Background: Coronavirus disease-2019 (COVID-19) outbreak is a global concern and the World Health Organization (WHO) has declared it as a public health emergency of international concern. Objectives: This study aimed to assess knowledge, attitude, and practices (KAP) toward COVID-19 among the general population of Palestine at the time of the COVID-19 pandemic. Materials and Methods: A cross-sectional study was conducted using an online questionnaire; a series of questions regarding the KAP of the population about COVID-19 was asked, and participants’ demographic characteristics and source of information regarding COVID-19 were collected and analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 26.0. Results: Seven hundred twenty-four individuals participated in this study. The average age of the participants was 28 years (standard deviation [SD] = 10.7), the majority were females 558 (77.1%), with a bachelor’s degree 480 (66.3%), and 229 (31.6%) students. Most of them from Hebron governorate 609 (84.1%) and many of them reported that they wear a mask when they leave their house and avoid shaking hands, 494 (68.2%), 424 (58.6%), respectively. The results indicate that Palestinians have a good level of knowledge about COVID-19 with a positive attitude and good compliance with Palestinian government measures. The result showed a significant correlation between female gender, higher age, and higher education with KAP. However, male gender, nonhealth-care-related professions, single, and lower level of education were significantly associated with lower knowledge scores. There was no clear satisfaction with the government’s role in limiting and controlling the spread of COVID-19. Conclusions: Palestinian population showed decent knowledge, appropriate practice, and a positive attitude toward the COVID-19 outbreak.
Keywords: Attitude, COVID-19, KAP, knowledge, Palestine, practice, SARS-CoV-2
|How to cite this URL:|
Hejaz HA, Nawajah I, Wredat M, Melhem W. Knowledge, attitude, and practice toward the novel coronavirus-2019 (COVID-19) outbreak: A cross-sectional study in Palestine. Adv Biomed Health Sci [Epub ahead of print] [cited 2022 May 25]. Available from: https://www.abhsjournal.net/preprintarticle.asp?id=335720
| Background|| |
Last December 2019 in the city of Wuhan, China, a group of people suffering from idiopathic pneumonia was admitted, and these symptoms were associated with eating bats and seafood, and then it was determined that the cause of infection was the new coronavirus. The World Health Organization (WHO) declared it a global pandemic on March 12, 2020 [1,2]. The current pandemic of coronavirus disease-2019 (COVID-19) is a type of coronavirus disease caused by the severe acute respiratory syndrome virus 2 (SARS-CoV-2), which causes serious respiratory illness such as pneumonia and lung failure. The WHO launched the virus that causes the novel coronavirus-2019, and then it was renamed by the International Committee for the Study of Coronavirus Group (CSG) as “SARS-CoV-2” and the disease named COVID-19 by the WHO . Coronaviruses are single-stranded RNA viruses, spherical, polymorphic, with a radius of 80–120 nm, and sizes ranging from 50 to 200 nm . They cause diseases in humans called human coronaviruses (HCoVs) and cause diseases related to the respiratory, nervous, and digestive systems in various species of birds and mammals . Coronaviruses belong to the Coronaviridae family of the order Nidovirales  and it constitutes the largest group within the Nidovirales suborder and this order includes four families, which are Coronaviridae, Arteriviridae, Mesoniviridae, and Roniviridae. Coronaviridae are divided into four subfamilies, including α−/β−/γ−/δ-coronavirus; α- and β-CoV have the potential to infect mammals, whereas γ- and δ-CoV induce infection in birds . Alpha coronavirus includes HCoV- 229E and HCoV-NL63, whereas beta coronavirus includes HCoVHKU1, HCoV-OC43, Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV . Human coronaviruses, HCoV-229E, HCoV-NL63, HCoV-OC43, and HCoV-HKU1, cause mild infections in the respiratory system and are responsible for 15%–30% of colds, especially in children and adults [7,8]. Coronaviruses have earned their name due to their complex structural shape, as coronaviruses feature an unusually large RNA genome and stick-like glycoprotein spikes projecting from the surface of their shell. These protrusions give rise to a distinctive substructure that resembles a solar corona .
