to follow some of the Coronavirus preventive measures more so than those not in the field. Specifically, the study found that students in health majors are more likely to adhere to wearing masks when visiting sick people, staying away from camels, and covering a mouth or using a tissue when coughing or sneezing. One explanation is that people in health fields are usually exposed to and more prone to Coronavirus cases inside health clinics and hospitals, thus taking extra precautions actions to avoid being infected with
Coronavirus. Additionally, health practitioners are compelled by hospitals and the MOH to strictly follow these guidelines on a daily basis. Yet, intensifying staff training, clear communications, reviewing and updating protocols, and monitoring staff practices are ways to ensure the safety of patients and the general population from Coronavirus and perhaps avoiding the mistakes made by the Texas hospital when treating Ebola.
Interestingly, however, the study indicates that respondents in health majors are significantly less likely to have enough sleep and to seek Coronavirus information than other people. One likely explanation is that students in health major are more likely to spend longer hours studying and working and perhaps having different shifts and on-call hours than students in other fields. Students in health fields may also have more knowledge and information about
Coronavirus, thus reducing their willingness to seek Coronavirus information. That is, they may be getting this information in their university classes and less likely have the need to seek information from other people and sources.
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Mediation of Self-Efficacy to HBM and Coronavirus Preventive Measures
The study shows that self-efficacy mediates the relationship between barriers and the preventive health behavior of following a healthy and balanced diet to boost the immune system.
Self-efficacy also mediates the relationship between benefits and the preventive health behavior of staying away from camels. Those two Coronavirus preventive measures are not only influenced by perceived benefits and barriers of individuals, but also by individuals’ ability and willingness to make a change and follow healthy practices. This indicates the importance of increasing individuals’ self-efficacy during major crises through education and seminars on how to properly maintain health preventive measures. In addition, the finding suggests that even if an individual comprehends the benefit of doing a health behavior, he/she has the confidence of implementing that particular behavior in a proper way.
Best Practices
One of the best practices to consider during a crisis is to ensure public safety first
(Coombs, 2014b). Overlooking public safety may increase the damage and intensify the impact of the crisis. Thus, addressing public safety must be a priority before considering financial concerns and reputation issues (Coombs, 2014b). Once an organization ensures public safety, they could look for other damages, such as reputation and financial loss (Coombs, 2014b).
Without releasing accurate, quick, and transparent information during a crisis via multiple communication channels to reach a wide range of audiences, an organization could jeopardize the public and put their safety at risk (Coombs, 2014b). This is clearly what happened at KSA when the MOH did not release quick and transparent information about the situation.
Working with the media as a partner before, during, and after the crisis is also considered one of the best practices organizations should follow to build a mutual relationship and mitigate 124 the damage of a crisis (Veil & Ojeda, 2010; Seeger, 2006; Reynolds, 2002). Although traditional media could reach a large number of audiences, social media, like Twitter, could be faster in reaching large numbers of people (Austin, Liu, & Jin, 2012). It is indispensable, therefore, to utilize multiple channels such as web sites, social media, and notification systems, especially during epidemics and major health crises, to reach a large number of people within a short period of time (O`Sullivan et al, 2003, Coombs, 2014b). This would ensure getting the message out to a wide array of publics and ensure their safety (Coombs, 2014b). This happened when the new minister of the MOH utilized multiple communication channels, like text messaging, radio, television, posters, brochures, the MOH’s website, and social media networking sites, like
Twitter, YouTube, and Facebook to deliver healthy behavior messages and Coronavirus preventive measures to a wide range of audiences and in many forms, such as print, video, virtual, and face-to-face communication.
Furthermore, the analysis of best practices in the crisis communication and management literature led to three lessons: be open, be quick, and be consistent. Being quick was the most recited lesson of crisis communication (Coombs, 2006). It means that during a crisis, an organization should release information quickly to the public. Most experts emphasized the significance of releasing information to the public within the first hour of a crisis to allow both stakeholders and the media to know what type of information an organization has about a crisis
(Flynn, 2009, Coombs, 2014b, Coombs, 2006). This, however, did not happen when the
Coronavirus crisis hit KSA. Therefore, officials in KSA should ensure the quickness of releasing information to the public during any future health crisis to save lives and protect KSA residents of any potential health threats. The need to release information quickly, however, should not come at the price of accuracy. 125
Scholars also emphasize the importance of using social media, like Twitter and
Facebook, during a crisis to reach a wide range of audiences (Wright & Hinson, 2008; Veil &
Ojeda, 2010; David, 2011; Coombs, 2011; Goldfine, 2011; Lerbinger, 2011; Baron, & Philbin,
2009; Coombs, 2014b; Fearn-Banks, 2007; Coombs, 2007). Utilizing social media, like Twitter hashtags, would allow citizens to engage and interact with an organization during a crisis (Palen,
2008). Social media’s popularity is evident as both the MOH and KSA residents used
Coronavirus hashtags to spread Coronavirus messages and preventive measures to reduce
Coronavirus from spreading. Furthermore, a study finding stated that more than 73% of respondents seek Coronavirus information from Twitter. Thus, opening a channel in this platform to engage the Saudi residents in a two- way communication would be considered a best practice by the MOH. The activation and integration of social media platforms by the MOH, such as Twitter and Facebook, to convey health messages and notifications openly, quickly, and consistently is consistent with best practices recommended by crisis communication scholars.
Taking the lead regarding dissemination of Coronavirus information, responding to the public inquiries, and correcting rumors were additional best practices followed by the MOH once the
We Can Stop it Campaign was launched.
Furthermore, Salmon & Atkins (2003) stated that a comprehensive understanding and careful planning for message types, exposure and attention given to health campaigns, amount of messages, intended responses, and careful selection of communication channels are some of the best practices that decision makers and health campaigners should follow when launching a health campaign. This was achieved when the MOH established the Command and Control
Center (CCC) website which was the first corrective action taken by the MOH to convey all information related to Coronavirus. The CCC improved internal communication with physicians, 126 scientists, and experts cooperating with international organizations, such as the WHO, to conduct research, control infections, manage clinical operations, and conduct data analysis (MOH, 2017;
Reuters, 2014a). As a result, more consistent and accurate messages are now being disseminated to the public.
Conclusions
The initial response by the MOH to the Coronavirus outbreak in the Kingdom of Saudi
Arabia (KSA) could best be described as both an operational and reputational crisis (Coombs,
2014). The virus became a serious threat to public safety, an operational crisis. At the same time, the MOH’s reputation was damaged as it failed to provide timely, factual information at the beginning of the Coronavirus crisis. As pointed out earlier, Minister of Health Abdullah al
Rabeeah told the public in a news conference that he had no idea why MERS was spreading across KSA and issued no preventive measures during the Muslim pilgrimage, where KSA hosts millions of people every year from all around the world. It also appears that the MOH did not have a crisis management plan in place when the crisis started. If it had, as Fearn-Banks (2007) described earlier, the MOH would have removed some of the risk, uncertainty, and negative public perception that resulted. Instead, the MOH lost credibility by not having planned key messages in the event of a health crisis. Better key messages would have included statements and updates, such as the MOH is working with physicians, researchers, and other officials to find the cause of the virus and would have given people specific instructions, such as hand washing, that are applicable to the spread of any virus, not just Coronavirus. The MOH also should have had a prepared crisis management plan to implement before the escalation of the situation. At the beginning of the crisis, the messaging could have focused on the announcement of an outbreak and precautions that could be taken for those entering or leaving the country. Additionally, 127 clarity of the situation and directive messages were absent during the initial stage of the
Coronavirus crisis which led to ambiguity and spread of rumors across society, especially on social media. This could have been avoided by providing updated information and transparent key messages about the situation.
Internal communications also proved to be problem. Without agreement among key people within the MOH, information was severely mismanaged in an effort to respond quickly to the public. This was the case when Ziad Memish rejected all the allegations made by some international researchers and asserted that the MOH took great scientific efforts with international health organizations to control the virus (Aljazeera, 2014). While it is critical that an organization’s response to the public during the first phases of a crisis be quick, accurate, and consistent, there must also be internal consistency among leaders, such as government, researchers and physicians, before key messages can be developed and released.
The absence of social media during the first phase of the crisis compounded the mismanagement of information. Coombs (2014) and other researchers suggest that an organization should use social media to release information about a crisis, and further suggest using social media before traditional media in some cases, something the MOH did not do initially. As mentioned earlier, social media has been proven to play a critical and effective role, especially in crises like the Boston marathon incident. The MOH was criticized for its lack of accurate and updated information to a large population, and the MOH’s website was quickly losing credibility. Incorporating social media during the first phase of the crisis would have been more effective in providing a mass audience with consistent key messages and timely updates.
