Patient’s Perspective of Awake Proning: A Cross-Sectional Interview-Based Survey From COVID-19–Recovered Patients

IMPORTANCE AND OBJECTIVES:

To assess the knowledge, attitude, and practice of the patients who underwent prone positioning during their COVID-19 illness in the hospital.

DESIGN:

Cross-sectional study.

SETTING:

Aga Khan University Hospital, Karachi, Pakistan.

PARTICIPANTS:

COVID-19–recovered patients.

INTERVENTIONS:

None.

MAIN OUTCOMES AND MEASURES:

Knowledge was assessed by five questions with a dichotomous response (yes/no). An yes response was awarded 1 score. Since there were five questions, five would be the highest score. Patients’ perceptions of the therapy were assessed by four questions, each scored on a Likert scale of 5 (5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, and 1 = strongly disagree). As it had four questions, the maximum score achieved could therefore be 20. Proning practices were assessed using seven questions: four were used to calculate practice scores, whereas three were open-ended regarding the patient’s experience. Each question carries a different score, and the maximum score was 8.

RESULTS:

The study included 98 patients. The mean age of the patients was 57 years (sd, 12.2 yr). Majority of the patients were males (70.4%). 69.1% of males and 76.6% of females fell in the poor knowledge group. The poor knowledge cohort had an educational level of 48% in high school, 45.5% in graduates, and 6% in postgraduates. Compared with 56.5% of males, 73% of females preferred prone positioning. Sixty percent of those with a high school education viewed prone positioning favorably, whereas 46% of those with graduate and postgraduate did. Seventy-nine percent of males and 63% of females scored positively on the practice questionnaire. Eighty percent of graduates and postgraduates preferred proning practices to 67% of participants with high school education levels.

CONCLUSIONS AND RELEVANCE:

Our study population had a little understanding of awake proning, found it unpleasant, and practiced for a shorter period than advised. Despite the overall negative attitude toward the position, our patients highly recommend this position to future patients.

KEY POINTS

Question: To assess the knowledge, attitudes, and practices of the COVID-19–recovered patients regarding awake proning?

Findings: In our study subjects, regardless of their education background, there was a lack of knowledge about awake proning. A more positive attitude toward awake proning was shown by females than by males. Across all educational groups, positive and negative attitudes were approximately equal. The prevalence of positive behavioral practice was higher among males than females and across all educational levels.

Meaning: Patients in our study had little knowledge of awake proning, perceived it to be unpleasant, and practiced it for a shorter period of time, but they highly recommended it to future patients because it relieved hypoxia due to COVID-19 pneumonia.

COVID-19 infection is a highly transmissible viral infection caused by severe acute respiratory syndrome coronavirus 2. As of December 2019, it began in Wuhan, China, and spread rapidly throughout the world. It has affected 48,539,872 people and caused 1,232,791 deaths in approximately more than 200 countries (1).

Acute respiratory distress syndrome (ARDS) is a well-known complication of COVID-19 infection, and around 42% of patients with COVID-19 pneumonia develop ARDS (2). Literature has shown that ventilating ARDS patients in a prone position improves their oxygenation (3, 4). The favorable effect of proning on improving oxygenation is multifactorial. Proning enhances the ventral-dorsal transpulmonary pressure difference and reduce dorsal lung compression. Changes in extravascular lung water and increase in functional residual capacity have also been hypothesized as proposed mechanism for improved oxygenation when a person is prone. Awake proning or proning in nonintubated patients is a newer concept, which was seldom used before the COVID-19 pandemic. In several studies done on COVID-19 patients, it was found to not only improve oxygenation but also decreased the risk of intubation (5–7).

On reviewing COVID-19 literature, we found nonadherence to awake proning protocols in different hospital setup throughout the world (8). Although nursing a fully conscious patient in prone position is a challenging task for the healthcare workers. Patient-related factors like anxiety, discomfort, pain, and agitation appear to be a major contributing factor for noncompliance (9, 10).

For this purpose, we developed a questionnaire to assess knowledge, attitude, and practice (KAP) of the patients who were managed in the hospital through prone positioning during their COVID-19 illness. The findings from this survey can provide a basis for improvement measures to facilitate nursing in a prone position and improve the quality of clinical care provided.