The first appearance of coronaviruses was in 1965 and 2002 [4,9]. SARS appeared for the first time in Guangdong Province, in China, which resulted in more than 8000 infections and 744 deaths, before it was controlled in 2003. In 2012, the MERS spread in Saudi Arabia, and from there it spread to countries around the world, resulting in 2494 cases and 858 deaths . The last outbreak was last December 2019 in Wuhan, China, where the SARS-CoV-2 spread and led to COVID-19. SARS-CoV-2 is similar to other coronaviruses, is an unsegmented, envelope of a single positive strand of RNA with a diameter of 65–125 nm belonging to β-CoV, and is characterized by the outer membrane consisting of trimeric-S glycoproteins that allow the virus to bind to the receptor for angiotensin-converting enzyme 2 (ACE2) . These receptors are present in the cells of the lower respiratory tract . SARS-CoV-2 enters the host cell using the transmembrane serine protease 2 (TMPRSS2) plus ACE 2,  following binding via the receptor-binding domain (RDB)-of the S glycoprotein. The S protein undergoes large-scale conformational changes that allow the virus to endocytose into the cell cytoplasm where it undergoes replication. SARS-CoV-2 is replicated by a continuous synthesis of RNA and a unique, muted transcription of DNA, and the regulation of the transcription process is linked to factors including the primary coronavirus, RNA protein, which increases transcription efficiency [12,13]. The source of COVID-19 is still unknown, and there are continuous attempts to know the host animal for this coronavirus, as it is believed that the host animal is bats, seafood, or pangolins, and hence the spread of the disease has been linked to the seafood market in Wuhan, China . All ages are susceptible to infection by people who show symptoms, through sneezing or coughing drops, and in other cases, an infection can occur from people who do not show symptoms and before symptoms appear. COVID-19 can be transmitted in several ways, including direct contact with infected animals, as is the case in the initial cases of the disease in the Chinese Wuhan market,  or from one person to person and this is considered to be the main form of transmission. The transmission of the disease from an infected person occurs in two ways: either through direct exposure to a sneeze or cough droplets or during the speech of an infected person or direct contact with him , or through indirect exposure to the infected person; by touching contaminated surfaces with the virus, and then the virus transmitted to the mucous membranes in the upper parts of the body, especially the mouth, eyes, or nose . Where many studies show the ability of the virus to survive on contaminated surfaces; coronavirus can survive for 72 h on a plastic surface, for 24 h on cardboard, and for up to 4 h on copper surfaces .
The clinical features of this disease vary, ranging from no symptoms to critical including death. The disease is classified according to its severity into mild, moderate, severe, and critical. Fever, cough, muscle pain or fatigue, shortness of breath, and headache are the most common mild-to-moderate symptoms seen in people with confirmed cases of COVID-19 [19,20]. At the same time, nausea, vomiting, diarrhea, and other digestive symptoms could be within an incubation period of 14 days following exposure to the virus [19,21]. Symptoms can develop into critical in some patients, including acute respiratory distress syndrome (ARDS), respiratory failure, and multiple organ dysfunction syndromes, in addition to chest pain, heart palpitations, acute myocardial infarction, heart failure, and other cardiovascular symptoms and may lead to death [22,23]. Most fatal and severe cases such as ARDS occurred between the elderly and people with underlying diseases such as cancer, hypertension, diabetes, heart, lung, and kidney diseases [22,24].