Furthermore, the initial response to the crisis did not adhere to Grunig’s two-way symmetrical model, instead providing a one-way flow of communication through press releases, 128 website, and press conferences. Grunig et al., (2006) have successfully argued over the years that the two-way symmetrical model makes an organization more effective and is the most ethical model in campaign development (Grunig & Grunig, 1992). It was not until Abdullah al Rabeeah was fired and a temporary (and later new minister of health) was appointed did significant changes in campaign planning and implementation take place. Best practices, as described by
Salmon & Atkins (2003), include comprehensive understanding and careful planning for message types, exposure and attention given to the campaign, number of messages, intended responses, and selection of communication channels. This means an organization should expect the unexpected by drawing worst case scenarios and the best ways to respond. This includes having communication strategies, crafted messages, trained personnel and spokespeople, and conducting practice drills before crises happens. This requires public relations practitioners to act proactively and look for any warning signs rather than be placed in a situation in which they are forced to act reactively.
A new Command and Control Center (CCC) improved internal communications with physicians, scientists, and experts cooperating with international organizations, such as the
WHO, to conduct research, control infection, manage clinical operations, and conduct data analysis (MOH, 2017; Reuters, 2014b). As a result, more consistent and accurate messages are being disseminated to the public. For example, the number of Coronavirus cases are announced on a daily basis through the MOH’s multiple communication channels, like the MOH’s website and Twitter account. In addition to that, specific key messages about how to prevent Coronavirus backed by experts’ opinions and findings have been also disseminated across the MOH’s communication channels. 129
Key messages have proven to be effective. The first was a pledge by the new minister that the MOH would fight Coronavirus until the country is free from the virus (Al-Arabiya,
2014). He also announced guidelines ensuring best practices of data gathering, reporting, and transparency of information. These include stricter control measures and infection prevention guidelines to control the spread of the virus in all health care facilities. Other key messages are providing the public with very specific actions to avoid getting and spreading the virus through the “We Can Stop It” campaign. This campaign is more comprehensive with its combination of traditional and social media, along with interactive educational lectures, videos, and demonstrations in schools.
In the “We Can Stop It” campaign, two-way communication has replaced the one-way model of the initial campaign. The emphasis on social media, especially Twitter, is allowing the public to be more interactive with the MOH. For example, the MOH tweets weekly updates on new cases and provides specific tips on how avoid the virus. People are then encouraged to retweet these health messages, providing all with consistent, accurate, and timely updates.
Although the virus has not been eradicated in KSA, the MOH is now following best practices in crisis communication and management. They are taking immediate action, implementing a comprehensive crisis campaign, establishing new guidelines to preclude the spread of the virus, and reducing the number of deaths. This does not mean that the MOH should stop here but rather increase its efforts to free the country from Coronavirus. This would not happen without the emphasis on social distancing strategy that focuses on reducing social interaction between people during the time of Coronavirus, isolating patients and sick people, and implementing travel restrictions. Saudi people must be clearly educated that close contact with people, giving kisses, and hugs are not acceptable during Coronavirus outbreaks. This can 130 be addressed via a national health campaign to encourage all people to play their roles in fighting
Coronavirus. Moreover, the MOH should extend its efforts to concentrate on the barriers that hurdle the public from doing it, like following a healthy diet and exercising to boost the immune system, wearing a mask when visiting sick people, and avoiding close contact with sick people.
Even though this study shows that majority of respondents have high self-efficacy when it comes to performing Coronavirus preventive measures, some of the healthy practices have been ignored for some reasons. Therefore, the next recommended step is for the MOH to identify the barriers that prevent the public from following the preventive measures. Once these have been identified, the MOH can develop a comprehensive plan to reduce these barriers and to persuade the public to change their behaviors. This can be reached through focus group research to draw in-depth details about the main obstacles that most Saudis encounter and provide the efficacy for practicing healthy behaviors.
Also, the MOH should move its current Coronavirus campaign from the individual level to the community or societal level. This means that once the majority of individuals are practicing healthy preventive behaviors, the campaign needs to progress to the community level where community-based key messages are designed. This shifts the responsibility from individuals eradicating the virus to a community-wide initiative. All members of the Saudi should be responsible for eradicating this disease and act upon the recommended guidelines. It is a national crisis that drains many of the country’s resources, including health staff, citizens, expats, and the MOH’s budget so it is critical to address the Coronavirus crisis at a societal level.
Moving it form an individual to a societal level provides a sense of camaraderie and possibly peer pressure to participate in steps to eradicate the virus. 131
Although most Saudi government entities prefer handling any crisis quietly and without panicking the public, there is a time in which this rule must be broken, especially when public safety is at risk. Threat messages, in fact, could be a successful strategy to encourage the public to adhere to Coronavirus preventive measures. While fear appeal as a key component of the
Extended Parallel Processing Model (EPPM) shows some effectiveness and change in behaviors in many studies (Witte, 1992; Witte, 1994), it also might cause negative outcomes. For example, a study done by Rogers & Mewborn (1976) found that threat messages regarding smoking cigarettes resulted in two distinctive responses. One group followed the recommendations regarding quitting smoking, while the other group continued to smoke even more frequently than before receiving threat messages. Thus, health care professionals should be careful when delivering threat or fear messages to the public (Witte, Cameron, Mckeon, & Berkowitz, 1996,
Witte, 1992). The main issue of the EPPM is that the fear perceptions could outweigh the efficacy perceptions and people believe that they are no longer capable of making behavioral changes to prevent harm (Witte et al., 1996). Witte (1994) also found that there is an association between fear and fear control responses, whereas there is indirect relationships between fear control responses and danger control responses. Therefore, it is being recommended here that if a fear appeal is used, it should be used sparingly.
Once the crisis has stabilized, the MOH should focus it messages on maintenance in which individuals are able to sustain practicing Coronavirus preventive measures and are more confident in their ability to maintain and continue their behavioral changes. This would ensure that healthy practices regarding Coronavirus are followed properly by the Saudi society.
Moreover, doctors and health care workers should be provided with persistent training and extra precautionary guidelines to better determine Coronavirus cases at early stages and 132 mitigate the risk of getting infected with the Coronavirus. A recent study by Abolfotouh et al.
(2017) assessed the level of concerns and fears pertaining to Coronavirus among health care workers in three hospitals of the Ministry of National Guard with the highest Coronavirus cases in KSA. The findings showed that around 70% of health care workers felt at risk of getting infected with Coronavirus at work. The study also found that around 87% of health care workers did not feel safe at work even when following standards precautions. The majority of health care workers agreed that the Saudi government should isolate Coronavirus patients and treat them in different and designated hospitals, agreed with travel restrictions, and emphasized the importance of avoiding invitations of expatriates and workers from infected areas of
Coronavirus.
The MOH has to review its policies and guidelines in regard to Coronavirus in work places, especially hospitals. This issue can be addressed by providing intensive training for staff, first responders, nurses, and physicians in how to deal with Coronavirus safely and without any fear. Increasing the self-efficacy and confidence of health care workers through following precautionary standards and guidelines would have a significant impact on Coronavirus eradication. Any weaknesses shown by doctors and nurses who are in the frontline of dealing with Coronavirus cases, like lack of training or absence of proper equipment would significantly impact the quality of treatment as well as the strategies drawn to combat Coronavirus in KSA.
Although the MOH has cooperated with international health organizations to develop aggressive policies toward fighting Coronavirus, it is important to cooperate with the Ministry of Health and
Welfare in South Korea to address challenges and similarities when fighting Coronavirus. This could allow the MOH to try new and similar techniques used by the Ministry of Health in South
Korea. Additionally, the MOH should also emphasize the importance of following the 133 preventive measures of MERS- CoV. This can be accomplished by increasing these healthy messages in all places, like airports, schools, workplaces, malls, and mosques.
This study also revealed that some Coronavirus preventive measures are not followed by some people, which indicates that the MOH has to increase its efforts until freeing the country from Coronavirus. The MOH could train volunteers by teaching them the proper ways of practicing Coronavirus preventive measures across the country, and in turn, the WHO would train others in public places. This would help move the campaign beyond education and knowledge through practice of the actual behavior being described. Using notification systems to notify the public rapidly and in a timely manner in case of Coronavirus would also save time and resources for the MOH. This can be done through text messages directing the public to avoid certain infected areas.
The journey to eradicate Coronavirus in KSA started out poorly but is now making a marked difference in the lives of the people in KSA. The efforts that have been taken by the
MOH show a high adherence to Coronavirus preventive measures among Saudi people. These include washing hands frequently, covering a mouth or using a tissue when coughing or sneezing, staying away from camels, etc. Following these preventive measures may not have happened without the MOH’s ability to regain the public’s trust and disseminate effective and credible key messages that direct Saudis to follow best practices and proper health guidelines to reduce Coronavirus inside the country.
