key: cord-0682582-3v5bc80z
authors: Matterne, Uwe; Egger, Nina; Tempes, Jana; Tischer, Christina; Lander, Jonas; Dierks, Marie-Luise; Bitzer, Eva-Maria; Apfelbacher, Christian
title: Health literacy in the general population in the context of epidemic or pandemic coronavirus outbreak situations: Rapid scoping review
date: 2020-10-10
journal: Patient Educ Couns
DOI: 10.1016/j.pec.2020.10.012
sha: bdcae754716142c2f092910368e6d3c8de23aa48
doc_id: 682582
cord_uid: 3v5bc80z

OBJECTIVE: The aim of this rapid scoping review, for which only studies from the general population were considered, was to describe the extent of existing research on HL in the context of previous coronavirus outbreaks (SARS-CoV-1, MERS-CoV and SARS-CoV-2). METHODS: We searched major databases and included publications of quantitative and qualitative studies in English and German on any type of research on the functional, critical and communicative domains of HL conducted in the context of the three outbreaks in the general population. We extracted and tabulated relevant data and narratively reported where and when the study was conducted, the design and method used, and how HL was measured. RESULTS: 72 studies were included. Three investigated HL or explicitly referred to the concept of HL, 14 were guided by health behaviour theory. We did not find any study designed to develop or psychometrically evaluate pandemic/epidemic HL instruments, or relate pandemic/epidemic or general HL to a pandemic/epidemic outcome, or any controlled intervention study. Type of assessment of the domains of HL varied widely. CONCLUSION: Theory-driven observational studies and interventions, examining whether pandemic-related HL can be improved are needed. PRACTICE IMPLICATIONS: The development and validation of instruments that measure pandemic-related HL is desirable.

In late 2019 an outbreak of a new viral disease occurred in Wuhan, China and later spread to almost all countries of the world [1] . It is caused by a novel beta coronavirus, the Severe Acute Respiratory Syndrome -Coronavirus -2 (SARS-CoV-2), which causes Coronavirus Disease (COVID) -19) [2] .

The clinical epidemiology of COVID-19 is currently being investigated intensely [3] . Course of disease may be very mild, asymptomatic to very severe with respiratory and systemic damage and requiring mechanical ventilation [4] . Responses of governments to the COVID-19 pandemic have been multifaceted including outbreak management (suppression versus mitigation), provision of adequate clinical treatment facilities for severe cases and measures to alleviate the economic and psychosocial impact of the pandemic and the measures taken to manage it [2] . Public health measures implemented in many countries across the globe encompass contact restrictions and physical distancing, hygiene rules (i.e. frequent and thorough handwashing or disinfection), mask wearing, eye protection and recommendations about how to sneeze and cough [3, 5] . Some of these measures, particularly contact restrictions, have been law enforced in many countries [6] . Relaxing regulations and re-organising social life requires people to voluntarily adhere to the named measures in order to avoid exponential growth of SARS-CoV-2 to reoccur. Further, people who contract SARS-CoV-2 need to know when and how to seek health care and/or be tested. Those who suffer from severe COVID-19 and survive will have to seek health care to mitigate the potentially long-lasting physical and psychological sequelae such as kidney damage [7] or post-traumatic stress disorder [8] . In all these and other different scenarios, the concept of health literacy (HL) becomes a vital public health concept that is essential to counterpart on the individual level the social restrictions enforced by law. When restrictions are gradually lifted, the role of individual level HL increases in order to prevent the resumption of these restriction, should infection numbers surge again. The currently prevailing integrated HL notion "entails the motivation, knowledge and competencies to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life throughout the course of life" [9] and is promoted by WHO (World Health Organisation) Europe [10] . While other notions refer, for instance to HL being the result of health education and distinguishes the distinct concepts of functional, critical and communicative HL [11] the aforementioned HL notion was arrived at by a systematic review and an integration of medical and public health views of HL [9] .

In other words, what is necessary beyond governmental regulations and policy, is an increase in the levels of COVID-19 related health literacy [12, 13] . We not only need to monitor the pandemic's epidemiology during the course of the pandemic including the creation of herd immunity but also HL and health behavioural responses related to the pandemic in the population [13] . HL is considered a major determinant of a person's health [14, 15] , a factor that contributes to health inequalities [14] , and a person's health behaviour, for instance, healthy diet adherence or non-smoking [15] and health care J o u r n a l P r e -p r o o f utilisation [16] . There is evidence that lower HL is consistently associated with mortality [16] or lower self-rated health status [17] .