SARS-CoV-2 is characterized by its rapid spread so early, rapid and accurate detection helps in limiting its spread and controlling it, and preventing the development of symptoms. It is not possible to rely solely on clinical diagnosis in diagnosing a patient with SARS-CoV-2; therefore, tests must be performed to ensure the presence or the absence of the virus. One of the most important and most common tests is the real-time reverse transcription polymerase chain reaction (real-time RT-PCR) test, which is the gold standard test for the molecular diagnosis of viral and one of the best and most accurate methods for detecting COVID-19 nucleic acids in nasopharyngeal swabs and the turnaround time is from a few hours to 2 days [25,26]. If a nasopharyngeal swab cannot be taken, an oropharyngeal sample (OP), a middle nasal swab (NMT), an anterior orifice sample (nasal swab, NS), and a nasopharyngeal wash/suction sample or a nasal aspiration (NA) sample can be collected instead . One of the real problems with the RT-PCR test is to show false-positive or false-negative results due to the presence of amplification inhibitors in the sample or insufficient organisms in the sample arising from improper aggregation, transport, or handling. To avoid inconsistent results, it would be better to use different types of samples (stool and blood) along with the respiratory system sample and the test requires high-quality samples to avoid false-negative results. There is currently no specific antiviral vaccine or drug regimen used to treat COVID-19 patients. There are many candidate vaccines, such as mRNA-1273, in phase III clinical trials, but it is unlikely that a vaccine will be available against the virus before the end of 2020 . At the beginning of the corona pandemic, antimalarial drugs (chloroquine or hydroxychloroquine) received widespread attention in treating COVID-19, and the Food and Drug Administration authorized their use. But after monitoring COVID-19 patients, the Food and Drug Administration issued a license to use antimalarial only in hospitals and for clinical trials because they were linked to the risk of heart rhythm problems, especially when combined with the antibiotic azithromycin [29,30]. The first case of corona was diagnosed in Palestine on March 5, 2020, and as a result, the Palestinian Consultative Council declared a state of emergency and imposed measures that include closure in the Bethlehem governorate, followed by a closure in other governorates in the West Bank on March 8 and imposed a curfew and prevented the movement of citizens between cities. By closing unnecessary shops and all educational facilities and religious places by the Palestinian government, these measures were effective in reducing the outbreak of the disease. Palestinian government also provided training to hospitals and health facilities on essential protective equipment, medical supplies, and medicines. The Palestinian government has also contained the spread of the virus by imposing a ban on citizens who are suspected of having COVID-19 (who show symptoms or have a positive test result) and isolating them in-home quarantine, as well as banning incoming travelers in government quarantine for 2 weeks [31,32]. The aims of this study were to assess knowledge, attitude, and practices (KAP) toward COVID-19, to detect related associated sociodemographic variables, and to enhance the KAP about COVID-19 in Palestine.
| Materials and methods|| |
This study was based on a cross-sectional survey conducted between December 2020 and January 2021 in Palestine. A structured questionnaire consisting of 38 questions was designed and developed by the research team according to the guidelines for clinical and community management of COVID-19 by the WHO. Some questions were based on previous studies carried out in other countries about COVID-19, with the needed adjustment and others were self-created by the research team. Then the questionnaire was translated to Arabic, validated by three experts, and distributed. The first section of the questionnaire (eight questions; [Table 1] and [Table 2]) included demographic characteristics (gender, educational level, marital status, and place of residence), whereas the second part was related to the KAP of Palestinians. The knowledge section of the questionnaire consisted of 12 questions (K1–K12) as shown in [Table 3] and [Figure 1]. To evaluate the attitude of the general public toward the disease, 14 questions were asked (A1–A14) [Table 4]. Regarding the general population’s practice and approach toward the disease, four questions were asked (P1–P4) [Table 5] and [Figure 2].
|Figure 1: (A) Is it possible that a person infected with coronavirus will not show any symptoms? (B) Can people with the disease without symptoms transmit the virus to others?|
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|Figure 2: Have you recently avoided cultural behaviors, such as shaking hands, due to coronavirus?|
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A cross-sectional and anonymous online population-based survey was conducted. A questionnaire was designed for the Google survey tool (Google Forms), and the generated link was shared with the public on social media (i.e., Facebook, WhatsApp). The link was also shared personally to the contact list of investigators and research assistants. The investigators’ decision to collect the data using online approaches was predicated on maintaining social distance during the strict lockdown in Palestine. Through the link, the participants could view the questions simply by clicking on them and answering the questions. The cover page of the questionnaire included a short introduction regarding the objectives, procedures, the voluntary nature of participation, declarations of confidentiality, and anonymity. After the questionnaire was evaluated, it was formatted on Google Form and placed online, and kept for about 2 months. Participation was voluntary and confidential. All the data were collected in 2 months’ period. Data were downloaded and entered into Microsoft Excel (Microsoft, Redmond, Washington). Descriptive statistics were computed for all variables by using the Statistical Package for the Social Sciences (SPSS) software program, version 26.0 (developed by IBM, Armonk, New York, USA).