Lessons learned from this study may benefit others in how to effectively develop crisis health campaigns, specifically the need to have comprehensive research and updated data about the issue along with trained personnel and excellent leadership that could utilize multiple communication channels and develop targeted key messages to better gain the public trust. 134
Lessons from this study could be useful for organizations around the world, especially in understanding the importance for two-way symmetrical communication during a crisis. After much public and media scrutiny, the MOH has shifted its communication efforts from public information and two-way asymmetrical models, deemed one-way communication, to two-way symmetrical communication that is based on mutual relationships, transparency, and trustworthiness.
135
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APPENDIX A. FREQUENCY DISTRIBUTIONS FOR THE HEALTH BELIEF MODEL
Table 14
Frequency Distributions for Perceived Susceptibility
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree
It is extremely likely I will get 20.23% 177 28.11% 246 41.49% 363 9.03% 79 1.14% 10 875 Coronavirus.
I feel I will get Coronavirus in 26.97% 236 36.80% 322 33.03% 289 2.63% 23 0.57% 5 875 the future.
I feel my chances of getting infected with 37.94% 332 36.23% 317 19.31% 169 5.71% 50 0.80% 7 875 Coronavirus are greater than other people. My family members are at 26.97% 236 32.11% 281 29.71% 260 10.29% 90 0.91% 8 875 risk of getting Coronavirus. My friends are at risk of 20.57% 180 25.83% 226 39.09% 342 13.49% 118 1.03% 9 875 getting Coronavirus.
154
Table 15
Frequency Distributions for Perceived Severity
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree
The thought of getting 19.12% 157 21.92% 180 16.81% 138 33.01% 271 9.14% 75 821 Coronavirus scares me. When I think about 40.44% 332 33.37% 274 16.20% 133 7.92% 65 2.07% 17 821 Coronavirus, my heart beats fast. I am afraid to think about 39.59% 325 31.30% 257 13.40% 110 13.03% 107 2.68% 22 821 Coronavirus. If I get Coronavirus I 24.97% 205 28.38% 233 35.57% 292 8.40% 69 2.68% 22 821 will die. Problems that I would experience with 15.96% 131 28.50% 234 37.03% 304 14.74% 121 3.78% 31 821 Coronavirus would last for a long time. If I get Coronavirus my 11.81% 97 21.92% 180 22.90% 188 33.62% 276 9.74% 80 821 life would be changed.
If I get Coronavirus other members 9.01% 74 15.71% 129 35.81% 294 33.13% 272 6.33% 52 821 in my home will get sick.
155
Table 16
Frequency Distributions for Perceived Barriers
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree Handwashing stations and/or antibacterial solutions are not 23.57% 186 31.18% 246 10.14% 80 22.43% 177 12.67% 100 789 available at the places where I spend most of my day. Washing my hands regularly with soap 37.52% 296 37.01% 292 11.79% 93 10.90% 86 2.79% 22 789 and water is not convenient. Washing my hands with soap and water 42.08% 332 36.88% 291 12.55% 99 7.10% 56 1.39% 11 789 regularly is time consuming. It is difficult to avoid close contact 16.48% 130 28.77% 227 22.43% 177 26.74% 211 5.58% 44 789 with sick people. Preventive measures regarding Coronavirus are 20.15% 159 33.71% 266 25.98% 205 16.73% 132 3.42% 27 789 difficult to apply in everyday situations. Washing my hands regularly with soap and water or 37.26% 294 41.83% 330 13.43% 106 5.96% 47 1.52% 12 789 antibacterial will cost me a lot of money. I am not comfortable wearing a mask to 12.67% 100 20.03% 158 14.32% 113 35.36% 279 17.62% 139 789 prevent getting Coronavirus. 156
Table 17 Frequency Distributions for Perceived Benefits
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree If I wash my hands with soap and water 4.37% 33 20.93% 158 41.32% 312 27.02% 204 6.36% 48 755 regularly, I will not get Coronavirus. If I avoid contact with camels, I will not get 8.87% 67 22.52% 170 32.72% 247 26.75% 202 9.14% 69 755 Coronavirus. If I avoid contact with sick people, I will not 3.31% 25 12.05% 91 22.91% 173 43.18% 326 18.54% 140 755 get Coronavirus. I cover my mouth and nose with a tissue when coughing and 1.59% 12 5.43% 41 7.42% 56 34.70% 262 50.86% 384 755 sneezing because it's a healthy behavior. If I follow the ministry of health's Coronavirus recommendations, I 1.72% 13 1.99% 15 7.15% 54 41.59% 314 47.55% 359 755 will reduce my chance of getting Coronavirus. If I follow the ministry of health's Coronavirus recommendations, I 1.72% 13 1.59% 12 6.36% 48 39.47% 298 50.86% 384 755 will help in minimizing the spread of Coronavirus disease. If I wear a mask when visiting sick people, I 2.91% 22 7.55% 57 23.05% 174 41.72% 315 24.77% 187 755 will avoid getting Coronavirus.
157
Table 18 Frequency Distributions for Cues to Actions
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree I wash my hands regularly with soap and water to 1.23% 9 3.68% 27 10.91% 80 49.66% 364 34.52% 253 733 maintain good health. I always follow medical advices, such as eating a healthy and balance 3.41% 25 13.23% 97 24.83% 182 39.29% 288 19.24% 141 733 diet because I feel it will benefit my health. I search for a new information to keep myself updated 13.92% 102 31.65% 232 25.51% 187 19.78% 145 9.14% 67 733 regarding Coronavirus. Maintaining good health is extremely 1.36% 10 2.46% 18 11.73% 86 45.29% 332 39.15% 287 733 important to me. Getting enough sleep will help me 0.68% 5 2.73% 20 6.68% 49 44.88% 329 45.02% 330 733 to be in good health. Maintaining proper hygiene is important 0.55% 4 0.82% 6 5.73% 42 34.24% 251 58.66% 430 733 to good health. Eating well- balanced meals will 0.68% 5 0.95% 7 4.23% 31 37.79% 277 56.34% 413 733 help to maintain good health. It's important to exercise to maintain 0.55% 4 1.36% 10 3.41% 25 39.15% 287 55.53% 407 733 good health.
158
Table 19 Frequency Distributions for Self- Efficacy
Neither Strongly Strongly Question n Disagree n agree or n Agree n n Total disagree agree disagree I am able to identify 6.41% 45 19.66% 138 28.06% 197 35.90% 252 9.97% 70 702 Coronavirus symptoms. I am capable of following the ministry of health's Coronavirus preventive 2.85% 20 10.11% 71 23.22% 163 46.87% 329 16.95% 119 702 measures in a daily life basis. I am capable of washing my hands with soap and 0.57% 4 2.71% 19 8.97% 63 46.87% 329 40.88% 287 702 water regularly. I am capable of searching for updated information 2.56% 18 6.84% 48 12.54% 88 48.15% 338 29.91% 210 702 regarding Coronavirus by myself. I am capable of avoiding close contact with sick 2.85% 20 6.27% 44 20.80% 146 44.73% 314 25.36% 178 702 people.
I am capable of using proper ways of Coronavirus preventive 1.00% 7 1.85% 13 8.12% 57 48.72% 342 40.31% 283 702 measures, such as using a tissue when I sneeze or cough. I am capable of keeping myself away from 1.14% 8 2.28% 16 5.84% 41 32.91% 231 57.83% 406 702 camels. I am able to seek medical help if I feel I have 2.14% 15 4.13% 29 13.96% 98 42.02% 295 37.75% 265 702 Coronavirus symptoms. I am capable of wearing a mask when I visit sick 1.42% 10 3.70% 26 9.69% 68 42.31% 297 42.88% 301 702 people.
159
APPENDIX B. FREQUENCY DISTRIBUTIONS FOR THE MEDIA CREDIBILITY
Table 20 Frequency Distributions for Believability
Not at all Not I don’t Extremely Channels n n n Believable n n Total believable believable know believable
Newspapers 6.10% 35 14.11% 81 40.07% 230 34.49% 198 5.23% 30 574
Television 4.36% 25 11.15% 64 33.10% 190 45.30% 260 6.10% 35 574
Radio 4.70% 27 9.76% 56 52.09% 299 29.44% 169 4.01% 23 574
Twitter 5.92% 34 19.16% 110 38.15% 219 30.31% 174 6.45% 37 574
Facebook 16.03% 92 18.99% 109 56.62% 325 7.32% 42 1.05% 6 574
YouTube 6.27% 36 11.32% 65 40.77% 234 36.59% 210 5.05% 29 574
The Internet (Google, 3.83% 22 12.54% 72 40.77% 234 36.59% 210 6.27% 36 574 Yahoo, etc.)