Research suggests that adequate HL may not be as prevalent among populations as might be necessary in order to navigate the increasingly complex healthcare landscape [15, 16, 18] . Synthesised evidence suggests a relationship between levels of HL and infectious disease prevention in non-pandemic contexts [19] . Inadequate HL was found to be associated with reduced adoption of protective behaviours such as vaccination uptake and poor understanding of antibiotics [19] . Large research gaps were found in relation to infectious diseases with a high clinical and societal impact, such as tuberculosis and malaria [19] . For instance, it was emphasised that critical HL, which focuses on supporting effective political and social action, was not considered in any of the reviewed studies [19] . The strengths of this relationship may be exponentially higher under pandemic circumstances, but no synthesised information on this topic appears to exist to date. Further, the importance of individual HL in pandemic control has been emphasised more urgently [12, 13] .

Therefore, the aim of this rapid scoping review, for which only studies from the general population were considered, was to describe the extent of existing research on HL in the context of previous coronavirus outbreaks (SARS-CoV-1, MERS-CoV and SARS-CoV-2). The World Health Organisation (WHO) declared only SARS-CoV-1 a pandemic [1] while MERS-CoV [20] and SARS-CoV-1 [21] remained epidemics. Facets of HL that were of particular interest were: type of assessment of HL (theory-based versus proxy assessment; validated instrument versus ad hoc assessment), interventions aiming to improve HL during outbreak situations, or HL surveillance during outbreak.

This scoping review was performed according to the methodological framework as outlined by Khalil et al. [22] . Their guidelines regarding scoping reviews build on the work of Arksey and O'Malley's fivestage scoping review framework [23] , complemented with the Joanna Briggs Institute methodology [24] , in order to (1) identify the research questions, (2) identify relevant studies, (3) select studies, (4) chart the data, and (5) collate and summarise the data. A scoping review's objective is to identify the nature and extent of the existing evidence. Unlike other types of review, it does not endeavour to systematically evaluate the quality of available research, but rather seeks to identify the contribution of existing literature to an area of interest [25] . Our methodology was also guided by the rapid review approach which inevitably uses less rigor as is required by a traditional systematic review due to the need for production within a short time-frame using limited resources [26] . The protocol for this rapid review was registered at OSFREGISTRIES on 06/04/2020 [27] .

Two authors (UM, NE) ran the search strategy on PubMed (MEDLINE®) and PsycINFO® on 20 th April 2020. Citations were downloaded to Citavi (Swiss Academic Software). We included publications in English and German of quantitative and qualitative studies. The same authors evaluated titles and abstracts excluding any irrelevant ones. Full texts of the remaining citations were obtained, and two authors (UM, NE) reviewed these, excluding any, which did not meet the inclusion criteria. Finally, reference lists of remaining papers were hand-searched for additional relevant studies. We then compared results from full text screening; there were only minor discrepancies, which were resolved through discussion with the whole team. Data extraction was carried out by five authors (UM, NE, JT, CT, JL) in independent pairs of two. Consensus was achieved through discussion and arbitration within the team. The search strategy was informed by HL theory (derivation of search terms) and is displayed in appendix 1. Inclusion criteria were:

We included reports on any type of research on the functional, critical and communicative domains of HL [11] conducted in the context of SARS-CoV-2, SARS-CoV-1 and MERS-CoV in the general population. This was a rational decision as an initial search using HL as the chief search term in conjunction with the aforementioned coronavirus outbreaks resulted in very few hits. We used the following definitions / concepts of functional, communicative and critical HL: Functional HL is broadly compatible with the narrow definition of 'health literacy' which can be considered to consist of healthrelated knowledge, risk perceptions, attitudes, motivation, behavioural intentions, personal skills, or self-efficacy [11] . Communicative HL means to be able …'to derive meaning from different forms of communication'…, while the ability to critically analyse information is referred to as critical HL [11] .

