Impact of COVID-19 on Public Knowledge and Attitudes Toward Participating in Clinical Trials in Saudi Arabia: A Cross-Sectional Study

Introduction

Clinical studies are medical experiments aimed at determining the results of patient health when they are participating in the study.¹ Depending on the type of study, patients in clinical trials can receive specific treatments. Clinical trial results may provide new information or techniques that can broaden medical knowledge for treatment or diagnostic purposes.²

Participation and enrollment of patients in clinical trials is one of the leading challenges faced by researchers. In 2020, Jin et al published a systematic review to investigate factors affecting people participation in clinical trials.³ The results included 63 studies from various countries and settings. The leading factor affecting participation is the level of trust in research entity and the researcher. Safety issues, include adverse drug reactions, were also perceived as an important factor. In addition, educational level might affect public attitude, studies have found that people with biomedical degrees are more willing to participate compared with other groups. As for gender and age, young people and men are more willing to participate compared with older adults and women. Finally, having a previous good experience with clinical trials will enhance the chance of future participation.

From this systematic review, there is a wide array of factors that affect people attitude toward participation in clinical trials. Efforts to enhance the trust in research institutions and researcher and utilizing mass media to reflect on successful experiences might further enhance participation in clinical research.

A multicenter study conducted in some Middle Eastern countries, including Egypt, the Kingdom of Saudi Arabia, and Jordan, showed that approximately 50% of study participants had positive attitudes toward participation in COVID-19 trials.⁴ The main factors that influenced public willingness to participate were the ethical conduct of the clinical trials and the desire to protect family members from COVID-19 from accelerating the return to normal life.

From this study, it was clear that people in the Middle East, including Saudi Arabia, are generally receptive to participation in clinical trials. However, the magnitude of change in perception compared with pre-pandemic levels was not measured.

Therefore, we aimed to update the literature about the main factors affecting public decisions to participate in a clinical trial. During the COVID-19 pandemic, we observed huge awareness campaigns through social media to increase knowledge about clinical trials and change public attitudes toward participating in clinical trials. Therefore, we assumed that knowledge and attitudes could change during the COVID-19 pandemic, and we assessed the impact of COVID-19 on the Saudi public’s perception of clinical trials and knowledge about clinical trial participation.

Methods

Study Design/Setting

We conducted a descriptive, cross-sectional analysis using self-administered questionnaires in both Arabic and English languages. The study took place at KFMC and King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. The data were collected between November 2019 and October 2020.

Inclusion and Exclusion Criteria

Using a convenience sampling approach, we invited patients who attended outpatient clinics to participate. Eligible participants were at least 18 years old and knew the term “clinical trial.” Patients who had abnormal mental health, an acute psychiatric emergency, or a critical illness were excluded.

Questionnaire Development

Previous studies similar to ours were reviewed to identify possible factors affecting patient knowledge of and attitudes toward participating in clinical trials.^5–7 Our questionnaire was then modified to fit the study’s aim.

The questionnaire consisted of 43 questions, which were classified into three sections. The first section consisted of questions about sociodemographic characteristics, such as age, gender, marital status, residential area, number of children (if any), educational level, educational background, reason for the visit, level of health insurance (if any), and regular source of care (if any). The second section evaluated the patient’s knowledge about clinical trials (six questions). Finally, the last section involved questions about the patient’s attitude toward clinical trials (27 questions).

A pilot study was carried out among 10 patients at KFMC to ensure good reliability; Cronbach’s alpha was 0.88, indicating the reliability of our tool, and no substantive changes were made to the questionnaire after the pilot study. We classified the knowledge question (ie, section 2) responses into “yes” and “no” groups. The attitude domain was assessed using a Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree).

Data Collection

The questionnaire was administered electronically using Google Forms to facilitate data collection, tracking, and validation. The questionnaire responses were collected by volunteers. The volunteers had medical backgrounds (eg, student or graduate student in medical fields), and four volunteers had access to the questionnaire and collected the data.

Sample Size

Our sample size was determined by the number of patients visiting outpatient clinics in KFMC and KSUMC. Overall, 14,736 people visited the outpatient clinics at these two locations. Using that number and the OpenEpi website,⁸ we calculated our necessary sample size to achieve a P value of 0.05 as 375 participants.

Statistical Analysis

Data analysis was performed using SPSS 25.0 software (SPSS Inc., Chicago, IL, USA). We used a descriptive-frequency test and the chi-square test to determine the intensity of the correlation between independent variables (age, gender, educational level, and marital status) and the major outcome variable of attention. To improve our analyses, we classified education levels into subgroups of uneducated, elementary school, middle/high school, bachelor’s degree, master’s degree, and doctorate degree.

Ethical Considerations Procedure

This study was conducted in accordance with the Declaration of Helsinki. Permission to conduct this study was obtained from the institutional review board at KFMC (project No. 19-516) and the ethical committee at KSUMC (project No. E-194380). Electronic informed consent was provided by each participant before they answered the questionnaire. Participants did not receive any compensation for participation in the study.

Results

From November 2019 to October 2020, 822 responses from participants in two medical cities were reported and included in the analysis. We aimed to identify and determine the main barriers that affect patient participation in clinical trials in Saudi Arabia.

