Knowledge, Attitudes and Practices (KAP) towards pandemic COVID-19 among Syrians


 Background Effective COVID-19 pandemic management requires adequate understanding of factors that influence behavioral changes. This study aims to assess knowledge, attitudes and practices towards COVID-19 among Syrians in a post-conflict context. Method This study is based on a web-based survey, conducted on Syrians of 16 years and above. It contains questions on knowledge, attitudes and practices (KAP) with respect to COVID-19. Participants’ demographic characteristics are recorded and analyzed. The study is conducted during the global outbreak of COVID-19.Results Among the 706 participants, more than 85% of respondents are aware of the main symptoms of COVID-19 infection and 56.2% know that the virus can be transmitted from ill to healthy persons even without fever symptoms. The overall achieved knowledge score towards the disease is about 60% while attitudes and practices score higher at 63.5% and 73.75%, respectively. The results from multiple linear regression indicate that lower knowledge scores are significantly associated with lower education level (P<0.05), whereas poor preventive practices are common among male, young and unemployed participants with significance levels of P<0.01, P=.000, P<0.01, respectively. Conclusion The findings of this study suggest that Syrians demonstrate modest knowledge, attitudes and practices towards COVID-19 at the time of its global outbreak. Efforts should be directed towards raising Syrians awareness of the disease to improve their practices in the current COVID-19 pandemic, as well as for future epidemics.


Background
The outbreak of novel coronavirus disease 2019 (abbreviated as COVID- 19) since December 2019 in China and its rapid spread across the globe constitutes a challenge to health systems in developed and developing countries alike. In Syria, the rst COVID-19 laboratory con rmed case is reported on 22 March.
The Syrian government has adopted similar measures to those adopted by other countries to prevent the spread of the disease. That is, a curfew was declared from 6 pm to 6 am, in addition to the closure of shops, markets and public transport. Classes at schools and universities were curtailed and all incoming and outgoing ights were also suspended.

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The World Health Organization (WHO) warned that Syria is at high risk of a major outbreak because of its fragile health system aggravated by a nine-year war and the lack of su cient equipment ( 1). In addition, a UN report stated that around 70% of the Syrian health workers had left the country as migrants or refugees ( 2). In 2018, the Syrian government spent less than one percent of its total government expenditure on health ( 3), which is amongst the lowest in the region. The number of beds is disproportionally distributed between private and government hospitals with an average number of population of 699 per bed ( 3). The total number of intensive care unit (ICU) beds is approximately 650 in hospitals all over Syria (excluding the city of Idlib) ( 1 2).

Aims
This paper aims at investigating the knowledge, attitudes and practices of the Syrian population towards COVID-19 pandemic in a post-con ict context. While the Syrian health authorities aims their control measures will curtail the spread of the pandemic, their effectiveness will depend on the individual and societal awareness and practices. Understanding how Syrians perceive the disease and their attitudes and practices towards it helps the Syrian health authorities formulate suitable measures to counter COVID-19 spread. It is interesting to nd out how similar measures can be perceived differently in different contexts; especially in the Syrian special case where underdeveloped health system associates con ict.
Summary of the existing literature Good knowledge, attitudes and practices (KAP) among the public are essential for successful control and outbreak prevention of pandemics. Particularly, the literature on severe acute respiratory syndrome (SARS) in 2003 ascertained that personal knowledge and perceptions play important role in subsequent behavior change ( 4,5,6). High-perceived threat of the disease led to higher rate of positive behavior change ( 7,8). Similarly, KAP factors also in uenced both self-and community protective behavior in an anticipated H5N1 epidemic ( 9), Swine Flu ( 10,11), and H1N1 ( 14,15), and COVID-19 ( 16,17,18).
In order to introduce effective control measures against pandemics, it is vitally important to investigate public knowledge about the disease and their commitment to these control measures. This study, conducted in the Syrian territories, aims to assess the public understanding towards COVID-19, and to investigate their attitudes and practices during COVID-19 quarantine. In Syria, there is no published study of public knowledge, attitude, and behavior regarding any pandemic disease neither before nor after the crisis.

Methods
This cross-sectional, web-based survey was conducted from 5 April to 9 April, during the second week after the lockdown of the Syrian territories. The questionnaire was designed and posted on social media platforms (Facebook and WhatsApp). Privacy of the original post was set as "public" to enable more people to participate in the questionnaire. This post contained a brief introduction on the background, objectives, voluntary nature of participation, and declaration of anonymity and con dentially. The questionnaire also included an informed consent form, which allowed participants to tick to con rm their consent to participate. The questionnaire was distributed to local Syrian citizens, and residents abroad were also eligible for this survey. However, the latter answers were excluded because this study focuses only on people reside in Syria.