The following data were extracted from the included studies: authors, publication year, country of study, type of epidemic or pandemic outbreak (SARS-CoV-2, SARS-CoV-1, MERS-CoV), participants (including sample size), design, method, and instruments, and measured constructs including how they were measured (only if applicable e.g. not in qualitative studies). Findings were synthesized quantitatively and narratively and reporting followed the guidelines as proposed in PRISMA-ScR [28] .

A critical appraisal of the quality of the included studies was not within the scope of this review. We do however, comment on major methodological issues regarding the studies.

There was no funding source for this study.

The search in PubMed (MEDLINE®) and PsycInfo® yielded 3394 references, two were obtained from colleagues [29, 30] , leading to 2766 references after removal of duplicates. Title and abstract screening All studies, while mainly not explicitly investigating HL, measured one or more components of HL (Appendix 2). Most studies were observational or short longitudinal (58 cross-sectional, eight pre-post) and six qualitative. All SARS-CoV-2 studies were conducted during, of the MERS-CoV studies 27 during, one during (first wave), eight after, of the MERS-CoV studies 24 during, one after and one both during and after the pandemic/epidemic outbreak. 66 studies used questionnaires, two used focus group discussions, four others used qualitative methods (e.g. interviews) for data collection. 49 studies investigated convenience or opportunity samples and 23 representative samples drawn from general populations. Sample size ranged from 19 -222.599 participants.

Within the nine quantitative SARS-CoV-2 studies, knowledge was measured in seven, attitude in seven, risk perceptions in four, self-efficacy in three, critical HL in five, communicative HL in three, Healthinformation seeking behaviour (HISB) in two, and behavioural aspects in four studies. Only one study [29] Table 1) . Wearing a mask was the most frequently assessed behaviour ( Table 1) . 31 quantitative studies were conducted in the context of SARS-CoV-1. 25 measured knowledge, 28 attitude, 20 risk perception, eight SE, 11 critical HL, 12 communicative HL, and 18 behaviour. One study [33] reported all six HL aspects, the others one to five aspects. Within knowledge, transmission mode was most often measured. Although 25 studies reported knowledge assessment, most studies did not comprehensively assess knowledge ( Table 1) . Handwashing was the most frequently measured behaviour ( Table 1) .

Of the 26 quantitative MERS-CoV studies 21 measured knowledge, 17 attitude, 18 risk perceptions, 3 SE, 4 critical HL, 17 communicative HL, and 10 behaviour. Two studies assessed five of the six HL aspects [34, 35] , the remainder one to four. Within knowledge, transmission mode was most often assessed. Again, most studies did not comprehensively assess knowledge. Handwashing was the most frequently assessed behaviour ( Table 1) .

The reported measured depth within the domains of HL varied widely among the studies (results not shown). For instance, the number of knowledge components ranged from one to at least eight.

HISB was measured in two (SARS-CoV-2), four (SARS-CoV-1), two (MERS-CoV) quantitative studies.

Our search failed to come across any studies designed to develop or psychometrically evaluate pandemic/epidemic HL instruments or relate pandemic/epidemic or general HL to a pandemic/epidemic outcome.

The number of items per HL aspect varied widely (data not shown), hardly any study reported on psychometric properties, two studies from three publications [31, 36, 37] were the notable exception (Appendix 3) and a clear distinction between knowledge, attitude, or risk perceptions was sometimes absent. For instance, perceived vulnerability was reported as an attitude [38] .

Six qualitative studies explored domains of HL in the context of SARS-CoV-2, SARS-CoV-1, and MERS-CoV. One focus group study [39] reported low risk perceptions and a lack of seeking relevant health information in relation to SARS-CoV-2. One interview study [40] and one focus group study [41] explored risk perceptions and preventive behaviour in relation to SARS-CoV-1, another interview study [42] explored individual experiences during quarantine. One interview study reported low knowledge about SARS-CoV-1 and its prevention [43] . Another interview study in the context of SARS-CoV-1 concluded that attitudes towards mask wearing had substantially changed in the post-SARS-CoV-1 period [44] .