Most study participants (47.2%) were between 18 and 30 years old. There was no significant difference between participant ages before versus during the pandemic. In our sample, 59% of participants were women. Overall, 37.7% of participants were single and 62.3% were married; 50.2% of married participants had children. Most participants lived in the city (90.9%), had a bachelor’s degree (59.9%), and had a nonmedical background (57.1%). In addition, 24.1% of patients were treated at a private hospital, but the majority (75.9%) received their regular care at governmental hospitals (75.9%); overall, 72.8% of participants had no health insurance (Table 1).

Table 1 Sociodemographic Information

As shown in Table 2, no differences existed between the number of participants who participated in clinical trials before versus during the COVID-19 pandemic (P = 0.129). Also, regarding patient knowledge about clinical trials, most patients (67.2%) had poor knowledge about the ethics committee in general before the pandemic, but knowledge increased significantly (P = 0.02) during the COVID-19 pandemic.

Table 2 The Knowledge About Participating in Clinical Trials

Unfortunately, most patients (75.3%) had poor knowledge about whom to contact for problems or adverse events during the clinical trial. This knowledge increased during the pandemic by 4.9%. A significant difference existed in participant trust of physicians (P = 0.08); 88.1% of participants believed that their physicians could not start a clinical trial without professional approval to protect patients. (Table 2).

In Table 3 shown the participant attitudinal fear from participating in a clinical trial before and during the COVID19 pandemic. We found most responses were worried about they might not receive good health care when they join a clinical trial (p=0.04). Moreover, most of them were afraid about they might the are not able to find transportation to reach them to the clinical trial treatment center (p=0.03).

Table 3 Attitudinal of Fear from Participating in a Clinical Trial

While most of them were willing to participate if they received benefits, risks, and full information about the trials (p=0.004). Also, most of them were willing to participate in a clinical trial if their physician explained it to them (p=0.003). The majority of them preferred to have more information from their physician about the trial (p=0.007).

Discussion

In this cross-sectional study, we found that the COVID-19 pandemic has had no impact on patient knowledge about clinical trials but has slightly affected patient attitudes about participating in clinical trials. Only 8% of the participants had previously participated in clinical trials. Generally, people had some basic knowledge about randomized, controlled trials, including awareness about the need for approval by the government. However, patients knew less about the requirements for reporting adverse events and the concept of informed consent. Knowledge about the process of informed consent and about the role of the ethics committee increased during the pandemic.

Only a few studies in Saudi Arabia have been conducted to assess factors that affect participation in clinical trials.^5,6 A study conducted by Al-Tannir et al found that 80% of the participants considered clinical trials essential for improving patient care and scientific knowledge.⁵ Regarding informed consent in that study, most participants reported awareness of confidentiality, expected risks, and benefits; however, knowledge about possible compensation, rights, and consequences of withdrawal was lower.⁵

Another study by Al-Rawashdeh et al found that the vast majority of participants were unaware of the institutional review board.⁶ Evidence from these studies cannot be extrapolated to the setting of our study. During the COVID-19 pandemic, the number of clinical trials has greatly increased.⁹ Therefore, public knowledge and attitudes toward enrollment in clinical trials are expected to increase simultaneously. In this study, participants were more receptive to the benefits of clinical trials during COVID-19. In addition, study participants demonstrated higher levels of trust in the health care system compared with previously reported levels. Abu-Farha et al assessed the public perception of clinical trials during COVID-19;¹⁰ 68% and 73% of the Jordanian public were willing to participate in COVID-19 clinical trials to find treatment and return to normal life respectively. This high percentage reflects the increased societal responsibility of the general public toward COVID-19 trials.

This study was one of the few studies, to our knowledge, that assessed the general public’s perception and knowledge of clinical trials during COVID-19.¹⁰ This study had some limitations. First, this study was conducted in two medical cities in Riyadh. Second, the vast majority of participants were relatively young and educated. Therefore, results cannot be generalizable to different age groups, educational levels, or settings. Moreover, the survey was self-administered, therefore the risk of social desirability bias might be introduced.¹¹ Finally, the research questionnaire was developed by the research team. Future studies should aim to develop a standardized tools which enable researcher to quantify the public attitude to clinical trials which in turn help in assessing the impact of policies and intervention that affect patients recruitment.

Social media has a major role in educating the public about clinical trials and COVID-19.^12,13

Simple, jargon-free language can explain the various aspects of clinical trials, including the potential benefits and risks. In addition, encouraging clinical trial participants to share their experiences could help recruit future eligible participants. These interactions should be regulated by entities that manage patient and public involvement in clinical trials. The involvement of patients and the public in improving awareness about clinical trials represents a substantial role in bridging the gap between researchers and the public.¹⁴ Efforts to reach patients can involve reviewing study documents to assess their appropriateness and clarity for the study participants, evaluating patient experiences, and disseminating study results to the public. In addition, the National Committee of Bioethics, the Ministry of Health, or research centers must conduct several awareness campaigns about the role of ethics committees and introduce patients who were enrolled in clinical trials before the community to transfer their experience about clinical trials.

Conclusion

The COVID-19 pandemic has had no impact on patient knowledge about clinical trials; however, the pandemic did have a slight impact on patient attitudes toward participating in clinical trials. The Saudi population knows about clinical trials but lacks knowledge about the role of the ethics committee and about informed consent. Also, most people do not have the experience of participating in a clinical trial. Still, they maintain moderately positive attitudes toward clinical trials. The conclusion needs to be interpreted with caution due to small sample and the high representation of young, educated subjects in comparison with other population groups.