PUBLIC KNOWLEDGE, ATTITUDES, AND PRACTICES TOWARDS COVID-19 PANDEMIC AMONG EGYPTIAN CITIZENS: A DESCRIPTIVE STUDY

Background: Coronavirus disease 2019 (COVID-19) pandemic has been transmitted rapidly worldwide and is recognized as a main threat to human health in 2020. The best methods to prevent its spread are to know about it and act accordingly. Aim: This study aimed to assess the knowledge, attitudes, and practices to respond to COVID-19 among a sample of Egyptian citizens. Methods: A community-based cross-sectional online survey was conducted on 501 Egyptian citizens during the early phase of the epidemic. Results: The study included 501 participants. Females account for 49.9% (n=250) .Most of the participants (n=380, 75.8%) were between 21-40 years old. of Transmission modes were recognized by 96% (n=481). The signs and symptoms were identified by 90.8% (n=455). About 91% (n=453) knew that all ages were liable to get infected with COVID-19 and 96% (n=481) knew that the elderly were more prone to develop severe disease. Almost all of the participants (99%, n=494) claimed that they kept hand washing, while only 56.7% mentioned regular use of hand antiseptics. Avoiding contact with symptomatic persons was reported by 97.6% (n=490) and 91.6% (n=459) said they were putting on face masks in crowded places. The concept of remote work was accepted by 89.4% (n=448) and 97.6% (n=489) believed that preventive measures could reduce the risk of catching the infection. Almost all the participants (98.4%, n= 493) would like to know more about the disease. Conclusion: Most of the studied sample of Egyptian citizens were knowledgeable about COVID-19, positive in their attitudes, and have appropriate practices regarding COVID-19 pandemic. However, these observations should be generalized with caution due to the limited size of the sample, and the representativeness of low socioeconomic citizens. Recommendations: Health education programs should be implemented among Egyptian citizens to maintain appropriate and updated knowledge and practices and keep positive attitudes towards COVID-19.


INTRODUCTION
An outbreak of pneumonia of unknown etiology commenced in December, 2019 in Wuhan city of central Hubei province of China. Chinese authorities along with World Health Organization (WHO) began working collectively, the etiological agent was established to be a new virus and was named Novel Corona Virus (2019-nCoV) (1). WHO declared COVID-19 as a pandemic disease on March 11, 2020 and by the beginning of April, 2020 COVID-19 cases were reported in 203 countries around the world (2). Fever is the most common clinical presentation of COVID-19. Other symptoms include cough, malaise, fatigue, shortness of breath, acute respiratory distress syndrome (ARDS) and cytokine storm. Worldwide concerns about the virus have risen due to its high transmissibility. The elderly and patients with chronic medical conditions are more prone to develop severe disease (3). To date, there is no approved specific treatment or vaccination against COVID-19. Strict infection control measures are the primary intervention to minimize the spread of the virus (4). Community awareness of how to deal with this highly infectious respiratory disease plays a critical role in controlling the pandemic. Egypt is one of the largest countries in the Arab region, Africa and the Middle East with more than 100 million citizens. Governmental efforts have been exerted to prevent the spread of the virus (5). The Egyptian Ministry of Health (MOH) launched a COVID-19 Taskforce to steer the country's prevention, containment and mitigation measures. The Egyptian government cancelled international flights, closed schools and banned large social gatherings including certain cultural and faith practices such as mass praying, large weddings and funerals. Health authorities need timely, accurate, and actionable data to design policies and interventions in order to make evidence-based adjustments as the outbreak evolves (6). Gathering data on public knowledge, attitudes, and practice (KAP) has long been beneficial in prevention, control, and mitigation measures during outbreaks. For example, during the 2014 Ebola outbreak, KAP surveys yielded vital information on the prevalence of misunderstanding about Ebola transmission and prevention, and the need to prevent stigmatization of Ebola survivors and foster safer case management and burial practices (7). During other recent outbreaks, such as SARS-CoV-1 or Zika virus, KAP surveys were used to evaluate how providers could better triage patient calls to fever hotlines and measure how the public responded to mitigation efforts (8&9). Hence, it is essential to study these domains among the Egyptian citizens during the current pandemic. Taking into consideration the massive time needed to conduct a national household survey and the commonly low response rate of phone surveys, online surveys are a promising tool to analyze and track KAP among the public during fast-moving infectious disease outbreaks within a short time-frame.