Blogs 9.76% 56 15.85% 91 55.92% 321 16.03% 92 2.44% 14 574
The Ministry of Health's 1.39% 8 0.70% 4 5.75% 33 25.26% 145 66.90% 384 574 website
The Ministry of Health's 1.57% 9 0.70% 4 10.45% 60 24.91% 143 62.37% 358 574 Twitter account
The Ministry of Health's 2.96% 17 1.74% 10 31.71% 182 18.99% 109 44.60% 256 574 Facebook account
The Ministry of Health's 1.39% 8 1.74% 10 16.72% 96 26.13% 150 54.01% 310 574 YouTube channel
World Health 0.87% 5 1.22% 7 15.68% 90 24.39% 140 57.84% 332 574 Organization
Centers for Disease 1.39% 8 1.05% 6 19.16% 110 26.13% 150 52.26% 300 574 Control and Prevention
Family and friends 6.62% 38 21.95% 126 43.03% 247 23.52% 135 4.88% 28 574
Doctors or other 0.52% 3 2.26% 13 14.46% 83 52.44% 301 30.31% 174 574 healthcare providers
160
Table 21 Frequency Distributions for Accuracy
Not Not I don’t Very Channels accurate n n n Accurate n n Total accurate know accurate at all
Newspapers 8.21% 46 30.54% 171 32.86% 184 24.11% 135 4.29% 24 560
Television 5.89% 33 25.54% 143 29.29% 164 34.46% 193 4.82% 27 560
Radio 7.32% 41 26.43% 148 42.32% 237 21.25% 119 2.68% 15 560
Twitter 8.93% 50 30.36% 170 32.32% 181 23.57% 132 4.82% 27 560
Facebook 14.46% 81 26.79% 150 50.18% 281 8.21% 46 0.36% 2 560
YouTube 7.50% 42 22.14% 124 38.57% 216 27.32% 153 4.46% 25 560
The Internet (Google, 7.14% 40 24.64% 138 32.50% 182 30.71% 172 5.00% 28 560 Yahoo, etc.)
Blogs 9.11% 51 26.25% 147 50.54% 283 12.32% 69 1.79% 10 560
The Ministry of 0.89% 5 1.61% 9 8.21% 46 31.25% 175 58.04% 325 560 Health's website The Ministry of Health's Twitter 1.43% 8 2.32% 13 13.21% 74 30.89% 173 52.14% 292 560 account The Ministry of Health's Facebook 2.32% 13 1.79% 10 32.14% 180 23.75% 133 40.00% 224 560 account The Ministry of Health's YouTube 1.07% 6 1.96% 11 22.68% 127 27.14% 152 47.14% 264 560 channel World Health 1.25% 7 1.43% 8 17.32% 97 25.89% 145 54.11% 303 560 Organization Centers for Disease Control and 1.43% 8 1.61% 9 18.93% 106 27.68% 155 50.36% 282 560 Prevention
Family and friends 12.14% 68 33.57% 188 35.71% 200 13.39% 75 5.18% 29 560
Doctors or other 1.07% 6 4.29% 24 15.54% 87 50.18% 281 28.93% 162 560 healthcare providers 161
Table 22 Frequency Distributions for Trustworthiness
Very I don’t Very Channels n Untrustworthy n n Trustworthy n n Total untrustworthy know trustworthy
Newspapers 8.62% 45 24.90% 130 33.52% 175 27.39% 143 5.56% 29 522
Television 7.09% 37 21.46% 112 30.46% 159 36.21% 189 4.79% 25 522
Radio 7.85% 41 22.22% 116 41.38% 216 24.90% 130 3.64% 19 522
Twitter 9.77% 51 30.46% 159 33.52% 175 23.75% 124 2.49% 13 522
Facebook 15.13% 79 30.84% 161 45.59% 238 6.90% 36 1.53% 8 522
YouTube 7.85% 41 24.33% 127 41.38% 216 22.80% 119 3.64% 19 522
The Internet (Google, 7.47% 39 27.20% 142 35.25% 184 27.01% 141 3.07% 16 522 Yahoo, etc.)
Blogs 9.77% 51 26.44% 138 51.34% 268 9.39% 49 3.07% 16 522
The Ministry of Health's 1.34% 7 0.77% 4 9.00% 47 29.69% 155 59.20% 309 522 website
The Ministry of Health's 1.34% 7 1.53% 8 11.69% 61 30.08% 157 55.36% 289 522 Twitter account
The Ministry of Health's 2.68% 14 1.72% 9 29.89% 156 22.99% 120 42.72% 223 522 Facebook account
The Ministry of Health's 1.34% 7 1.34% 7 19.73% 103 27.01% 141 50.57% 264 522 YouTube channel
World Health 1.34% 7 0.77% 4 17.82% 93 25.10% 131 54.98% 287 522 Organization
Centers for Disease Control 1.53% 8 1.34% 7 20.69% 108 24.90% 130 51.53% 269 522 and Prevention
Family and 10.54% 55 27.78% 145 35.63% 186 19.35% 101 6.70% 35 522 friends
Doctors or other healthcare 1.15% 6 3.64% 19 16.67% 87 47.51% 248 31.03% 162 522 providers 162
Table 23 Frequency Distributions for Biasness
Not Very I don’t Not Channels n Biased n n n biased n Total biased know biased at all
Newspapers 9.05% 44 20.58% 100 46.50% 226 20.99% 102 2.88% 14 486
Television 8.23% 40 22.63% 110 42.18% 205 23.25% 113 3.70% 18 486
Radio 5.76% 28 19.14% 93 53.70% 261 17.90% 87 3.50% 17 486
Twitter 8.85% 43 20.78% 101 41.56% 202 21.81% 106 7.00% 34 486
Facebook 8.85% 43 14.61% 71 60.49% 294 11.93% 58 4.12% 20 486
YouTube 5.97% 29 18.31% 89 52.88% 257 18.31% 89 4.53% 22 486
The Internet (Google, 4.73% 23 20.78% 101 47.12% 229 21.81% 106 5.56% 27 486 Yahoo, etc.)
Blogs 6.38% 31 16.26% 79 60.49% 294 13.58% 66 3.29% 16 486
The Ministry of 9.05% 44 11.93% 58 26.13% 127 24.90% 121 27.98% 136 486 Health's website The Ministry of Health 9.05% 44 10.49% 51 30.45% 148 22.84% 111 27.16% 132 486 Twitter account The Ministry of Health's Facebook 8.44% 41 9.05% 44 41.15% 200 18.72% 91 22.63% 110 486 account The Ministry of Health 7.82% 38 9.67% 47 35.60% 173 23.05% 112 23.87% 116 486 YouTube channel World Health 9.05% 44 5.14% 25 34.77% 169 21.40% 104 29.63% 144 486 Organization Centers for Disease 8.64% 42 5.76% 28 35.80% 174 20.99% 102 28.81% 140 486 Control and Prevention
Family and friends 9.05% 44 20.37% 99 46.50% 226 16.46% 80 7.61% 37 486
Doctors or healthcare 5.56% 27 12.55% 61 34.57% 168 28.40% 138 18.93% 92 486 providers
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Table 24 Frequency Distributions for Completeness
I don’t Very Channels Very n Incomplete n n Complete n n Total Incomplete know complete
Newspapers 14.54% 66 35.46% 161 28.85% 131 16.08% 73 5.07% 23 454
Television 11.89% 54 35.68% 162 28.41% 129 18.94% 86 5.07% 23 454
Radio 14.10% 64 33.70% 153 38.11% 173 12.33% 56 1.76% 8 454
Twitter 17.40% 79 35.46% 161 26.21% 119 18.50% 84 2.42% 11 454
Facebook 20.48% 93 27.97% 127 43.39% 197 6.83% 31 1.32% 6 454
YouTube 13.22% 60 29.74% 135 34.14% 155 18.94% 86 3.96% 18 454
The Internet (Google, 10.13% 46 24.23% 110 27.31% 124 32.38% 147 5.95% 27 454 Yahoo, etc.)