The data were analyzed using the SPSS software program, version 26.0. Chi-square analyses were performed to see if there is a relation between different variables. The frequency distribution of independent variables (sociodemographic characteristics and study characteristics) was computed for all 724 participants.
| Results|| |
A total of 724 participants (98% response rate) responded to the questionnaires. The personal characteristics (including number and percentage) for the subjects are presented in [Table 1]. As shown in [Table 1], 22.9% of the participants were men and 77.1% are women, and the majority of them were married (47.9%). The education level of the participants was as follows: 17.1% of the participants did not finish their schools or studied up to 12th grade, 10.9% diploma, 66.3% bachelors, and 5.7% postgraduate. The majority of the participants (43.2%) had a low family income (less than US$600). The mean age of the respondents was 28 years (standard deviation [SD] = 10.7) with the majority (65.1%) between 20 and 35 years. As shown in [Table 2], most of the respondents lived in cities (69.8%).
Participants’ knowledge toward coronavirus disease-2019
As shown in [Table 3], the main sources for finding out information about COVID-19 were the Internet (62.6%) and social media (72.4%). They believed that the main cause of the disease is viruses (86.3%), whereas the percentage of those who do not know the cause is 8.7%. Two hundred seventy-three (37.7%) of the respondents showed that the source of the disease was from animals and then transmitted to humans from the animals, and 50% of the participants believed that the COVID-19 virus was manufactured by humans in laboratories. The respondents answered that the groups who are most vulnerable to infection with the virus are people with low immunity (80.9%) and those with chronic diseases such as diabetes and high blood pressure. The largest percentage of respondents (69.5%) showed that the incubation period ranged between 1 and 14 days, and the symptoms that appear on the patients were fever (91.7%), headache (75.7%), shortness of breathing (88.5%), fatigue (78%), and cough (71.5%). Nevertheless, as shown in [Figure 1], the largest percentage of respondents get complicated because the infection can take place without showing symptoms (91%) and the patient can transmit it to another person (71.7%(. Five-hundred forty of the respondents (74.6%) mentioned that the virus can be transmitted through coughing or sneezing to an infected person, whereas 76.4% mentioned the transmission of the virus can be through direct contact with an infected person. Five hundred ninety-three (81.9%) showed that the ideal time for handwashing is 1–2 min and that all persons should wear a mask whether infected or not. Five hundred fifty-two (76.2%) mentioned that disease prevention is through social and self-distance, 592 (81.8%) through isolation, 575 (97.4%) by using sterilizer, 566 (78.2%) by washing hands with soap, and 588 (81.2%) by avoiding crowded places.
Participants’ attitudes (A) toward coronavirus disease-2019
[Table 4] contains questions to assess participants’ attitudes toward COVID-19. Most of the respondents (419, 54.9%) believed that the Palestinian government was not responding effectively to the corona epidemic, 288 participants (39.8%) were dissatisfied with that, and 182 (25.1%) agreed that effective treatment or vaccination against the disease could be available, and it also included measures. The majority of the participants’ (n = 552, 76.2%) mentioned the preventive from the disease includes wearing masks for all persons (infected and non-infected). Most of the participants (n = 575, 79.4%) also mentioned it is possible to limit the spread of COVID-19 by keeping social distance/avoiding crowds and crowded places. In this regard, the crowded places mentioned by the respondents which should be avoided during corona disease to be protected/prevent the disease was as the following: parties and weddings (n = 627, 86.6%), places of mourning (n = 547, 75.6%), and hospitals (n = 463, 64%) as shown in [Table 4]. While 546 of the participants (75.4%) mentioned by avoid shaking hands/kissing the face, the society can limit the spread of the corona disease. Five hundred forty-five (75.3%) of the respondents followed up, respected, and adhered to the health recommendations of the country, whereas 622 (85.9%) agreed on the necessity of self-isolation in case of contact with an infected person. When the participants were asked how they feel about the corona pandemic and the current situation, their answers were as the following: 431 of the respondents (59.5%) are feeling boredom, 206 (28.5%) feels fear and tension, 195 (26.9%) they do not care/lack of interest, and 77 (10.6%) feel optimistic. The media/social media coverage of the corona epidemic makes some respondents feel more anxious. Two hundred sixty-four (36.5%) of respondents said that there are more lies than the truth in the media/social media, whereas 121 (16.7%) said that they are very satisfied, as the media provides them with all the updates. To adapt to the current situation, it was reported that the majority of respondents (441, 60.9%) were spending time with family with 333 (46%) watching TV and movies, 306 (42.3%) working from home, and 217 (30%) reading books and magazines. [Table 4] shows also prevalence, the risk factors for developing, transmitting the disease, opinion about the vaccine (no vaccines were available during collecting the data), and treatment of corona disease.
