Health-care institutions are expected to have a major role during a pandemic , when HCWs are at a high risk of exposure and infection . During the most recent outbreak of SARS, HCWs suffered considerable stress, partly from an overstretched health-care system [17, 18]. A similar scenario is expected should a MERS outbreak occur in Saudi Arabia. Our results show that the attitude of a sample of HCWs in Saudi Arabia toward MERS-CoV infection is in the negative range, with an overall average concern score of 40 out of a maximum possible score of 93 points, indicating a moderate level of concern. In a study conducted in a tertiary teaching hospital in Greece, more than half of the surveyed HCWs experienced moderately high levels of worry about the A/H1N1 influenza pandemic . In our study, one-fourth of HCWs had high levels of concern regarding the MERS outbreak. This finding is in accordance with the results of a similar study, published in 2015, of HCWs at Makkah hospitals, Saudi Arabia . High levels of concern have also been demonstrated in the Saudi public . These negative attitudes and high levels of concern could be attributed to the novelty of MERS-CoV infection and the lack of previous experience with, or exposure to, MERS. However, perceptions are not always negative, and results published in 2014 from a study in the Al Qassim region of Saudi Arabia demonstrated positive attitudes in HCWs towards MERS . There has been possibility that media coverage may be influencing HCWs’ attitudes to MERS-CoV.
When comparing our findings with those from other studies, other factors that might contribute to any observed differences should be taken into consideration. Prominent among these are the variability in definition of high concern (cut-off point beyond which the high level of concern is considered), age difference between studied subjects and time of the study. Lack of standardization in methodology between different studies creates difficulties for making proper comparisons between different populations.
An important finding in our study was that high level of concern was prevalent among HCWs, although it took different forms. Concern was mainly observed when respondents replied negatively to questions regarding fears of infection of a family member, risk of infection if one of the colleagues gets infected, risks associated with dealing with a febrile patient, or obligation of care provision for patients infected with MERS-CoV and lack of faith in standard precautions. Similar responses have been recorded in relation to MERS and other diseases. More than half (55%) of surveyed HCWs in Japan indicated a high level of fear and anxiety of SARS-CoV infection, even in the absence of an epidemic, and a high proportion (92%) preferred to avoid patients with SARS . Approximately 90% of surveyed HCWs in Thailand accepted the personal risk of caring for patients with H5N1 infections , and approximately 78% of the Saudi public who were surveyed agreed that schools should close in case of an H1N1 influenza epidemic . However, this finding was not in agreement with the finding of the present study where only 19% of HCWs agreed that schools and shopping markets need to be closed.
MERS-CoV is continuing to spread to countries outside the Middle East, and MERS remains a public-health risk. The possible consequences of this spread are serious in view of the pattern of nosocomial transmission. Five days after the publication of a WHO report in May 2015  denying the possibility of sustained outward transmission to persons in close contact with those affected by MERS, on aircraft or in countries outside the Middle East, the first case of a MERS-CoV infection was reported in Seoul, South Korea.  In our study, the majority of participants agreed that the government should isolate patients with MERS in special hospitals, that it should avoid inviting expatriate workers from areas where the disease is prevalent, that it should restrict travel to and from such areas, and that they felt at risk of contracting a MERS-CoV infection at work. Further spread of the virus to countries with poorly developed health-care systems and laboratory facilities, in which an unexpected virus cannot be rapidly identified, may result in a widespread outbreak or epidemic; this description applies to many of the 182 countries from which Ramadan, Hajj and Umrah pilgrims originate.
The WHO has highlighted the importance of preparedness plans in reducing the effect of outbreaks . The MNG-HA has developed a plan documenting the medical and public-health responses to a MERS outbreak. The plan describes health-care institutions as vital components in an outbreak, and makes provisions to protect HCWs through infection-control measures and personal-protection practices. However, our results show that the majority of HCWs feel unsafe at work when using the standard infection-control precautions. Moreover, the majority feel at risk of contracting a MERS-CoV infection at work. This result is similar to the findings of a study of doctors in the UK, in which approximately two-thirds felt that their health-care system would have problems coping with a pandemic . Ensuring that adequate protective measures are in place could provide a measure of reassurance to HCWs. The provision of knowledge and skills could help HCWs to feel better prepared and maintain staff morale during an outbreak.
The complex situation of the MERS outbreak in Saudi Arabia highlighted the importance of some cultural issues; such as the strong ties with family members, relatives and friends, which means that Saudis are likely to visit and care for loved ones who are afflicted with MERS . This cultural issue may partly explain the higher concern among Saudi HCWs compared with non-Saudis. Non-Saudi HCWs, as expatriate workers, are more likely to be single and/or to have family members living outside Saudi Arabia, so they might have less immediate concern about transmitting the disease. Saudi nationals are more likely to be exposed to local media, or more likely to be critical of their own government’s policies than foreign nationals.
Our results show that physicians have less concern than other HCWs in relation to MERS. This finding was evident in all domains except for infection control-related domain. This finding differed from the results of previous studies [10, 11, 22, 28]. A low level of concern among physicians could be attributed to their greater opportunities for professional development and clinical training compared with other HCWs, along with possible previous experience of similar diseases with infectious viral origins, such as SARS and swine flu. Clinicians may have more access to professional journals, whereas others may obtain more information from mass media. Knowledge and experience could result in positive attitudes that can be explained by the theory of reasoned action, which predicts that behavioral intent is caused by both attitudes and subjective norms. 
In emergency situations, HCWs face conditions that lead to physical and mental exhaustion . The critical situation in central region, where PHASE III of the Infectious Diseases Epidemic Plan has previously been activated, resulting in closure of the Emergency Department and Outpatient and Inpatient Services because of the MERS outbreak, is likely to have affected the perception and attitudes of HCWs in the central region more than in other regions of the Kingdom. Our results show that location in the central region is associated with higher concern scores in relation to MERS compared with location elsewhere, even after adjusting for covariates. This finding was evident for self-satisfaction, workplace and government-related domains. The experience of the effects of the outbreak in the central region could have contributed to this elevated level of concern.
Because this study had a cross-sectional design, relationships between the predictor variables and the dependent variable (the concern score) can only be described as general associations rather than causal relationships. As with any survey based on a self-administered questionnaire, the self-reported information on which the analysis and interpretations are based may not be entirely accurate, mainly because of the possibility of recall bias of HCWs giving a more positive response than would be revealed by other data-collection methods. The study might be subjected to a selection bias due the possibility of not having all disciplines involved equally. However, the response rate ranged from 62 to 68% in the three regions, a finding that should not reflect a high level of systematic bias, if any. Moreover, the respondents were all HCWs in tertiary military hospitals, and the results might not reflect the concerns of all HCWs, or those in non-military hospitals in Saudi Arabia. In addition, the design process for the questionnaire did not include a qualitative focus-group discussion to investigate the attitudes of HCWs in depth. Despite the identified limitations, these results contribute to the information relating to a major health problem faced by HCWs in Saudi Arabia, especially in the MNG-HA. Very little research has previously been carried out in this field.