Questionnaire
The questionnaire was developed to assess the knowledge, attitudes and practices (KAP) regarding COVID-19 pandemic based on a similar questionnaire on COVID-19 ( 16) and other questionnaires on H1N1 ( 11,12), and Severe Acute Respiratory Syndrome, SARS ( 13) as well as concepts theories of health behaviors ( 19). The questionnaire takes about 5 minutes to complete. This questionnaire collected basic demographic data on age, gender, education level, employment status, and residents above 60 or younger than 16 in the house. Questions on knowledge aimed to assess general knowledge on clinical presentations of COVID-19 and the severity of the disease (Q1-Q6). These questions were answered as on a yes/no basis with an additional "maybe" option. Questions on attitudes (A1-A4) were about the agreement with the measures adopted to prevent the spread of the pandemic COVID-19 and the con dence in winning the battle against COVID-19. Questions on practices were used to assess the individuals' compliance and behaviors during the quarantine (P1-P8). A summary of questions assessed are shown in Table 1.

Statistical Analysis
The calculation of the required sample size was done by assuming con dence level of 99%, and a con dence interval of 5, suggests the need for 666 participants. To determine the scores for each individual question, responses were recorded as 0 for an undesired response and 1 for a desired response. Frequencies of the desired answers of knowledge, practice and attitudes were computed. Independent sample t test and one-way analysis of variance (ANOVA) test of signi cance were used to examine the relation between the demographic characteristics and the means of knowledge, attitudes and practice. In multiple linear regression, signi cant demographic variables were used as independent variables to identify factors associated with poor knowledge. The same method was used to identify factors associated with poor attitudes and practices. Unstandardized regression coe cients β were shown to quantify the association between variables and poor KAP scores. A Pearson correlation test was used to evaluate the possible association between knowledge and attitudes, knowledge and practices, and practices and attitudes. All statistical analysis were performed using IBM SPSS 24for Windows, with level of signi cance set at 5%.

Results
A total number of 825 participants completed the survey questionnaire. After excluding 119 respondents who live outside Syria, the nal sample consisted of 706 participants. Among the nal sample, 444 (62.9%) were female, 405 (57.4%) aged between 16-29 years, 642 (90.9 %) were either at higher education level or above, 316 (44.8%) were employed in private or public occupations and 516 (73.1%) had residents in their houses aged above 60 and/ or younger than 6 years. Demographic characteristics are shown in Table 2.
This study shows that the Syrians' Basic knowledge of COVID-19 is moderate. The correct answer rates of the 6 questions on the COVID-19 knowledge questions ranged between 22.7-85% ( Table 1). The mean knowledge score was 3.54 (SD: 1.207, range: 0-6) suggesting an overall 59% (3.54/6*100) correct rate on this knowledge test. Knowledge scores signi cantly differed across age groups (P<0.05), education levels (P=0.001), and occupations (P<0.05) ( Table 2). Knowledge regarding COVID-19 symptoms was the highest (85.1%), whereas perception of the severity of COVID-19 was the lowest (22.7%). Having a child under 16 or aged persons above 60 did not make a statistical difference in the COVID-19 knowledge. Furthermore, no statistical difference was found between genders with regard to Knowledge scores ( Table  2). For the attitudes, the majority of respondents believed that school closure and curfew were effective at controlling the spread of COVID-19; scores were 91.5% and 78.2%, respectively (Table 1). Only 15.4% of the respondents expected the pandemic to spread in Syria, whereas about 60% had con dence that COVID-19 will eventually controlled. Attitude scores were signi cantly different between males and females (P<0.05) ( Table 3).