Participants’ practices toward coronavirus disease-2019 (P)
[Table 5] includes four questions to assess practices for preventing COVID-19. The first question was about the extent of the participant’s compliance with the compulsory government measures it imposed, in which 333 (46%) of participants adhered to most measures, 131 (18.1%) adhered to all measures, and 44 (6.1%) did not comply to the procedures. The second question was about the type of muzzle they wear when they leave the house, 494 of the participants (68.2%) answered that they wear a medical mask, while 138 (19.1%) wear a household cloth mask, and 79 (10.9%) they do not wear any type of muzzles. The third question was about who is responsible for the outbreak of corona disease in Palestine, as 456 of the respondents (63%) answered that the citizens are mainly to blame for the outbreak of COVID-19; because most of them do not adhere to or follow the government’s order or the compulsory measures taken in combating corona disease. While 341 (47.1%) and 175 (24.2%) of the participants mentioned that the community and the Israeli occupation respectively were responsible for the outbreak of the corona case in Palestine [Table 5]. The fourth question was about avoiding cultural behaviors such as shaking hands, 424 of the participants (58.6%) answered that they avoid shaking hands and 231 of them (31.9%) avoid shaking hands sometimes.
| Discussion|| |
This study is the first epidemiological survey that aimed to assess the KAP of individuals in Palestine regarding COVID-19. Citizens’ commitment to the preventive measures imposed by the Palestinian government toward COVID-19 depends on the level of knowledge and awareness about this epidemic. The level of knowledge and awareness of citizens about COVID-19 plays an important role in adhering to the preventive measures imposed by the Palestinian government to limit the spread of the disease. This poll was dominated by women 558 (77.1%), bachelors 372 (51.4%), people aged 20–35 years 471 (65.1%), and holders of a Bachelor’s degree 480 (66.3%). Through the survey results of the questionnaire, it was found that the level of knowledge is good about COVID-19 among the studied sample in this survey. Our results were similar to a previous study regarding the KAP toward COVID-19 in China,  which also showed an overall correct rate of 90% knowledge among the Chinese; however, a lower knowledge regarding the transmission routes and groups at higher risk was achieved among the general population of Palestine. The high correct answer rate regarding knowledge about COVID-19 among the Palestinian population may be due to high exposure to the information provided by the government and media about the virus since the start of the outbreak. Another reason could be the fact that 66.3% of the participants held an academic degree and responded actively to the severe condition of the pandemic and the overwhelming news reports, by collecting information from reliable sources. This is supported by the considerably positive correlation between the level of education and knowledge regarding COVID-19 and is similar to the results of other studies in this regard .
Our study showed that the majority of participants obtained their information from social media and the Internet. Also, there was a significant correlation between having higher knowledge of the disease and health-care workers whose source of information was social media as well as scientific articles and journals. In this regard, health-care-related professionals should carefully evaluate COVID-19-related information and use scientific and authentic materials as their source of information. The levels of knowledge and practices we found were significantly higher in women and in those who were ever married, who were older, those with higher education levels, those working in the health-care sector or related areas, and those who were worried about getting COVID-19.