While individual HL is recognised as an increasingly important construct in public health [45] , it is of note that only three studies emerged from our extensive search, which explicitly referred to the construct of HL in the context of any of the three coronavirus outbreaks. One used the Newest Vital Sign (NVS), a test measuring nutrition label information processing ability [32] , another study [31] administered a short form of the HLS-EU-Q47, an HL instrument rooted in testable theory [46] and the third [30] study used a version of the HLS-EU-Q47 adapted to SARS-CoV-2. However, the latter provided no evidence on the psychometric properties of the adapted instrument. Hence, at present there seems to be no tested instrument designed to measure coronavirus pandemic-related HL. There is, however, one HL instrument assessing print and multimedia literacy in respect to respiratory diseases [47] .

Most of the other included studies were not theory-based. It is important to highlight that these studies did not purport to measure HL, but were included in this review because the search strategy was based on a pragmatic application of suggested HL components within domains [11, 48] . Of those that were theory-driven, the majority employed health-behaviour theory as conceptualised by social cognition models. There is substantial overlap between socio-cognitive predictors of health behaviour and HL.

For instance, attitude and self-efficacy (defined as behavioural control) are part of the theory of planned behaviour [49] , risk perceptions part of the health belief model [50] or knowledge part of protection motivation theory [51] . Theory-based research allows the formulation of testable a priori hypotheses, and if necessary revision of the theory. Nonetheless, the measures obtained from those studies lacking an explicit theoretical foundation can be considered proxies of HL because they constitute or at least contribute to one or more HL domains.

While there appears to be no evidence linking validly measured (epidemic or pandemic) HL to coronavirus outbreak/pandemic outcomes there is evidence that HL can be linked to other epidemic outbreaks, e.g. the 2014-2016 Ebola epidemic outbreak in West Africa resulted among other factors from low health literacy [52] . A Center for Disease Control and Prevention campaign, with input from partners, helped increase HL [53] . HL has also been shown to be associated with health and health behaviour in general. Hence, one would expect that this association would hold in coronavirus outbreak situations.

Communicative HL included the measurement of access to different sources of information. Whether this had anything to do with better decisions about health in relation to any of the three outbreaks, remained unclear. Knowledge items were generally devised by the authors, and very few reported to have items checked against guidelines. This and the lack of an objective standard for cut-offs make knowledge assessment arbitrary as it cannot be established whether knowledge items reflect current and correct evidenced knowledge. Similarly, while risk perceptions generally pertain to perceptions of vulnerability/susceptibility to and severity of a disease, they were not always measured accordingly or sometimes subsumed under the term attitudes or knowledge.

We also observed very little evidence about the psychometric properties of instruments used to measure socio-cognitive variables such as attitude, risk perceptions, and self-efficacy. It is desirable to know whether measures are reliable and valid, and sensitive to change if the aim is to reflect the effects of health literacy interventions by e.g. education (responsiveness).

Even if knowledge, attitudinal constructs, risk perceptions or self-efficacy were composed in a clear-cut and unequivocal way and psychometrically sound, uncertainty as to whether HL in its broader definition [9, 54] as a composite/compound construct was measured, would still prevail. HL was proposed to be a latent construct [46] thus indicators for its measurement are necessary. There is the need for the development of adequate measurement models.

The present review cannot ascertain, whether established instruments such as TOFHLA (Test of Functional Health Literacy) [55] , or the broader dimension based instruments, for instance the HLQ (Health Literacy Questionnaire) [56] could be used to predict a pattern of association between HL and epidemic or pandemic outcomes (and antecedents such as favourable behaviours and practices), because no such investigations appear to have been carried out, yet. The study [31] that used a short form of the J o u r n a l P r e -p r o o f HLS-EU-Q did not investigate the relationship between HL and pandemic outcome/preventive behaviour but coping responses to the outbreak (depression, quality of life). Okan et al. [30] reported individuals' subjective perceptions about how well they could access, understand, appraise and apply information in the SARS-CoV-2 context but did not test the actual level of what these skills pertain to and whether they are related to better/more favourable behaviour/practices. Further, it also not possible to state at present whether pandemic outbreaks require a specific HL instrument, that is able to explain variance in relevant behaviour and practices over and above that of general instruments (i.e. latent trait/construct measured by discrete manifest cognitive antecedents of behaviour).

In this rapid review, the systematic search was restricted to two major data bases and no grey literature search was conducted. Also, as this review was conducted as a scoping review, we did not look at the strengths of any reported associations between HL aspects and behavioural aspects. Further, it is beyond the scope of this review to assess the quality of the reviewed studies according to standard guidelines for observational studies.