MATERIAL AND METHODS

Study Setting and Design

We investigated patient’s perspective of being managed in a prone position by assessing three continuous processes of KAP that explains human behavior.

We did a cross-sectional survey using KAP model, which was conducted by a telephonic-administered questionnaire at the Aga Khan University Hospital (AKUH) Karachi, Pakistan. AKUH is a 760-bedded Joint Commission International accredited tertiary care university hospital that started the first inpatient admissions under COVID-19 in the country.

This telephone-based survey was done on COVID-19 patients who were previously hospitalized from June 2020 to August 2020 with hypoxic respiratory failure requiring oxygen therapy at the isolation units of AKUH, Karachi, Pakistan. The survey was conducted from September to November 2020.

Only those patients who underwent proning during their hospital stay were included in this survey. All the patients were fully conscious and had a Glasgow Coma Scale score of 15/15 during their practice of proning in the hospital stay. The survey questionnaire was composed of two parts. The first part contained general information regarding the patient’s demographics like age, gender, educational status, and date of acquiring COVID-19 infection. The second part assessed the patient’s knowledge attitude and practice regarding awake prone positioning. Telephone-based interviews were conducted from 12:00 pm to 6:00 pm by interviewers, who were well trained by the principal investigator for this purpose. Patients were briefed about the nature of the study, its deliberate nature, and the right to withdraw at any time without negative consequences. Only patients who consented to be a part of the study were included.

Content of the Questionnaire

As there were no previous studies at the time of survey, we designed our questionnaire based on available proning literature on COVID-19 patients.

Five questions pertaining to the patient’s knowledge were included. These questions had a dichotomous response with “Yes” and “No.” An Yes response was awarded 1 score, and no score was given for a negative answer. As there were five questions in total regarding patients’ knowledge, therefore 5 could be the highest score in the knowledge group. Based on the scores achieved, the knowledge group was further subdivided into good (score ≥ 3) and poor knowledge category (score < 3).

Patient’s perceptions of the therapy were assessed by four questions, and each question was then scored by means of Likert scale of 5 (5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, and 1 = strongly disagree). As there were four questions in total regarding patients’ perceptions, the maximum score achieved could therefore be 20. Cumulative score was calculated, and based on perceptions scores, the patients’ perceptions were categorized into positive (having score range from 15 to 20), neutral (score range from 10 to 15), and negative attitude (score < 10).

Seven questions regarding proning practices were used to measure the patients’ behavioral practices. Four of the questions were used for calculating practice score, whereas three of the questions were open-ended regarding patient’s experience of awake prone position. The first question was about their practice, which had Yes/No answers. An “Yes” answer got 1 score, and a no answer got 0 score. As for the second question, those patients who underwent prone position once were awarded a 1 score. Those who proned two or three times a day were assigned a score of 2. Those who were proned more than three times a day were given a score of 3. The third question was about the duration of proning session, and those who remained prone for less than an hour were given 1 score and those who remained prone for 1–2 hours were given 2 scores. In addition, those who prone for more than 2 hours were rewarded with 3 score. Final scoring question was regarding future recommendations, and those who made recommendations received 1 point. Patients who scored equal to or more than 4 were termed as having positive practice behavior, whereas patients who scored less than 4 were termed negative practice behavior.

Ethical Approval

The study followed in accordance with the ethical standards of the Ethical Review Committee of the Aga Khan University Hospital and with the Helsinki Declaration of 1975. Following are the details:

• Board name: Ethical Review Committee of the Aga Khan University Hospital

• Approval number: Ethical Review Committee No: 2020-5171-13902

• Approval date: 04-September-2020

• Study title: Amber Sabeen: Patient’s perspective of awake proning; an interview-administered questionnaire survey from COVID-19–recovered patients.

• Informed consent: A verbal informed consent was obtained from the patients before initiating the interview.

Statistical Analysis

R studio Version 4.1.2, Posit, PBC was used to analyze data. Categorical data were described by frequency and percentages. Comparison of proportion among different groups was made.