Blogs 12.11% 55 23.57% 107 48.68% 221 13.00% 59 2.64% 12 454
The Ministry of 2.42% 11 5.51% 25 13.66% 62 33.70% 153 44.71% 203 454 Health's website
The Ministry of Health's Twitter 2.42% 11 9.47% 43 22.03% 100 28.85% 131 37.22% 169 454 account
The Ministry of Health's Facebook 3.30% 15 8.15% 37 35.68% 162 20.04% 91 32.82% 149 454 account
The Ministry of Health's YouTube 2.86% 13 7.05% 32 27.31% 124 27.75% 126 35.02% 159 454 channel
World Health 2.64% 12 2.64% 12 24.67% 112 25.33% 115 44.71% 203 454 Organization
Centers for Disease 2.64% 12 2.86% 13 26.21% 119 26.87% 122 41.41% 188 454 Control and Prevention
Family and friends 16.30% 74 37.00% 168 32.38% 147 9.47% 43 4.85% 22 454
Doctors or healthcare 2.20% 10 10.13% 46 24.67% 112 39.21% 178 23.79% 108 454 providers
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APPENDIX C. TABLES
Table 25
Comparison between the Credibility of MOH’s Website, Traditional Media, and Social Media
Medium M SD **Believability Newspapers 3.19 0.95 Television 3.38 0.92 Radio 3.18 0.84 Twitter 3.12 0.99 Facebook 2.58 0.88 YouTube 3.23 0.94 Blogs 2.86 0.89 The Ministry of Health's website 4.56 0.76 **Accuracy M SD Newspapers 2.86 1.01 Television 3.07 1.01 Radio 2.86 0.93 Twitter 2.85 1.03 Facebook 2.53 0.85 YouTube 2.99 .0.99 Blogs .2.71 0.86 The Ministry of Health’s website .4.44 0.78 **Trustworthiness MM SD Newspapers 2.96 1.04 Television 3.10 1.02 Radio 2.94 0.96 Twitter 2.79 0.99 Facebook 2.49 0.88 YouTube 2.90 0.96 Blogs 2.70 0.88 The Ministry of Health’s website 4.45 0.80 **Completeness M SD Newspapers 2.67 1.07 Television 2.70 1.06 Radio 2.54 0.94 Twitter 2.53 1.05 Facebook 2.41 0.93 YouTube 2.71 1.04 165
Blogs 2.70 0.93 The Ministry of Health’s website 4.13 1.00
**Biasness M SD Newspapers 2.88 0.94
Television 2.92 0.96 Radio 2.94 0.86 Twitter 2.97 1.03
Facebook 2.88 0.88 YouTube 2.97 0.89 Blogs 2.91 0.82
The Ministry of Health’s website 3.51 1.26
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Table 26 Likelihood of Using Different Communication Channels to Seek Coronavirus Information
Extremely Extremely Question n Unlikely n Neutral n Likely n n Total unlikely likely Newspapers 44.50% 263 23.01% 136 19.12% 113 11.00% 65 2.37% 14 591
Television 12.69% 75 17.26% 102 29.61% 175 29.61% 175 10.83% 64 591 Radio 42.47% 251 21.49% 127 18.78% 111 14.55% 86 2.71% 16 591
Twitter 7.45% 44 6.77% 40 12.69% 75 34.01% 201 39.09% 231 591
Facebook 57.19% 338 20.81% 123 13.37% 79 6.26% 37 2.37% 14 591
YouTube 11.68% 69 8.12% 48 21.66% 128 34.52% 204 24.03% 142 591 The Internet (Google, 2.54% 15 2.03% 12 8.12% 48 30.12% 178 57.19% 338 591 Yahoo, etc.) Blogs 24.53% 145 18.95% 112 30.96% 183 16.92% 100 8.63% 51 591 The Ministry of Health's 6.77% 40 9.64% 57 18.95% 112 24.70% 146 39.93% 236 591 website The Ministry of Health's 9.64% 57 7.78% 46 12.86% 76 27.41% 162 42.30% 250 591 Twitter account The Ministry of Health's 51.95% 307 17.94% 106 13.20% 78 6.60% 39 10.32% 61 591 Facebook account The Ministry of Health's 21.32% 126 12.18% 72 20.81% 123 23.01% 136 22.67% 134 591 YouTube channel World Health 18.95% 112 12.86% 76 22.84% 135 21.49% 127 23.86% 141 591 Organization Centers for Disease 23.86% 141 14.04% 83 24.87% 147 19.29% 114 17.94% 106 591 Control and Prevention Family and 7.95% 47 11.34% 67 25.89% 153 35.03% 207 19.80% 117 591 friends Doctor or other 4.06% 24 5.92% 35 17.60% 104 41.29% 244 31.13% 184 591 healthcare providers
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Table 27 Adherence of Coronavirus Preventive Measures among Participants Coronavirus’ preventive measures % Do you cover your mouth or use a tissue when coughing or sneezing? Yes (87.50%) No (12.50%)
Do you keep yourself away from camels? Yes (90.40%) No (9.60%)
How often do you wash your hands daily? I don't wash my hands (0.37%) 1-2 times (3.89%) 3-5 times (23.33%) 5-7 times (30.74%) 7-9 times (21.30%) 10 or more times (20.37%)
Do you wear a mask when you visit sick people? Yes (17.39%) No (27.36%) I don’t visit sick people (55.25%)
Do you follow healthy and balanced diet to increase Yes (44.20%) your immune system? No (55.80%) For how many minutes do you exercise weekly? I don’t exercise (36.41%) Less than 75 minutes (34.24%) Between 75- 140 minutes (15.58%) 150 minutes or more (13.77%) Do you get enough sleep every day? Yes (67%) No (32.78%) Frequency of seeking Coronavirus information Daily (0.23%) 1-2 times a week (4.33%) 1-2 times a month (9.79%) Once a month (9.75%) Once every other month (23.46%) 1-2 times a year (52.62%0 I seek information about Coronavirus?
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APPENDIX D. HUMAN SUBJECTS REVIEW BOARD CONSENT FORM
School of Media and Communication
Informed Consent for Online Survey
The Coronavirus Project in Riyadh, Saudi Arabia
Principle Investigator is Saud Alsulaiman, Ph.D. Student, School of Media and Communication Bowling Green State University, Ohio, the United States of America 214-213-4397 or [email protected]
You are invited to participate in a research study of Saudis’ knowledge of Coronavirus, attitudes toward the Ministry of Health’s Coronavirus Preventive Campaigns, and trust in Coronavirus Messages in the Media. You must be 18 years of age or older to participate in this study.
Explanation of Procedures: As part of the research for my dissertation in the School of Media and Communication at Bowling Green State University, Ohio, the United States of America, this survey is being conducted to understand your knowledge of Coronavirus, attitudes toward the Ministry of Health’s Coronavirus preventive campaigns, and your trust in Coronavirus messages in the media. If you agree to participate, you will be invited to complete and submit the survey in an online format. The survey will take about 20 minutes to complete. Your submission of this completed online survey is an indication of your informed consent to participate in this study. The survey will be available to you via a link to an online survey available at this web address: https://bgsu.az1.qualtrics.com/SE/?SID=SV_8J3DW01I5igAERf Benefits: Information obtained from this study will be used to better understand Saudis’ knowledge of Coronavirus, attitudes towards the Ministry of Health’s preventive campaigns, and trust in Coronavirus messages in the media. Your participation is needed to understand how Saudi people implement Coronavirus preventive measures on a daily basis, as well as what type of medium is trusted the most when seeking Coronavirus information. You will not be paid to participate in this study. Risk and Discomfort: The anticipated risks to you are no greater than those normally encountered in daily life. Anonymity: The raw data will be accessible to me and my committee members. The survey responses in this study are anonymous. Thus, no names or other identifiers are obtained from your responses in this study. Data will be stored on my personal computer in password- protected files with only members of the research team having access to the data you provide. Published results will be presented only in summary manner. Voluntary Participation and Withdrawal without Prejudice: You may ask any questions regarding the study and they will be answered fully and completely. Your participation in this study is voluntary; refusal to participate will involve no penalty. If you choose not to complete the study, you may withdraw from the study at any point without penalty, without prejudice, and 169 without affecting your relationship with Bowling Green State University or King Saud University or any individual involved in or participating in this study. Agreement: By completing and submitting this survey you are indicating your consent to participate in this study. Your participation or not in this study will have no impact on your grades, class standing, or relationship to Bowling Green State University or King Saud University in any way. You are making a decision to participate or not in this study. Your completion and submission of the survey indicate that you have read the information provided above, have had all your questions answered, you are 18 years of age or older, and have decided to participate. You are also giving the investigator the authorization and permission to record your responses and to use the information for research and publication.
Contact information: if you have any questions or comments about this study, you can contact me, Saud Alsulaiman, at 214-213-4397 or [email protected] or Terry Rentner, my dissertation advisor, at 419-372-2079 or [email protected]. Also, if you have any questions about your rights, you can contact the HSRB at Bowling Green State University, Ohio, the United States at 419-372-7716 or [email protected].