At present HL in the context of coronavirus outbreaks is at an early stage to inform public health/educational strategies aimed at improving the public's HL in order to contain the spread of pandemics. One study [29] appears to be able to shed light on the question of whether HL related aspects change over the course of the pandemic as its survey is conducted in weekly intervals.

We recommend future research be guided by theory from HL research [9, 48] in the much needed work on HL in pandemic outbreak situations. Consequently, assessment of HL should be based on the ability to access, understand, critically appraise and eventually apply information to make better choices about one's health in pandemic outbreak situations when viewed as a set of meta-cognitive skills or a latent trait [46] . Nevertheless, operationalisations at the manifest level, for example, knowledge, or attitudes (which influence critical appraisal) need to be considered, as latent constructs cannot be directly measured. Nevertheless, in the interim, public health communication could benefit from what is generally known from HL research. Health information should be clear so that all members of the public can access needed health information for routine and critical decisions [57] .

Beside theory-driven observational studies, we also need interventions, examining whether coronavirus pandemic-related HL can be improved. In addition, research should also attempt to develop HL instruments that measure coronavirus pandemic-related HL and test the reliability, validity and responsiveness to change. The latter is of particular importance, if we want to be able to examine change during the stages of a pandemic. 

Records identified through database searching (n =3394) 

Novel Coronavirus(2019-nCoV)SITUATION REPORT-121

Can we contain the COVID-19 outbreak with the same measures as for SARS?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges

COVID-19 and Italy: what next?

Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis

COVID-19 pandemic: the effects of quarantine on cardiovascular risk

Kidney disease is associated with in-hospital death of patients with COVID-19

Psychosocial Impact of Quarantine Measures During Serious Coronavirus Outbreaks: A Rapid Review

Health literacy and public health: a systematic review and integration of definitions and models

Health Literacy: The Solid Facts, World Health Organization

Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century

Critical health literacy and the COVID-19 crisis

COVID-19: health literacy is an underestimated problem

Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL)

Functional health literacy and health-promoting behaviour in a national sample of British adults

The costs of limited health literacy: a systematic review

The Relationship Between Health, Education, and Health Literacy: Results From the Dutch Adult Literacy and Life Skills Survey

The prevalence of limited health literacy

Health literacy and infectious diseases: why does it matter?

World Health Organisation, Middle East respiratory syndrome coronavirus (MERS-CoV)

World Health Organisation, SARS (Severe Acute Respiratory Syndrome)

An Evidence-Based Approach to Scoping Reviews

Scoping studies: towards a methodological framework

Joanna Briggs Institute Reviewer's Manual

A typology of reviews: an analysis of 14 review types and associated methodologies

Evidence summaries: the evolution of a rapid review approach

Health literacy in the context of pandemic and epidemic (outbreak): rapid scoping review

Germany COVID-19 Snapshot MOnitoring (COSMO Germany): Monitoring knowledge, risk perceptions, preventive behaviours, and public trust in the current coronavirus outbreak in Germany

Gesundheitskompetenz der Bevölkerung im Umgang mit der Coronavirus-Pandemie

People with Suspected COVID-19 Symptoms Were More Likely Depressed and Had Lower Health-Related Quality of Life: The Potential Benefit of Health Literacy

Awareness, Attitudes, and Actions Related to COVID-19 Among Adults With Chronic Conditions at the Onset of the U.S. Outbreak: A Cross-sectional Survey

Sources of information and health beliefs related to SARS and avian influenza among Chinese communities in the United Kingdom and The Netherlands, compared to the general population in these countries

The Effects of Repetitive Information Communication through Multiple Channels on Prevention Behavior during the 2015 MERS Outbreak in South Korea

Exploring the Determinants of Perceived Risk of Middle East Respiratory Syndrome (MERS) in Korea

Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

A longitudinal study on the mental health of general population during the COVID-19 epidemic in China

Your Health Essential for Your Hajj": Muslim pilgrims' knowledge, attitudes and practices regarding Middle East respiratory syndrome coronavirus (MERS-CoV) during Hajj season

Travel health risk perceptions of Chinese international students in Australia -Implications for COVID-19