Discussion
This study is expected to be the rst to examine the KAP towards COVID-19 among Syrians. In this predominantly female and well-educated population, the overall correct rate of around 60% on the knowledge questions, indicating that most respondents have modest knowledge about COVID-19.
The majority of the participants believed that the school closure and curfew were effective at preventing the spread of COVID-19. However, 15.4% of participants believed that the virus would spread in Syria and only 60% had con dence that COVID-19 will eventually be successfully controlled. Despite this, the practices of the Syrian residents were cautious: 92.5% avoided crowded places and shaking hands and 90.8% practiced better hygiene than before the quarantine, like washing hands and using disinfectants. Surprisingly, however, only 27.9% wore facemask when leaving homes. This study also analyses the characteristics of KAP towards COVID-19 and identi ed some demographic factors associated with KAP; these ndings are useful for public health policy-makers and health workers to identify and target people for COVID-19 prevention and health education in the case of future outbreaks.
The nding of a modest knowledge score of COVID-19 of participants although the majority are well educated was unexpected. There scores are lower than their counterparts in China ( 16) and in Iran ( 17) which showed an overall correct rate of 90% among the Chinese and Iranian populations, respectively. However, Syrians score higher in terms of their towards COVID-19 knowledge compared to the population of northern Thailand in the early period of the outbreak ( 18). In Thailand, 73.4% had poor knowledge towards COVID-19 ( 18). The nding of moderate knowledge score probably because Syrian residents have not experienced previous pandemics such as H1N1 or SARS. In addition, this survey was conducted during the very early stages of COVID-19 in Syria when the country was not seriously affected by the outbreak, with the number of laboratory con rmed COVID-19 cases was only 19 (Ministry of Health) the lowest among other countries in the region. This underlines the importance of the Syrian health authorities providing consistent clear updates and information about the emerging virus as well as the need to continuously assess whether their messages are being understood within the community.
Since the World Health Organization (WHO) declaration of the COVID-19 outbreak to be pandemic on March 12, 2020 ( 20), countries around the world had implemented different measures to prevent further spread of the virus. Many countries had applied school closure as a response to COVID-19 according to UNESCO ( 21). Other restriction also included curfews and stay-at-home orders. Similarly, the Syrian government has also closed schools and enforced curfew based on time while allowing some essential business to open. The vast majority of Syrians included in this survey believed that these measures were effective against COVID-19.
Furthermore, Compared to KAP studies in China and Iran, Syrians under study were less optimistic about the disease control than the Chinese ( 16) and Iranians ( 17). The underlying reason could be related to the quality of the Syrian health care system that has been seriously affected by the nine-year war, and further deteriorated due to sanctions ( 22). Second, efforts to aid the COVID-19 control was limited due to shortages of medical workers and medical materials ( 23).
Although attitudes towards COIV-19 were unassertive, Syrians took precautions to prevent infection by COVID-19: not going to crowded places and practiced better hygiene with an overall practice score was about 74%. This may be attributed to their doubts on the ability of the health care system to accommodate them if they are infected. However, this score was lower than other practice scores towards COVID-19 among Chinese ( 16) and Iranians ( 17). Unfortunately, the present study showed that only approximately 30% wore facemasks when going outside home. This could be primarily attributed to the unavailability of quality facemasks and the surge in their prices which increased by 6 to 10 folds particularly during the time of this survey.
The potentially poor documented practices were associated with younger age males. This is in agreement with the ndings of similar COVID-19 studies in China ( 16) and Iran ( 17). The nding that women are more likely to practice non-pharmaceutical health behavior (e.g., hand washing) is also consistent with a previous study on SARS pandemic ( 24). Furthermore, this study is on line with previous evidence that late adolescents were also more likely to engage in risk taking behaviors ( 25). It is not surprising that unemployment is also associated with poor practices because have less exposure to the COVID-19 virus.
Therefore, they are less adherent to health safety measures of keeping social distance and wearing facemasks.
This study provides evidence on the positive and signi cant correlations between knowledge-attitudes, knowledge-practice, and attitudes-practices among the respondents (Pearson correlation coe cient approximately 0.2). This rea rms that better knowledge and attitudes associate with better practices.
Similar levels of association between these variables were documented in a previous study on H1N1 pandemic ( 26). Therefore, health authorities should not only focus their efforts on improving health services but also give equal importance to raising people awareness and knowledge towards COVID-19.

Conclusion
In summary, this study provides insights into Syrians' knowledge, attitudes and practices towards COVID-19 during the quarantine in post-con ict context. This is expected to help Syrian health authorities formulate suitable measures to counter the spread of current COVID-19 and develop best practices for future epidemics. Yet, the successfulness and impact of current measures in controlling of COVID-19 are still unclear, and constitute venues for future research.
Limitations in the study include the methodological limitations of internet-based survey. First, people who do not have internet access or Facebook/whatsApp may be missed. Second, the sample population had respondents with higher education level compared to other levels. This may overestimate the overall results, as these groups are probably more knowledgeable and have better practices towards pandemics in general. Third, it could have been more informative to divide the higher education level into undergraduates, graduates and master/Ph.D holders.
The results of this study may not be generalizable to other countries or cities that have experienced previous severe epidemics such as SARS. This study presents a unique reference for pandemic cautious behavioral response in post-con ict context. Nevertheless, it was challenging to nish data collection within a short period (5 days) before lockdown measures were eased off.

Declarations
Ethics approval and consent to participate The present study was approved by the ethics committee at the Faculty of Pharmacy and the Faculty of Pharmacy council at Al-Rasheed International University for Science and Technology. The purpose of this research was explained to all participants and were assured of con dentiality by the researcher. The survey also include an informed consent form, which allows participants to tick to con rm their consent. Completion of this form followed by completion of the survey shows that participant consents to the study. Participation in the study questionnaire is optional and a statement in the introductory section of the questionnaire clearly indicates the voluntary nature of participation, and declaration of anonymity and con dentially and that the study results will be used for research purposes only.

Consent for Publication
Not applicable Availability of data and material The data of this article are attached as a supplement le.
Competing interests I know of no con icts of interest associated with this publication, and there has been no signi cant nancial support for this work that could have in uenced its outcome.

Funding
This study is supported by the Higher Commission for Scienti c Research (Syria) for the subscription to electronic resources. No additional funding was required.