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الموافقة المبدئية على الدراسة اللكترونية دراسة مرض كورونا في الرياض، المملكة العربية السعودية الباحث الرئيسي هو سعود بن عبدالعزيز السليمان، مرشح الدكتوراه في كلية العلم والتصال جامعة بولينغ غرين ستيت بولية أوهايو، الوليات المتحدة المريكية هاتف 2142134397 أو [email protected]
أنت مدعو للمشاركة في دراسة بحثية تستطلع مدى معرفة المجتمع السعودي عن مرض كورونا، وآرائهم تجاه الحملت الوقائية التي تقوم بها وزارة الصحة لمكافحة مرض كورونا، ومدى ثقة المجتمع في الرسائل العلمية المطروحة من قبل وزارة الصحة عبر مختلف وسائل العلم لمكافحة مرض كورونا. يجب أن تكون في الثامنة عشرة من العمر أو أكثر للمشاركة في هذه الدراسة. شرح الجراءات: كجزء من بحثي في رسالة الدكتوراه في كلية العلم والتصال بجامعة بولينغ غرين ستيت، فإن هذه الدراسة تهدف إلى قياس معرفتك بمرض كورونا، ورأيك حول الحملت الوقائية التي تقوم بها وزارة الصحة لمكافحة مرض كورونا، وأيضا قياس مدى ثقتكم في الرسائل العلمية المطروحة عبر مختلف وسائل العلم لمكافحة مرض كورونا. إذا كنت موافقا على المشاركة في هذه الدراسة, فأنت مدعو لكمال إجاباتك وتسليمها عبر الستبانة اللكترونية على النترنت. إجابتك وتسليمك لهذه الستبانة تعني موافقتك على المشاركة فيها علما بأن الدراسة سوف تستغرق حوالي 20 دقيقة لكمالها. ستكون الدراسة متاحة لك عبر الرابط التالي: https://bgsu.az1.qualtrics.com/SE/?SID=SV_8J3DW01I5igAERf
الفوائد: ستسهم المعلومات التي يتم الحصول عليها من هذه الدراسة في فهم أفضل لمدى معرفة السعوديين بمرض كورونا، وآرائهم تجاه الحملت الوقائية التي تقوم بها وزارة الصحة، و أيضا قياس مدى الثقة في الرسائل العلمية المطروحة من قبل وزارة الصحة عبر مختلف وسائل العلم لمكافحة مرض كورونا. مشاركتك في هذه الدراسة مهمة لمعرفة التدابير الوقائية اللزمة التي يقوم بها المجتمع السعودي بشكل يومي للوقاية من مرض كورونا و أيضا لمعرفة نوع الوسيلة العلمية الكثر ثقة في المجتمع السعودي عند البحث عن معلومات تتعلق بمرض كورونا. لن يتم دفع أي مبلغ لك جراء مشاركتك في هذه الدراسة.
الخطر والزعاج: إن المخاطر المتوقعة لك ل تتعدى تلك التي تواجهها عادة في الحياة اليومية. عدم إظهار الهوية الشخصية: إن البيانات الولية من هذه الدراسة ستكون في متناول الباحث الرئيسي وأعضاء اللجنة. جميع المعلومات التي يتم جمعها من الدراسة ستظل سرية ولن يتم الكشف عن هويتك. بالتالي، لن يتم التعرف على اسمك أو جمع أي معلومات عن هويتك الشخصية. سيتم تخزين البيانات و المعلومات التي تقدمها في جهاز الحاسب الخاص بي وباستخدام ملفات محمية ومغلقة بأرقام سرية ولن تكون متاحة إل لعضاء فريق البحث كما سيتم عرض النتائج المنشورة بطريقة موجزة. المشاركة اختيارية والنسحاب منها دون أي ضرر: يمكنك الستفسار عن أي سؤال متعلق بهذه الدراسة و ستتم الجابة عليك بشكل كامل وتام. إن مشاركتك في هذه الدراسة اختيارية؛و الرفض عن المشاركة لن يترتب عليه أي ضرر. في حال عدم إكمال الدراسة، يمكنك النسحاب من الدراسة في أي لحظة من دون أي عقوبة أو ضرر وأيضا من دون أن يؤثر على علقتك مع جامعة بولينغ غرين ستيت وجامعة الملك سعود أو أي فرد ضالع في هذه الدراسة أو مشارك فيها. التفاقية: إكمال هذه الدراسة وتقديمها يدل على موافقتك على المشاركة في هذه الدراسة. مشاركتكم في هذه الدراسة لن يكون لها تأثير سواء على الدرجات الخاصة بك أو على مستواك الدراسي، أو على علقتك بالمؤسسة التعليمية بأي شكل من الشكال. أنت من يتخذ قرار المشاركة من عدمها في هذه الدراسة. إن إكمال الدراسة وتقديمها يدل على أنك قد قرأت المعلومات الواردة أعله، وأنك قد أجبت على جميع السئلة الخاصة بك، وأنك تبلغ من العمر 18 سنة أو أكثر،أنك قد قررت المشاركة. أيضا مشاركتك تعني إعطاء الذن للباحث الرئيسي في هذه الدراسة لتسجيل ردودك واستخدام المعلومات لغراض البحث والنشر. معلومات التصال: إذا كان لديك أي أسئلة أو تعليقات حول هذه الدراسة، يمكنك التصال بي، سعود السليمان،[email protected] 2142134397،أو الدكتورة تيري رينتنر المشرفة على الطروحة4193722079 أو bgsu.edu @ trentne. أيضا، إذا كان لديك أي أسئلة عن حقوقك، يمكنك التصال على HSRB في جامعة بولينغ غرين ستيت، 419-372-77167716-372-419 أو [email protected]. 171
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APPENDIX E. SURVEY INSTRUMENT
Perceived Susceptibility to Coronavirus Q1: To what extent you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly
Neither Strongly Strongly Disagree (2) agree or Agree (4) disagree (1) agree (5) disagree (3) It is extremely likely I will get Coronavirus. I feel I will get Coronavirus in the future. I feel my chances of getting infected with Coronavirus are greater than other people. My family members are at risk of getting Coronavirus. My friends are at risk of getting Coronavirus.
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Perceived Severity of Coronavirus. Q2: To what extent do you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly agree)
Neither Strongly Disagree agree or Strongly disagree Agree (4) (2) disagree agree (5) (1) (3) The thought about Coronavirus scares me. When I think about Coronavirus, my heart beats fast. I am afraid to think about Coronavirus. If I get Coronavirus I will die Problems that I would experience with Coronavirus would last for a long time. If I get Coronavirus my life would be changed. If I get Coronavirus other members in my home will get sick.
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Perceived Barriers to the Ministry of Health's Coronavirus preventive measures Q3: To what extent you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly agree)
Neither Strongly Disagree agree or Agree 4 Strongly disagree (2) disagree (4) agree (5) (1) (3) Handwashing stations and/or antibacterial solutions are not available at the places where I spend most of my day. Washing my hands regularly with soap and water is not convenient. Washing my hands with soap and water regularly is time consuming. It is difficult to avoid close contact with sick people. Preventive measures regarding Coronavirus are difficult to apply in everyday situations. Washing my hands regularly with soap and water or antibacterial will cost me a lot of money. I am not comfortable wearing a mask to prevent getting Coronavirus.
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Perceived Benefits Q4: To what extent you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly agree)
Neither Strongly Strongly Disagree (2) agree or Agree (4) disagree (1) agree (5) disagree (3) If I wash my hands with soap and water regularly, I will not get Coronavirus. If I avoid contact with camels, I will not get Coronavirus. If I avoid contact with sick people, I will not get Coronavirus. I cover my mouth and nose with a tissue when coughing and sneezing because it's a healthy behavior. If I follow the ministry of health's Coronavirus recommendations, I will reduce my chance of getting Coronavirus. If I follow the ministry of health's Coronavirus recommendations, I will help in minimizing the spread of Coronavirus disease.
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If I wear a mask when visiting sick people, I will avoid getting Coronavirus.
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Cues to Actions Q5: To what extent you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly agree)
Neither Strongly Strongly Disagree (2) agree or Agree (4) disagree (1) agree (5) disagree (3) I wash my hands regularly with soap and water to maintain good health. I always follow medical advices, such as eating healthy and balance diet because I feel it will benefit my health. I search for a new information to keep myself updated regarding Coronavirus. Maintaining good health is extremely important to me. Getting enough sleep will help me to be in good health. Maintaining proper hygiene is important to good health. Eating well-balanced meals will help to maintain good health. It's important to exercise to maintain good health.
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Self- efficacy Q6: To what extent you agree or disagree to the below statements? (1= being strongly disagree, 5= being strongly agree)
Neither Strongly Disagree Strongly agree or Agree (4) disagree (1) (2) agree (5) disagree (3) I am able to identify Coronavirus symptoms. I am capable of following the ministry of health's Coronavirus preventive measures in a daily life basis. I am capable of washing my hands with soap and water regularly. I am capable of searching for updated information regarding Coronavirus by myself. I am capable of avoiding close contact with sick people. I am capable of using proper ways of Coronavirus preventive measures, such as using a tissue when I sneeze or cough. I am capable of keeping myself away from camels. I am able to seek medical help if I feel I have Coronavirus symptoms. I am capable of wearing a mask when I visit sick people.