RESULTS

Demographics Characteristics

Three hundred patients who received awake proning during their hospital stay were contacted to participate in this study. Only 98 patients consented to be part of the study and responded completely to the questionnaire survey (Supplemental A, http://links.lww.com/CCX/B109).

The mean age of the patients was 57 years (sd = 12.2). Age was subcategorized into three groups, that is, less than or equal to 40 years as group 1, 41–60 years as group 2, and greater than or equal to 61 as group 3. Over half of the participants (53.1%) belonged to group 2 (age range: 41–60 yr). Majority of the patients were males (70.4%).

Education levels among participants were also divided into three categories, that is, up to high school as group 1, undergraduate to graduates as group 2, and postgraduate as group 3. Half of the participants (50%) had a bachelor’s or professional degree, whereas half of them belonged to up to high school group.

KAP Response from Patients

In our study, only 40% of patients had prior knowledge about awake proning before hospitalization, and the source was mostly friends or family. The majority of the patients (61 %) had no prior knowledge about the position before hospital admission. Only 34.7% of patients were aware about its beneficial effect on oxygen level in COVID-19 infection. One third of patients (32.7%) understood its importance in treating respiratory distress associated with COVID-19. Based on the knowledge, two third of patients (67.3%) belonged to poor knowledge group, and nearly one third (32.7%) belonged to good knowledge group (Table 1).

Table 1.

Answer to the Knowledge Questionnaire Among Participants and Their Grouping

Knowledge Questionnaire	Yes, n (%)	No, n (%)
1) Have you ever heard about awake proning (sleeping on the tummy)?	37 (37.8)	61 (62.2)
2) Did any of your friends and or family members have heard or discussed about sleeping on the tummy?	32 (32.7)	66 (67.3)
3) Do you know sleeping on a tummy is a useful exercise in COVID-19 infection?	34 (34.7)	64 (65.3)
4) Do you know sleeping on a tummy improves respiratory distress?	32 (32.7)	66 (67.3)
5) Do you know that this therapy increases your oxygenation levels?	33 (33.7)	65 (66.3)
For each “Yes” answer, 1 score was awarded, and for “No,” the score was 0. So maximum score can be 5 and minimum score can be 0.
Based on the scores achieved, the knowledge group was subdivided into good and poor knowledge category taking score 3.
Knowledge Group	n (%)
Good knowledge (score ≥ 3)	32 (32.7)
Poor knowledge (score (< 3)	66 (67.3)

Regarding attitude to awake proning, half of the patients (50%) found awake proning an uncomfortable exercise. One third of the patients (29.6%) were either afraid of awake proning or had anxiety before attaining the posture. Majority of the patients (59.2%) had negative attitude toward awake proning and did not like the position (Table 2).

Table 2.

Answers to Attitude Related Questionnaire and Their Overall Attitude

Attitude Questionnaire	Strongly Agree, n (%)		Agree, n (%)	Neutral, n (%)	Disagree, n (%)	Strongly Disagree, n (%)
1) Comfortable exercise	10 (10.2)		33 (33.7)	6 (6.1)	42 (42.9)	7 (7.1)
2) Easier posture to maintain	2 (2)		42 (42.9)	5 (5.1)	42 (42.9)	7 (7.1)
3) Afraid of awake proning	2 (2)		27 (27.6)	6 (6.1)	60 (61.2)	3 (3.1)
4) Anxious of awake proning	3 (3.1)		28 (28.6)	5 (5.1)	59 (60.2)	3 (3.1)
Overall Attitude		n (%)
Positive attitude		31 (31.6)
Negative attitude		58 (59.2)
Neutral		9 (9.2)

Nearly all of our survey patients (93.9%) underwent awake proning exercise during their hospitalization (Table 3). Nearly two third of our patients (64.3%) underwent awake proning two to three times a day. Forty-two patients (42.8%) remained prone for less than 1 hour in a single session, and 37 patients (37.8%) remained in the position for greater than 1 hour per session. The two reasons for changing posture were uncomfortable position (36.8% of respondents) and tiredness (34.7% of respondents). Seventy-one patients (72.5%) had moderate to significant improvement in respiratory distress after awake proning therapy. Eighty-two of the patients (83.7%) learned this therapy from the healthcare workers during their hospital admission. Majority of the patients (88.8%) will recommend this therapy in future to the other COVID-19 patients who have respiratory distress and dyspnea.