Responses of Chinese elderly to the threat of severe acute respiratory syndrome (SARS) in a Canadian community

The perceived threat of SARS and its impact on precautionary actions and adverse consequences: a qualitative study among Chinese communities in the United Kingdom and the Netherlands

The Experience of Quarantine for Individuals Affected by SARS in Toronto

Experiencing SARS: perspectives of the elderly residents and health care professionals in a Hong Kong nursing home

Qualitative study on the shifting sociocultural meanings of the facemask in Hong Kong since the severe acute respiratory syndrome (SARS) outbreak: implications for infection control in the post-SARS era

Health Literacy: A Prescription to End Confusion

Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q)

Measuring health literacy regarding infectious respiratory diseases: a new skills-based instrument

Advancing health literacy: a global challenge for the 21st century

The theory of planned behaviour: Reactions and reflections

The health belief model: Explaining health behavior through expectancies

Handbook of health behavior research 1: Personal and social determinants

Caring for critically ill patients with ebola virus disease

Lessons of Risk Communication and Health Promotion -West Africa and United States

A tale of two health literacies: public health and clinical approaches to health literacy

The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills

The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ)

Health literacy and early insights during a pandemic

Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey

Use of Rapid Online Surveys to Assess People's Perceptions During Infectious Disease Outbreaks: A Cross-sectional Survey on COVID-19

Is Pakistan prepared for the COVID-19 epidemic? A questionnaire-based survey

Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic

Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey

Knowledge, attitude and practice towards SARS

Media effects on students during SARS outbreak

The public's response to severe acute respiratory syndrome in Toronto and the United States

SARS risk perception, knowledge, precautions, and information sources, the Netherlands

Improving older adults' knowledge and practice of preventive measures through a telephone health education during the SARS epidemic in Hong Kong: a pilot study

Psychosocial Factors Predicting SARS-Preventive Behaviors in Four Major SARS-Affected Regions

Restaurant diners' self-protective behavior in response to an epidemic crisis

Stigmatization of newly emerging infectious diseases: AIDS and SARS

Social factors associated with AIDS and SARS

The Singaporean response to the SARS outbreak: knowledge sufficiency versus public trust

An evaluation of information dissemination during the severe acute respiratory syndrome (SARS) outbreak among selected rural communities in Kuala Kangsar

Estimation of the impact of providing outpatients with information about SARS infection control on their intention of outpatient visit

Monitoring community responses to the SARS epidemic in Hong Kong: from day 10 to day 62

SARS-related perceptions in Hong Kong

SARS preventive and risk behaviours of Hong Kong air travellers

The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong

Longitudinal assessment of community psychobehavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in Hong Kong

A tale of two cities: community psychobehavioral surveillance and related impact on outbreak control in Hong Kong and Singapore during the severe acute respiratory syndrome epidemic

Community psychobehavioural surveillance and related impact on outbreak control in Hong Kong and Singapore during the SARS epidemic

War with SARS: an empirical study of knowledge of SARS transmission and effects of SARS on work and the organisations

Population-based post-crisis psychological distress: an example from the SARS outbreak in Taiwan

Crisis prevention and management during SARS outbreak

A study on SARS awareness and healthseeking behaviour -findings from a sampled population attending National Healthcare Group Polyclinics

The knowledge level and precautionary measures taken by older adults during the SARS outbreak in Hong Kong

Severe acute respiratory syndrome epidemic and change of people's health behavior in China

An outbreak of the severe acute respiratory syndrome: predictors of health behaviors and effect of community prevention measures in Hong Kong, China

Psychosocial Factors Influencing the Practice of Preventive Behaviors Against the Severe Acute Respiratory Syndrome Among Older Chinese in Hong Kong

Public perceptions of quarantine: community-based telephone survey following an infectious disease outbreak

SARS knowledge, perceptions, and behaviors: A comparison between Finns and the Dutch during the SARS outbreak in 2003

Practice of habitual and volitional health behaviors to prevent severe acute respiratory syndrome among Chinese adolescents in Hong Kong

Knowledge of and attitudes toward severe acute respiratory syndrome among a cohort of dental patients in Hong Kong following a major local outbreak

Perceived threat, risk perception, and efficacy beliefs related to SARS and other (emerging) infectious diseases: Results of an international survey

Bin Saeed, Knowledge, attitude and practice of secondary schools and university students toward Middle East Respiratory Syndrome epidemic in Saudi Arabia: A cross-sectional study

Awareness among a Saudi Arabian university community of Middle East respiratory syndrome coronavirus following an outbreak

Awareness, Attitudes, and Practices Related to Coronavirus Pandemic Among Public in Saudi Arabia

To what extent are Arab pilgrims to Makkah aware of the middle east respiratory syndrome coronavirus and the precautions against it?