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Information seeking Q7: The first place I seek information about Coronavirus is: The Ministry of Health's (Website, Twitter, Facebook, YouTube). The Internet (Google, Yahoo, etc.). The World Health Organization's (Website, Twitter, Facebook, YouTube). Traditional Media (television, newspapers, radio, etc.) Centers for Disease Control and Prevention's (Website, Twitter, Facebook, YouTube). Family and friends. Doctors or other health providers. I have never sought information about Coronavirus. Other. If I have never sought information... Is Selected, Then Skip To How often do you wash your hands daily?
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Q8: Please indicate your likelihood of using the below communication channels to seek information about Coronavirus knowing that 1= very unlikely and 5= very likely.
Extremely Extremely Unlikely (2) Neutral (3) Likely (4) unlikely (1) likely (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc.) Blogs The Ministry of Health's website The Ministry of Health's Twitter account The Ministry of Health's Facebook account The Ministry of Health's YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctor or other healthcare providers 181
Media Credibility Q9: On scale of 1 to 5, to what extent do you think the crisis information obtained about Coronavirus from each medium below is believable knowing that 1= not at all believable and 5 = extremely believable.
Not Extremely Not at all I don't know Believable believable believable believable (1) (3) (4) (2) (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc.) Blogs The Ministry of Health's website The Ministry of Health's Twitter account The Ministry of Health's Facebook account The Ministry of Health's YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctors or other healthcare providers 182
Q10: On scale of 1 to 5, to what extent do you believe the crisis information obtained about Coronavirus from each medium below is accurate knowing that 1= not accurate at all and 5= very accurate.
Not accurate Not accurate I don't know Very Accurate (4) at all (1) (2) (3) accurate (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc.) Blogs The Ministry of Health's website The Ministry of Health's Twitter account The Ministry of Health's Facebook account The Ministry of Health's YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctors or other healthcare providers
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Q11: On scale of 1 to 5, to what extent do you believe the crisis information obtained about Coronavirus from each media below is trustworthy knowing that 1= very untrustworthy and 5= very trustworthy.
Very Very Untrustworthy I don't know Trustworthy untrustworthy trustworthy (2) (3) (4) (1) (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc. Blogs The Ministry of Health's website The Ministry of Health's Twitter account The Ministry of Health's Facebook account The Ministry of Health's YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctors or other healthcare providers
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Q12: On scale of 1 to 5, to what extent do you believe the crisis information obtained about Coronavirus from each medium below is biased knowing that 1= very biased and 5= not biased at all.
Very biased I don't know Not biased Not biased at Biased (2) (1) (3) (4) all (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc.) Blogs The Ministry of Health's website The Ministry of Health Twitter account The Ministry of Health's Facebook account The Ministry of Health YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctors or healthcare providers
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Q13: On scale of 1 to 5, to what extent do you believe the crisis information obtained about Coronavirus from each medium below is complete knowing that 1= Very incomplete and 5= very complete. Very Incomplete I don't know Complete Very
incomplete (1) (2) (3) (4) complete (5) Newspapers Television Radio Twitter Facebook YouTube The Internet (Google, Yahoo, etc.) Blogs The Ministry of Health's website The Ministry of Health's Twitter account The Ministry of Health's Facebook account The Ministry of Health's YouTube channel World Health Organization Centers for Disease Control and Prevention Family and friends Doctors or healthcare providers 186
Q14: I seek information about Coronavirus: Daily (2) 1-2 times a week (4) 1-2 times a month (3) Once a month (5) Once every other month (6) 1-2 times a year (7)
Q15: How often do you wash your hands daily? I don't wash my hands (5) 1-2 times (1) 3-5 times (2) 5-7 times (3) 7-9 times (4) 10 or more times (10)
Q16 Do you wear a mask when you visit sick people? Yes (1) NO (2) I don't visit sick people (3)
Q17 Do you follow healthy and balanced diet to increase your immune system? Yes (1) No (2)
Q18 Do you get enough sleep every day? Yes (1) No (2)
Q19 Do you cover your mouth or use a tissue when coughing or sneezing? Yes (1) No (2)
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Q20 Do you keep yourself away from camels? Yes (1) No (2)
Q21 For how many minutes do you exercise weekly? I don't exercise (1) Less than 75 minutes (2) Between 75- 140 minutes (3) 150 minutes or more (4)
About You Q22: I am Female (1) Male (2)
Q23: My education level is: First year (9) Second year (8) Third year (7) Fourth year (6) Fifth year (5) Sixth year (4) Graduate level (3)
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Q24: What year were you born? 2000 (1) 1999 (2) 1998 (3) 1997 (4) 1996 (5) 1995 (6) 1994 (7) 1993 (8) 1992 (9) 1991 (10) 1990 (11) 1989 (12) 1988 (13) 1987 (14) 1986 (15) 1985 (16) 1984 (17) 1983 (18) 1982 (19) 1981 (20) 1980 (21) 1979 (22) 1978 (23) 1977 (24) 1976 (25) 1975 (26) 1974 (27) 1973 (28) 1972 (29) 1971 (30) 1970 (31) 1969 (32) 1968 (33) 1967 (34) 1966 (35) 1965 (36) 1964 (37) 1963 (38) 1962 (39) 189
1961 (40) 1960 (41) 1959 (42) 1958 (43) 1957 (44) 1956 (45) 1955 (46) 1954 (47) 1953 (48) 1952 (49) 1951 (50) 1950 (51) 1949 (52) 1948 (53) 1947 (54) 1946 (55) 1945 (56) 1944 (57) 1943 (58) 1942 (59) 1941 (60) 1940 (61) 1939 (62) 1938 (63) 1937 (64) 1936 (65) 1935 (66) 1934 (67) 1933 (68) 1932 (69) 1931 (70) 1930 (71) 1929 (72) 1928 (73) 1927 (74) 1926 (75) 1925 (76) 1924 (77) 1923 (78) 1922 (79) 190
1921 (80) 1920 (81) 1919 (82) 1918 (83) 1917 (84) 1916 (85)
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Q1 :إلى أي درجة توافق أو تعارض على العبارات التالية؟ 1 = أعارض بشدة، =5 أوافق بشدة
ل أعارض ول أوافق أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 3 هناك احتمال كبير بأن أصاب بمرض كورونا. أشعر بأني سوف أصاب بمرض كورونا في المستقبل . أشعر بأن إمكانية إصابتي بمرض كورونا أكبر من الناس الخرين. أفراد عائلتي معرضون لخطر الصابة بمرض كورونا. أصدقائي معرضون لخطر الصابة بمرض كورونا .
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Q2 :إلى أي درجة توافق أو تعارض على العبارات التالية؟ 1=أعارض بشدة، 5=أوافق بشدة
ل أوافق ول أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 أعارض3 التفكير حول إحتمالية إصابتي بمرض كورونا يخيفني عندما أفكر بمرض كورونا، تتسارع نبضات قلبي. أنا خائف بمجرد التفكير بمرض كورونا. إذا أصبت بمرض كورونا، فسوف أموت. المشاكل التي سأواجهها عندما أصاب بمرض كورونا ستبقى فترة طويلة. إذا أصبت بمرض كورونا فإن حياتي ستتغير. إذا أصبت بمرض كورونا، فإن أفراد عائلتي الخرين سيصابون بالمرض.
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Q3 : إلى أي درجة توافق أو تعارض على العبارات التالية؟ =1أعارض بشدة، 5=أوافق بشدة
ل أوافق ول أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 أعارض3 مغاسل اليد أو مطهرات اليد غير متوفرة في الماكن التي أقضي معظم الوقت بها. غسل اليدين بالماء والصابون بانتظام غير مريح بالنسبة لي. غسل اليدين بالماء والصابون بانتظام فيه استهلك للوقت. من الصعوبة تجنب الختلط بالشخاص المرضى. الجراءات الوقائية المتعلقة بمرض كورونا هي صعبة التطبيق في الحياة اليومية. غسل اليدين بالماء والصابون أو استخدام المعقمات يكلفني الكثير من المال. ل أشعر بالراحة عند لبس كمامة النف لتجنب الصابة بمرض كورونا.
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Q4 : إلى أي درجة توافق أو تعارض على العبارات التالية؟ 1 = أعارض بشدة،= 5 أوافق بشدة
ل أوافق ول أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 أعارض3 عندما أقوم بغسل اليدين بالماء و الصابون بانتظام فلن أصاب بمرض كورونا. عندما أتجنب الختلط بالبل، فلن أصاب بمرض كورونا. عندما أتجنب الختلط بالشخاص المرضى، فلن أصاب بمرض كورونا. أقوم بتغطية الفم والنف بمنديل عند السعال أو العطس لنه سلوك صحي. عندما أتبع توصيات وزارة الصحة المتعلقة بمرض كورونا ، فإني أقلل فرصة إصابتي بالمرض. عندما أتبع توصيات وزارة الصحة المتعلقة بمرض كورونا، فسوف أساعد على التقليل من انتشار المرض. إذا قمت باستخدام كمامة النف عند زيارة المرضى، فإني سأتجنب الصابة بمرض كورونا.