Table 3.

Response to Questionnaire Pertaining to Practice

Practice Questionnaire	n (%)
1) Do you slept on your tummy?
Yes	92 (93.9)
No	6 (6.1)
2) How often did you perform this therapy in a day?
Only once	19 (19.4)
2–3 times	63 (64.3)
> 3 times	10 (10.2)
Not slept	6 (6.1)
3) For how long, do you remained prone (slept on tummy) for a session?
< 1 hr	42 (42.8)
1–2 hr	37 (37.8)
> 2 hr	13 (13.3)
Not slept	6 (6.1)
4) What was the most common reason for changing posture during this therapy?
Tired	34 (34.7)
Backache	16 (16.3)
Uncomfortable after a period of time	36 (36.8)
Doctor advise completed	6 (6.1)
Not slept	6 (6.1)
5) After the therapy, do you feel more relax and have less respiratory difficulty?
Mild improvement	21 (21.4)
Moderate improvement	51 (52.1)
Severe improvement	20 (20.4)
Not slept	6 (6.1)
6) Who taught or advised you about this therapy?
Healthcare worker	82 (83.7)
Learned online	6 (6.1)
Relative/friends	6 (6.1)
No one taught	4 (4.1)
7) Will you recommend this therapy to others?
Yes	87 (88.8)
No	9 (12.2)

Differences in Knowledge, Attitude, and Prone Practices as per Gender, Age, and Educational Level of Participants

In this study, knowledge scores were significantly low for participants of both genders as 69.5% of males and 75.9% of females fell in the poor knowledge group. Similarly low knowledge about proning was prevalent in all age groups, where 60% of age group 1, 67.4% of age group 2, and 75% of age group 3 fall in the poor knowledge cohort. Nearly half of the participants in the poor knowledge group (48% of patients) had received education only up to high school. Graduates form the next cohort constituting about 45% of participants of the poor knowledge group. Ten percent of poor knowledge group participants had education up to postgraduate levels.

Female participants had more positive attitude about the position than their male counterparts. 72.4% of female participants showed a favorable attitude toward prone positioning, compared with 56.5% of male participants. With respect to age group, younger group has negative attitude toward proning compared with their elder counter parts. Only 20% of participants in age group less than 40 years favored prone positioning, whereas 59.6% of those in age group 2 and 55.5% of participants in age group 3 have positive attitude toward prone position. 60.4% of lower education level (up to high school had positive attitude toward prone positioning, whereas 47.5% of those having undergraduate or graduate level and 50% with higher education level showed positive attitude toward proning.

In terms of proning practices, both gender had positive response to adopting the position where 79.7% of male participants and 62.1% of female participants scored positively in practice questionnaire. All age groups showed positive response to proning practices although the practice was more easily adopted by younger age group cohort (90% of age group 1, 76.9% of age group 2, and 66.6% of age group 3). Eighty percent of participants with graduate or higher education level preferred the proning practices compared with 66.6% of participants with education level up to high school level (Supplemental B, http://links.lww.com/CCX/B109).

DISCUSSION

Awake proning was recognized as a low cost and efficient treatment strategy in hypoxic COVID-19 patients. Yet despite these benefits, our study showed extremely poor knowledge about awake proning in our patients. Only 32.7% of patients knew that awake proning alleviates respiratory distress, whereas only 33.7% understood that it enhances oxygenation. The study also highlighted negative attitude of patients toward prone positioning. When it comes to adopting the position, majority of the participants adopted proning practices while in hospital, although it was for shorter duration than recommended.

This is the first study done from our region to understand a patient’s perspective on awake proning for management of hypoxic respiratory failure due to COVID-19. Findings of this study are informative to physicians and healthcare authorities for designing measures and appropriate interventions to increase adherence to proning protocols adopted in healthcare settings.