Study design and population
This study was designed as a cross-sectional survey and was carried out between March and May 2020 in Egypt using a snowball sampling technique. As there have been no similar published studies, the sample size calculations were based on the assumption that the likelihood of having public good knowledge and positive attitude towards preventive measures against COVID-19 was 50.0% (10). At 95% confidence interval; margin of error 5%, with a design effect of 1.0, the calculated sample size was 501 participants.

QUESTIONNAIRE DEVELOPMENT AND VALIDATION
The survey was developed by the principle author using the frequently asked questions for public posted on WHO website and translated in Arabic, the native language in Egypt. The final questionnaire was reviewed for validity with the aid of biostatistics expert and was pilot examined on 20 subjects from the target population who were not included in the study. Cronbach's alpha was calculated to be 0.7. The survey consisted of the following parts: (1) Basic demographic data of the participants including age, gender, and education level (2) Nine multiple-choice close-ended knowledge questions tested the following aspects in relation to SARS-CoV-2 infection: methods of transmission, symptoms, vulnerable and high risk groups (3) Ten close-ended practices questions (4) Three questions to check the public attitude (5) one question about the essential source of information.

ETHICAL APPROVAL & DATA COLLECTION
Ethical approval was received from Zagazig University -Faculty of Human Medicine Institutional Review Board (IRB). The survey was carried out during March and May, 2020 when a strict lockdown was imposed by the Egyptian government to implement the social distancing policy. Thus, the online survey was selected for this study since a population-based survey was not feasible under that critical condition. Respondents were pulled across all the Egyptian governments. The questionnaire was electronically sent to the participants through e-mails, WhatsApp, and social networks. Only a single set of responses to the questionnaire was permitted for each person. Consent was implied by the completion of the questionnaire.

STATISTICAL ANALYSIS
Data management and analysis were performed using the Statistical Product and Service Solution (SPSS) version 25 (IBM SPSS Statistics, New York, United States). Descriptive statistics were performed by reporting the number and percentages for the different categorical variables. Percentages of responses were calculated according to the number of respondents per response with respect to the number of total responses of a question. Continuous variables were expressed as mean and standard deviation (SD). Chi-square test was used for comparison of the categorical variables. All tests were two-tailed, p value ≤ 0.05 was considered statistically significant.