Association between Australian Hajj Pilgrims' awareness of MERS-CoV, and their compliance with preventive measures and exposure to camels

Camel exposure and knowledge about MERS-CoV among Australian Hajj pilgrims in 2014

Public response to MERS-CoV in the Middle East: iPhone survey in six countries

Knowledge and awareness of Middle East respiratory syndrome coronavirus among Saudi and Non-Saudi Arabian pilgrims

Knowledge and Apprehension of Dental Patients about MERS-A Questionnaire Survey

MERS-CoV infection: Mind the public knowledge gap

Hajj pilgrims knowledge about Middle East respiratory syndrome coronavirus

Identification of information types and sources by the public for promoting awareness of Middle East respiratory syndrome coronavirus in Saudi Arabia

Adequacy of public health communications on H7N9 and MERS in Singapore: insights from a community based crosssectional study

Knowledge and practices regarding Middle East Respiratory Syndrome Coronavirus among camel handlers in a Slaughterhouse

The effects of social determinants on public health emergency preparedness mediated by health communication: The 2015 mers outbreak in south korea

Preventive behaviors by the level of perceived infection sensitivity during the Korea outbreak of Middle East Respiratory Syndrome in 2015

Tuning in and catching on? Examining the relationship between pandemic communication and awareness and knowledge of MERS in the USA

Effectiveness of an education health programme about Middle East respiratory syndrome coronavirus tested during travel consultations

Public awareness of coronavirus in Al-Jouf region

Knowledge, attitudes and practices concerning Middle East respiratory syndrome among Umrah and Hajj pilgrims in Samsun

Australian Hajj pilgrims' knowledge about MERS-CoV and other respiratory infections

Middle East respiratory syndrome risk perception among students at a university in South Korea

Associations Between Hand Hygiene Education and Self-Reported Hand-Washing Behaviors Among Korean Adults During MERS-CoV Outbreak

The effects of SNS communication: How expressing and receiving information predict MERS-preventive behavioral intentions in South Korea

Germany COVID-19 Snapshot MOnitoring (COSMO Germany): Monitoring knowledge, risk perceptions, preventive behaviours, and public trust in the current coronavirus outbreak in Germany

Gesundheitskompetenz der Bevölkerung im Umgang mit der Coronavirus-Pandemie

To what extent are Arab pilgrims to Makkah aware of the middle east respiratory syndrome coronavirus and the precautions against it?

Identification of information types and sources by the public for promoting awareness of Middle East respiratory syndrome coronavirus in Saudi Arabia

 yes;  no; n.a.: not applicable; HISB: health information seeking behaviour; n.r.: not reported; * includes related concepts (e.g. outcome expectancies, response efficacy); † perceived vulnerability and/or severity; ‡ Skills (self-efficacy, skills, preparedness)J o u r n a l P r e -p r o o f 25 [29, 61] 10 [33, [63] [64] [65] [66] 68, 73, 87, 91, 94] 9 [38, 97, 98, 102, 104, 107, 112, 113, 116] Transmission mode 4 [29, 36, 37, 60, 62] 18 [63] [64] [65] 67, 68, [72] [73] [74] [75] [76] [78] [79] [80] [81] [82] [84] [85] [86] [87] 18 [34, 38, [95] [96] [97] [98] [101] [102] [103] [104] [106] [107] [108] [111] [112] [113] 115, 116] Symptoms 6 [29, 32, [58] [59] [60] [61] [62] 8 [33, 63, 64, 68, 72, 87, 91, 94] 13 [34, 38, [95] [96] [97] [98] [99] [100] [101] [102] 104, 112, 113, 116] [108] [109] [110] HB: health behaviour; HISB: health-information seeking behaviour; note: cited references do not correspond to number of studies but publications J o u r n a l P r e -p r o o f