Findings of this study indicated that knowledge about proning position for management of hypoxia associated with COVID-19 was less than optimal among participants. In this study, the patients obtained their information on awake proning for COVID-19 mainly from family and friends. This was surprising as social media networks and different online learning platforms were extensively used during the pandemic. It seems that the beneficial low cost measure of awake proning to combat COVID-19 is still not advocated enough on educational websites and knowledge platforms in internet and requires proper education among masses.

Our study showed discomfort (39.1%) and tiredness (36.9%) as the commonest reasons for changing the posture respectively. As before COVID-19, prone positioning was traditionally used only in critically ill patients in ICUs (ICU) who were deeply sedated and ventilated, and the observation coming from fully awake patient is novel. Pain and discomfort was probably the reason behind negative attitude toward awake proning in our patients. Majority of the patients believed it was a difficult posture to maintain and an uneasy maneuver to perform. Another study done on patient’s perspective about COVID-19 at Harvard University also showed similar results (11). Other studies also found discomfort, coughing, and uncooperativeness as the main reasons for not performing a proning procedure while awake proning (12, 13).

Pain or discomfort is still not addressed in widely adopted proning protocols throughout the world. This is probably one of the major reason behind poor adherence to proning for non-ICU patients (1, 9). This study stressed the importance of pain and discomfort assessment as measuring tool for successful implementation of this position. Similar findings on proning practices from the studies throughout the world covering different patient populations would help in designing interventions in future to make this position more comfortable. In our study, anxiety also appeared as a potential barrier in adopting this position. This is also an issue, which would need timely management. Despite the benefit of awake proning if the patient-related concerns are not addressed and alleviated, it would remain difficult for any healthcare setting to achieve 100% adherence to this cheap management strategy. It is therefore important to frequently access the tolerability of awake proning among patients.

The results of our study also showed that in our study population, a higher level of knowledge was positively related to favorable attitude toward proning and toward adopting proning practice. However, the attitude toward proning was predominantly negative. This could be due to indirect effects of knowledge on practices mediated via attitudes and might need in depth psychologic analysis in the future.

The success of proning in a conscious awake patient can easily be interpreted from our study, which showed that 72.4% of participants admitted to have moderate to significant improvement in their respiratory discomfort after adopting the position. Despite having low knowledge and negative attitude toward proning, majority of our patients (88.8%) recommended this position to future patients. This reflects the success of this maneuver in coping with hypoxic respiratory failure due to COVID-19.

This is the first study from our region, which evaluated the subjective patient’s experience about awake proning practices for management of COVID-19. This study could help in designing and adapting proning protocols throughout the world for COVID-19 or any similar hypoxic respiratory failure conditions arising in future. Another strength of our study was that participants who responded in this study were from both genders and had variable educational level and belong to all age groups. By including participants who were themselves previous patients being managed on awake proning during their hospital stay added validity, depth, and width to the findings of this study.

Our study has certain limitations. The sample size was small because of more than half of our cohort’s refusal to participate. This would decrease the significance of our results as the findings might show different results on increasing sample size. Another limitation was study population as it was sampled from discharged patients of a private tertiary care hospital, which decreased the generalizability of sample. Although we found similar results from another study done on the topic, but a mixed patient population from all layers of social strata would have been more informative.

It was a cross-sectional study, and as the pandemic continues to unfold, the findings might change later on with increasing knowledge about the disease process. There might be an issue of recall bias as it was a retrospective questionnaire, and some of the participants found it difficult to remember and answer all the questions. Randomized control trials and meta-analysis is a necessity to compare and identify the outcomes and to develop protocols that should be followed in these patients.

CONCLUSIONS

The benefit of awake proning remains debated. Our study was not designed to check the merits and demerits of awake proning but patient’s perception of a new position that is now widely offered in the healthcare facilities throughout the world.

Based on the findings of this study, we conclude that our study population had a little understanding of awake proning, found it unpleasant, and practiced for a shorter period than advised. Despite the overall negative attitude toward the position, our patients highly recommend this position to future patients. This signifies the subjective benefit of awake proning position to alleviate hypoxia due to COVID-19 pneumonia.