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Q5: إلى أي درجة توافق أو تعارض على العبارات التالية؟= 1=أعارض بشدة، 5= أوافق بشدة
ل أوافق ول أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 أعارض3 أقوم بغسل اليدين بالماء والصابون بانتظام للمحافظة على صحة جيدة. أقوم دائما بمتابعة النصائح الطبية مثل، المحافظة على الغذاء الصحي والمتوازن لنها مفيدة للصحة. أقوم بالبحث عن معلومات جديدة تتعلق بمرض كورونا لتحديث معلوماتي عن المرض. المحافظة على الصحة الجيدة هو أمر مهم للغاية بالنسبة لي. أخذ قسط كا ف من النوم يساعدني بأن أكون بصحة جيدة. العناية بالنظافة الشخصية هو أمر مهم للحصول على صحة جيدة. تناول غذاء صحي و متوازن يساعد على الحصول على صحة جيدة. التمارين الرياضية مهمة للحفاظ على صحة جيدة.
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Q6: إلى أي درجة توافق أو تعارض على العبارات التالية؟1= أعارض بشدة، 5= أوافق بشدة
ل أوافق ول أوافق بشدة5 أوافق4 أعارض2 أعارض بشدة1 أعارض3 أنا قادر على التعرف على أعراض مرض كورونا. أنا قادر على اتباع توصيات وزراة الصحة المتعلقة بالتدابير الوقائية لمكافحة مرض كورونا بشكل يومي. أنا قادر على غسل اليدين بالماء والصابون بانتظام. أنا قادر على البحث عن معلومات جديدة بنفسي تتعلق بمرض كورونا. أنا قادر على تجنب الختلط بالمرضى. أنا قادر على استخدام الطرق السليمة لتخاذ التدابير الوقائية لمرض كورونا كاستخدام المناديل في حال العطس أو السعال. أنا قادر على تجنب مخالطة البل. أنا قادر على الحصول على الرعاية الطبية اللزمة عندما أشعر أن لدي أعراض مرض كورونا. أنا قادر على استخدام كمامة النف عند زيارة المرضى.
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Q7: أول مكان أذهب إليه للبحث عن معلومات تتعلق بمرض كورونا هو:
وزارة الصحة ) الموقع الرسمي للوزارة ,حساب وزارة الصحة في تويتر، فيسبوك، أو يوتيوب.( النترنت) جوجل، ياهو، الخ(. منظمة الصحة العالمية) الموقع الرسمي للمنظمة، حساب المنظمة على تويتر، فيسبوك، أو يوتيوب.( العلم التقليدي) تلفزيون ,صحف، راديو، الخ.( مراكز السيطرة على المراض والوقاية منها) الموقع الرسمي للمركز ,حساب المركز على تويتر، فيسبوك ,أو يوتيوب.( العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية. لم يسبق لي البحث عن معلومات تتعلق عن مرض كورونا أخرى If I have never sought informa... Is Selected, Then Skip To How often do you wash your hands daily?
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Q8: نرجو أن توضح مدى إستخدامك لوسائل التصال التالية للبحث عن معلومات تتعلق بمرض كورونا .علما بأن 1= من المستبعد جدا، 5= من المرجح جدا.(
من المرجح جدا5 من المرجح4 محايد3 من المستبعد2 من المستبعد جدا1 الصحف التلفزيون الراديو تويتر فيسبوك يوتيوب النترنت) جوجل، ياهو، الخ(. المدونات اللكترونية الموقع الرسمي لوزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك حساب وزارة الصحة على يوتيوب منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC الهل والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q9: مصداقية وسائل العلم : من مقياس 1 إلى5 ، إلى أي مدى تعتقد أن المعلومات التي يتم الحصول عليها حول أزمة مرض كورونا من كل وسيلة اتصال هي صادقة .علما بأن = 1 ل يمكن تصديقها على الطلق و = 5 صادقة للغاية.
ل يمكن تصديقها صادقة للغاية5 صادقة4 ل أعلم3 ل يمكن تصديقها2 على الطلق1 الصحف تلفزيون راديو تويتر فيسبوك يوتيوب النترنت) جوجل وياهو، الخ( المدونات اللكترونية موقع وزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك قناة وزارة الصحة على يوتيوب منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q10: من مقياس 1 إلى5 ، إلى أي مدى تعتقد أن المعلومات التي يتم الحصول عليها حول أزمة مرض كورونا من كل وسيلة اتصال هي دقيقة .علما بأن = 1 غير دقيقة على الطلق و = 5 دقيقة جدا.
غير دقيقة على دقيقة جدا5 دقيقة5 ل أعلم3 غير دقيقة2 الطلق1 الصحف تلفزيون راديو تويتر فيسبوك يوتيوب النترنت) جوجل وياهو، الخ( المدونات اللكترونية موقع وزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك قناة وزارة الصحة على يوتيوب منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q11: من مقياس 1 إلى5 ، إلى أي مدى تعتقد أن المعلومات التي يتم الحصول عليها حول أزمة مرض كورونا من كل وسيلة اتصال هي جديرة بالثقة .علما بأن = 1 ل يمكن الثقة بها على الطلق و = 5 ثقة عالية.
غير جديرة بالثقة جديرة بالثقة جدا5 جديرة بالثقة4 ل أعلم3 غير جديرة بالثقة2 على الطلق1 الصحف تلفزيون راديو تويتر فيسبوك يوتيوب النترنت) جوجل وياهو، الخ( التدوينات اللكترونية موقع وزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك وزارة قناة يوتيوب الصحة منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q12: من مقياس 1 إلى5 ، إلى أي مدى تعتقد أن المعلومات التي يتم الحصول عليها حول أزمة مرض كورونا من كل وسيلة اتصال هي حيادية .علما بأن = 1 غير حيادية إطلقا = 5 حيادية جدا .
غير حيادية على حيادية جدا5 حيادية4 ل أعلم3 غير حيادية2 الطلق 1 الصحف تلفزيون راديو تويتر فيسبوك يوتيوب النترنت) جوجل وياهو، الخ( المدونات اللكترونية موقع وزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك قناة وزارة الصحة على يوتيوب منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q13 :من مقياس 1 إلى5 ، إلى أي مدى تعتقد أن المعلومات التي يتم الحصول عليها حول أزمة مرض كورونا من كل وسيلة اتصال هي معلومات كاملة .علما بأن = 1 غير كاملة على الطلق و = 5 كاملة جدا.
غير كاملة على كاملة جدا5 كاملة4 ل أعلم3 غير كاملة2 الطلق1 الصحف تلفزيون راديو تويتر فيسبوك يوتيوب النترنت) جوجل وياهو، الخ( المدونات اللكترونية موقع وزارة الصحة حساب وزارة الصحة على تويتر حساب وزارة الصحة على فيسبوك قناة وزارة الصحة على يوتيوب منظمة الصحة العالميةWHO مراكز السيطرة على المراض والوقاية منهاCDC العائلة والصدقاء الطباء أو غيرهم من مقدمي الرعاية الصحية
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Q14: أبحث عن معلومات تتعلق بمرض كورونا:
يوميا مرة -مرتين في السبوع مرة -مرتين في الشهر مرة واحدة في الشهر مرة واحدة كل شهرين مرة -مرتين في السنة
Q15: كم مرة تقوم بغسل اليدين يوميا؟ أنا ل أغسل يدي مرة -مرتين 5-3مرات 7-5مرات 9-7مرات 10مرات أو أكثر
Q16: هل تستعمل كمامة النف عند زيارة المرضى؟ نعم ل ل أقوم بزيارة المرضى
Q17: هل تتبع نظام غذائي صحي ومتوازن لزيادة المناعة لديك؟ نعم ل
Q18: هل تحصل على قسط كا ف من النوم كل يوم؟
نعم ل
Q19: هل تقوم بتغطية الفم أوتستخدم المناديل الورقية عند السعال أو العطس؟
نعم ل
Q20 :هل تبقي نفسك بعيدا عن البل؟ نعم ل
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Q21 :كم دقيقة تمارس الرياضة أسبوعيا؟
ل أمارس الرياضة أقل من 75 دقيقة بين 140 -75 دقيقة 150دقيقة أو أكثر
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Q22:الجنس:
أنثى ذكر
Q23أنا حاليا في السنة:
السنة الولى السنة الثانية السنة الثالثة السنة الرابعة السنة الخامسة السنة السادسة دراسات عليا
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Q24:سنة الميلد؟
2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 208
1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 209
1918 1917 1916
Q 25:هل أنت طالب/طالبة في إحدى التخصصات الطبية؟ نعم ل
Q26:هل أنت طالب /طالبة في إحدى التخصصات الزراعية؟
نعم ل