RESULTS
Five hundred and one participants from 23 governorates completed the survey. Demographic traits of the studied participants are shown in Table  ( 1). Nearly half of the respondents were females (n=250, 49.9%). Most of the respondents (n=380, 75.8%) were between 21-40 years old. Approximately 69% of the participants were university graduates, 11.6% had completed postgraduate studies, and 19.6% had a high school education or less. Results of knowledge questions are shown in Table  (2). Ninety six percent of the respondents recognized the means of spread, 87% knew that the use of public toilets at work, restaurants, or malls could also transmit infection from others. About 65% were knowledgeable that avoiding uncooked animal product, unboiled or unpasteurized milk might help limiting the transmission of coronavirus. Ninety eight percent were aware that they should clean surfaces and office supplies with disinfectants and avoid public transportation or any crowded areas to limit the spread of the new coronavirus. Almost 91% could identify the signs and symptoms of the disease. About 64% percent knew that diarrhea was likely a clinical symptom of the disease. Most of the respondents (n= 453, 90.4%) recognized that any age may be infected and 96% (n=481) knew that elderly or people with chronic medical conditions ought to develop severe disease. Results of practice and attitude questions are shown in Table (3). About 99% of the respondents said they kept hand washing. However, solely half of the respondents (n= 284, 56.7%) used hand antiseptics. Ninety seven percent said they used tissues when coughing or sneezing and about 98% said they practiced secure disposal of used wipes in a closed waste bin. Ninety four percent stated they used bent elbow for coughing or sneezing when tissues were not available. Ninety four percent of the respondents claimed they avoided hand contact with mouth, nose, or eyes. About 98% stated they kept away from contact with infected people. Approximately, 92% stated they put on masks in crowded spaces. About 67% of the participants said they ketp away from gathering spaces, 23% said they avoided hand shaking, 7% and 3% of the respondents stated they practice balanced food regimen and sufficient sleep as preventive measures against COVID-19 infection, respectively. About 93% said they dedicated to staying at home to stop spread of the infection. Regarding the attitude of the participants, about 89% said they agreed to work remotely in order to preserve the workflow and employee's safety at the same time. Approximately 98% accepted the statement that using preventive measures reduces the hazard of developing the disease. Almost all the individuals (n= 493, 98.4%) stated they make sure to recognize more about the disease to stop it. Based on age, the 15-20 years old respondents had the highest correct answer rate concerning the identification of the emerging coronavirus symptoms (n=55/63, 87.3%) compared to other groups (p =0.01) as shown in Fig. (1). Regarding the practices and attitudes, all participants (100%) aged between 15 -20 years (n=63), 41-50 years (n= 42), and over 60 years (n=2) claimed they were committed to staying at as home compared to 91.6% (n=175/191) of the participants aged 21-30 years, 89.9% (n=170/189) of those aged 31-40 years, and 92.9% (n=13/14) of those aged 51-60 years ( p = 0.05) as shown in Fig. (2). No statistically significant differences between participants' attitude based on their age group were detected. Based on sex, there were no statistical differences between males and females regarding knowledge questions. Yet, certain practices were statistically distinct between male and female participants as shown in Figure (3). One hundred and seventy eight females (178/250, 71.2%) claimed to avoid congested places in contrast to 156 male participants (156/251, 62%), p = 0.03. Twelve male individuals (12/ 251, 4.8%) stated they practiced adequate sleep as preventive measure against COVID-19 in contrast to two females (2/250, 0.8%), p = 0.006. Female participants were more committed to staying at home (240/250) in distinction to male participants (225/251), p=0.005. Regarding attitude, 234 males (234/251, 93.2%) said they agreed to work remotely to keep workflow and employee's safety in contrast to 214 female (214/250, 85.6%), p =0.005. Based on education level, both university graduates and individuals with post-graduate studies were more informed about the modes of transmission of emerging coronavirus when compared to individuals with secondary school education or less (p = 0.02). They were also more knowledgeable that avoiding public transportation and crowded places helped limit the spread of the new disease (p =0.05). University graduates were the most expertised about COVID-19 symptoms. About 85% of the university graduates (293/345) identified correctly the symptoms of COVID-19 in comparison to 69% (40/58) and 78% (77/98) of the individuals with postgraduate or secondary school education, respectively (p =0.05). Additionally, university graduates and individuals with post-graduate studies were the best informed that all ages could be infected with the emerging coronavirus ( p = 0.0001) and that elderly people and people with chronic medical conditions were more susceptible to severe disease when compared to individuals with secondary school education or less (p = 0.001). There were no statistically significant differences between participants' practices or attitude based on their level of education. The main source of participants' information is shown in Figure (4). Most of the participants (n= 372, 74.3%) reported social media as their major source of information, whereas 66 participants (13.2%) mentioned TV and radio, unfortunately, only 55 (11%) and 8 (1.6%) participants mentioned physicians and training courses or lectures as their source of information, respectively.    (19).

Implications of the study
Surveys of KAP can gather data on what is known, believed, and carried out by a specific population. Such data are necessary because unclear information and negative attitude toward infectious diseases may lead to public distress and panic. The findings of our study could be used by public health policy-makers and campaigns, health care workers, and media for targeting the populations in need for COVID-19 prevention and health education.

Limitations of the study
Being an online study, illiterates, farmers, rural and semi-urban residents, underprivileged and vulnerable, and in particular older adults were not included in the study. Thus, our sample population was obviously over-representative of well-educated people.

CONCLUSION
Most of the studied Egyptian citizens were knowledgeable about COVID-19, positive in their attitudes, and had appropriate practices regarding COVID-19 pandemic. However, these observations must be generalized with caution due to the limited sample representativeness of low socioeconomic level citizens.

RECOMMENDATIONS:
Health education programs should be implemented among Egyptian citizens to maintain appropriate and updated knowledge and practices and keep positive attitudes towards COVID-19.

AUTHOR CONTRIBUTIONS
Dina M. Ali is the principle investigator, and contributed to conception and design, acquisition, analysis and interpretation of data, drafting the manuscript and revising it critically. Mona S. Hamed & Lubna A. El-Korashi are co-authors, and contributed to critical revision of the data analysis and reviewing the final manuscript.

CONFLICT OF INTEREST
The authors have declared no competing interests.

FUNDING
The work is self-funded and there is no competing financial interest.