The percentage of respondents whose answer was correct about the cause of the disease was a virus (625, 86.3%), and the main symptoms of the virus were fever (664, 91.7%) and shortness of breath (641, 88.5%). It was found that most of the participants in this study know the incubation period of the virus which is 1–14 days "the period from the infection of the disease until the appearance of the symptoms" as 503 of the respondent (69.5%) mentioned that. While the majority of the participants (n = 553, 76.4%) know that direct contact with the infected person with the virus contributes to the spread of infection to the disease and that self-isolation (n = 592, 81.8%), and avoiding crowded places contributes to reducing the disease prevalence (n = 588, 81.2%). Most of the respondents (n = 333, 46%) were reported to comply with the majority of government directives and wear a mask (n = 494, 68.2%), avoiding cultural behavior such as shaking hands (n = 424, 58.6%). This knowledge by the participants was reflected positively in the benefit of the awareness campaigns carried out by the Palestinian government on prevention and curbing the spread of COVID-19 through television and social media. However, there is a significant percentage who did not respond to government orders (n = 44, 6.1%) and did not wear masks when leaving the house (n = 79, 10.9%). If we compare the practices of residents of Palestine toward COVID-19 in wearing masks with other studies in different countries such as Bangladesh, Malaysia, and Nepal [34-36]. In Bangladesh, the percentage of those who do not wear face masks is 24.45%, which is a higher percentage than the percentage of Palestinians (10.9%) . while in Malaysia, a low percentage (48.8%) of people wear face masks , whereas in Nepal a high percentage (88.2%) of people wear face masks . Thus, Palestinians are better than Malaysian and Bengali people in wearing face masks during COVID-19, but not better than Nepalese in this issue. The high percentage of adhering to government orders and wearing a face mask when leaving the house indicates good knowledge and awareness of citizens about preventing SARS-CoV-2 infection and limiting its spread. However, good knowledge and awareness of Palestinians toward COVID-19 should not prevent the proliferation of educational programs and awareness campaigns by the Palestinian government, and it is advisable to use social media and TV channels to avoid infection and to increase knowledge and awareness of the disease; since they are the primary sources for the information about corona disease and its symptoms. Another parameter we looked at regarding knowledge and practices toward COVID-19 was the attitude parameter of how worried our participants were about getting infected. Indeed, we found that being worried about the possibility of being infected with the COVID-19 causing virus does significantly associate with higher knowledge. Our participants had a positive overall attitude toward COVID-19, particularly, the isolation of the COVID-19 cases, optimism about finding a treatment, and developing a vaccine. This is similar to the attitude of participants in relevant studies [33,35]. However, our sample showed concern about catching the disease and did not seem to have trust in the measures taken by the Palestinian government to manage the COVID-19 epidemic. Our findings indicate that the educational background and occupation (the different health-care fields) are correlated positively with knowledge and practices. Men typically showed less knowledge and attitudes as well as less cautionary practices as compared with women. This issue might be that most of the men in this survey may have been obliged to go to work and not adhere to the lockdown/social distancing as many families in Palestine rely mainly on men for income. Our sample participants show good practices as the majority avoided cultural behaviors (such as shaking hands), wear masks/muzzles, and comply with and adhere to most of the procedures which the Palestinian government has taken to reduce the spread of the disease. On the contrary, it was found that On the contrary, it was found that people with health complications and serious concerns about getting COVID-19 did not have better knowledge and attitude.
| Conclusion|| |
In short, this study was able to provide a comprehensive examination of the KAP of Palestinians toward COVID-19. The results indicate that Palestinians have a good level of knowledge about COVID-19 with a positive attitude and good compliance with Palestinian government measures. Knowledge and awareness of the mode of disease transmission, basic hygiene principles, and measures in public health crises are vitally important for developing effective control measures. This can help in controlling the spread of COVID-19 if individuals were forced to adhere to social distancing and appropriate preventative practices. There was no clear satisfaction with the government’s role in limiting and controlling the spread of COVID-19. The two governments must intensify their efforts in spreading knowledge and awareness, and establishing educational programs, and broadcasting them through social media and television, as there was a noticeable role for social media in contributing to obtaining information about COVID-19.
One of the obstacles of the study is the distributing the questionnaire online and through social media, as there is a possibility that the questionnaire will not reach all people due to the lack of internet access/people having no internet access or otherwise, thus many people unable to participate in the study. The largest percentage of those who filled out the questionnaire are young and the percentage of elderly is small. This may be due to the inability to reach the questionnaire through the Internet, so it is best to develop technology that helps them.
Ethical policy and institutional review board statement
The study was approved by the Palestinian MOH. The identities of participants remained unknown and confidential; the data were only used for research purposes.
Conflicts of interest
There are no conflicts of interest.
HAH is the supervisor, developed the mythology, and wrote the article. IN carried out the analysis part and wrote the analysis section. MW and WM carried out the research and collected the results.
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Hatem A Hejaz,
Department of Pharmacy, College of Pharmacy and Medical Sciences, Hebron University, P.O. Box 40, Hebron.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]