key: cord-0700938-lnyzwgx4 authors: Li, W.; Liao, J.; Li, Q.; Baskota, M.; Wang, X.; Tang, Y.; Zhou, Q.; Luo, X.; Ma, Y.; Fukuoka, T.; Ahn, H. S.; Lee, M. S.; Chen, Y.; Luo, Z.; Liu, E. title: Health Education for Parents During the COVID-19 OutbreakPublic Health Education for Parents During the Outbreak of COVID-19: A Rapid Review date: 2020-04-19 journal: nan DOI: 10.1101/2020.04.14.20064741 sha: 5ce30af3132c0dc22f7d67cbf485a2e8054125db doc_id: 700938 cord_uid: lnyzwgx4 Background: It is well-known that public health education plays a crucial role in the prevention and control of emerging infectious diseases, but how health providers should advise families and parents to obtain health education information is a challenging question. With COVID-19 (Coronavirus disease 2019) spreading around the world, this rapid review aims to answer that question and thus to promote evidence-based decision making in health education policy and practice. Methods: We systematically searched the literature on health education during COVID-19, SARS (severe acute respiratory syndrome) and MERS (middle east respiratory syndrome) epidemics in Medline (via PubMed), Cochrane Library, EMBASE, Web of Science, CBM (China Biology Medicine disc), CNKI (China National Knowledge Infrastructure), and Wanfang Data from their inception until March 31, 2020. The potential bias of the studies was assessed by Joanna Briggs Institute Prevalence Critical Appraisal Tool. Results: Of 1067 papers found, 24 cross-sectional studies with a total of 35,967 participants were included in this review. The general public lacked good knowledge of SARS and MERS at the early stage of epidemics. Some people's knowledge, attitude and practice (KAP) of COVID-19 had been improved, but the health behaviors of some special groups including children and their parents need to be strengthened. Negative emotions including fear and stigmatization occurred during the outbreaks. Reliable health information was needed to improve public awareness and mental health for infectious diseases. Health information from nonprofit, government and academic websites was more accurate than privately owned commercial websites and media websites. Conclusions: For educating and cultivating children, parents should obtain information from the official websites of authorities such as the World Health Organization (WHO) and national Centers for Disease Control, or from other sources endorsed by these authorities, rather than from a general search of the internet or social media. Since late 2019, the COVID-19 outbreak has become the most urgent public health issue threatening lives over the world (1) . The disease is caused by SARS-CoV-2, a new type of coronavirus, and it usually presents manifestations of pneumonia that takes a severe form in approximately 20 percent of confirmed patients (2) . As of March 30th, 2020, over 720,000 laboratory-confirmed COVID-19 patients have been diagnosed globally, and the number will probably continue to increase until the epidemic trend tempers, which caused a significant impact on the health care and economy of affected areas. With over 200 countries affected and thousands of deaths, World Health Organization (WHO) declared the outbreak as a global pandemic on March 11, 2020 (3) . It is well-known that public health education plays a crucial role in the prevention and control of infectious diseases, but how health providers advise families or parents to obtain health education information is a challenging question. In the context of a public health emergency, health education practice was often neglected or unprepared. This rapid review focuses on this . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 topic to answer that question and aims to promote evidence-based decision making in health education policy and practice. A rapid review has emerged as a helpful approach to provide actionable and relevant evidence in a timely and cost-effective manner (4) . Rapid reviews, as well as rapid advice guidelines, should be conducted in a limited time to offer prompt evidence for the public health emergency. This review intends to support a rapid advice guideline for children with about how health providers should advise families and parents to obtain health education information on SARS-CoV-2 infection. There were various existing methods to expedite the conduct of a rapid review, yet we followed the WHO rapid review practical guide (4) . The pre-search found that the most original studies on the topic were cross-sectional surveys, and the participants were people from non-specific groups rather than parents. However, a health education strategy is urgently needed to help prevent the disease. So, it was implied that this rapid review would use indirect evidence to draw the conclusion. We expanded the search range to SARS and MERS, since these two other coronaviruses have similar transmission routes and clinical outcomes as SARS-CoV-2. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 Three researchers (W Li, J Liao and Q Li) independently performed a comprehensive search of the following electronic databases: Medline (via PubMed), Cochrane Library, EMBASE, Web of Science, CBM (China Biology Medicine disc), CNKI (China National Knowledge Infrastructure), and Wanfang Data from their inception until March 31, 2020. We only included studies published in Chinese or English. Using the Boolean approach, the databases will be searched for the following key terms in titles or abstracts: (Health We included observational studies, such as cohort and cross-sectional studies, that focused on the health education and health promotion issues during COVID-19, SARS, and MERS epidemics. We included studies with participants from the general public. We excluded studies only focusing on specific groups, like different occupations. Duplicates, studies with specific data missing, studies where full-text was unavailable, comments and letters were also excluded. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 After eliminating duplicates, two reviewers (W Li and J Liao) independently performed the search in two steps. Any discrepancies were discussed or solved with a third researcher (Q Li). We used the bibliographic software Endnote. In Step 1, all titles and abstracts were screened using the pre-defined criteria, and studies will be sub-categorized into three (potentially eligible, excluded, and unsure) groups. In Step 2, full-texts of potentially eligible and unclear studies were reviewed to identify the final inclusion. All reasons for exclusion of ineligible studies were recorded, and the process of study selection was documented using a PRISMA flow diagram (6). Two researchers extracted the data independently using a structured form. Then the forms were cross-checked to ensure the data accuracy. If any disagreements occurred, they were resolved by discussion. We extracted the following data: 1) study characteristics, including the first author, publication year, and the country or area; 2) participants' characteristics; 3) aims of survey, and the sample size; and 4) the education resources mentioned in surveys. Two researchers (W Li and J Liao) independently assessed the potential bias of the studies. All discrepancies in quality ratings were discussed with a third researcher (Q Li). Based on the results of the pre-test, we used the Joanna Briggs Institute Prevalence . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 Critical Appraisal Tool ( 7), which is specifically used for systematic reviews of prevalence studies. Sample representativeness, sampling method, sample size, study subjects and setting, coverage of the identified sample, using of standardized criteria for the measurement, reliability of the measurement, appropriateness of the statistical analysis, confounding factors/subgroups/differences, and objectiveness of the criteria of subpopulations were evaluated in all included studies. For dichotomous outcomes we calculated the risk ratio (RR) and the corresponding 95% confidence interval (CI) and P value. For continuous outcomes, we calculated the mean difference (MD) and its corresponding 95% CI when means and standard deviations (SD) were reported. If sufficient data were available, we considered examined the robustness of meta-analyses in a sensitivity analysis.When effect sizes could not be pooled, we reported the study effectives narratively. The quality of evidence for each outcome was assessed using the GRADE (The Grading of Recommendations Assessment, Development and Evaluation) approach (8). The criteria mainly considered included study methodological quality, directness of the evidence, heterogeneity of data, precision of effect estimates, and risk of publication . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 bias. The quality of evidence for each outcome was graded as high, moderate, low, or very low. As COVID-19 is a public health emergency of international concern and the situation is evolving rapidly, our study was not registered in order to speed up the process. Our rapid review included 24 cross-sectional survey studies (9-32) ( Figure 1 and Table 1 ) with a total of 35,967 participants, conducted during the COVID-19, SARS and MERS epidemic. Six anonymous network sampling surveys (9-14) were conducted during the COVID-19 outbreak, and the other 18 surveys (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) were for SARS and MERS. Nine studies (11, 13, 15, 16, 18, 20, 22, 43, 44) mentioned the channels from where people obtained health education information. We also found out three studies about health education campaigns (33-35). Seven studies (15, 20, 24, 26, (30) (31) (32) revealed that the public did not know how to face emerging infectious diseases. However, three surveys (9,10,12) showed that people had good knowledge attitude and practice (KAP) of COVID-19, yet it is necessary to strengthen the community publicity, and the health education of residents. One survey (10) revealed that most Chinese residents are knowledgeable about COVID-19, hold optimistic attitudes, and have appropriate practices (like wearing mask) towards showed that myths, fear and stigmatization of potential . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 SARS patients emerged in the outbreak, as global media reported dramatic stories from the media, television, and the Internet. Another study (37) revealed that emerging health hazards were over-reported in mass media in comparison to the common threats to public health. A survey (26) from Saudi Arabia suggested that epidemiological knowledge received by the public was inadequate, and their recognition of MERS-CoV relied on the clinical manifestations, rather than epidemic features. Age≤30 years, male gender, and not having tertiary education were independent predictors of poor epidemiological knowledge. Five studies (19, 21, 23, 25, 27) showed that pilgrimage travelers lacked awareness of infectious diseases. The Middle East, where MERS outbroke, is also a region with a great number of religious pilgrimage sites. A study in Australia evaluated pilgrims' awareness of MERS-CoV during travel, preventive measures, and the contact with camel exposure, and found that only 28.0% of Australian pilgrims knew that Saudi Arabia was affected by the MERS-CoV outbreak (23). A survey in France (19) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 April 19, . . https://doi.org/10.1101 April 19, /2020 doi: medRxiv preprint 1 0 We explored the current information-seeking strategies and preferences. Two surveys (11, 13) showed that participants tended to obtain the COVID-19 information through Internet, social media by cellphone. One survey (18) (22) compared the sources of information used by the public during the SARS epidemic in 2003 and the H1N1 epidemic in 2010 and found that traditional mass media were still the most commonly used sources for information in both groups of surveys. Information . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 1 1 could be also obtained from friends and relatives, but they were not considered very useful or credible. More and more people are using multiple sources for information: the proportion of people following at least five sources for information has increased by 60.0% between 2003 and 2010. A survey (10) were also more behavior changes (P<0.01) in the prevention of SARS, which fully testifies the effect of comprehensive health education publicity (15) . Another study showed that the awareness of four items of MERS knowledge was significantly higher after a health education intervention than before (P<0.01). The health behavior formation rate of MERS was also higher after the intervention than that before (P<0.01) (23). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 The world has experienced several acute public health emergencies requiring global coordination. Since the global epidemic of SARS in 2003, many institutions and organizations have launched health education programs ( Table 2) . It is worth mentioning that the British government launched a public information campaign on coronavirus quickly after the diagnosis of the first local SARS-CoV-2 infection to inform citizens how to slow the spread of SARS-CoV-2 in the UK. Because of the limitations in the type of study we could not perform the assessment of quality of evidence using GRADE. Overall, the included surveys had acceptable design and reporting quality ( Table 3) , but the sampling methods were not described with sufficient details in some studies. Many online surveys had a large sample size but their reliability was questioned. Improved public health awareness for emerging infectious diseases plays a critical role in at least two ways. On one hand, appropriate behavior of the public, like adhering to self-quarantine and practicing the necessary hygienic habits will definitely slow down the spreading and help control the epidemic. On the other hand，outbreaks of emerging infectious diseases can often lead to negative social phenomena such as fear, stigma, and discrimination (36). Individuals who are feared and stigmatized may deny early . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 clinical symptoms, delay seeking care, and remain in the community undetected, which may aggravate the spread of infection. Better knowledge and awareness promote understanding and communication between different groups of people and improve mental health. WHO had developed guidelines for preventing and addressing social stigma (45), and governments, media, and local organizations working on the SARS-CoV-2 epidemic should follow the recommendations. To control the spreading of COVID-19, boosting public health education should be a priority. The general public may lack adequate knowledge about emerging infectious diseases, and this situation may be even worse in special groups, like children, the elderly, travelers, and other vulnerable groups. This review found that the uneducated and young people lacked appropriate information about infectious diseases and adequately behavior in this outbreak (26). Children may have difficulties in understanding of mass health education. Parents have an obligation to explain disease prevention measures to their children. Furthermore, they should help children to be aware of infectious diseases. We identified three studies (38-40) that evaluated the health care staff's knowledge of SARS or MERS, and found out the importance of providing related health education to them. In the context of globalization, the speed and mode of infectious disease transmission have changed substantially. An outbreak of an infectious disease commonly restricted in . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 epidemic focus, and travel bureaus or visa agencies usually post an alert or warning when the destination undergoes an epidemic, reminding people to be cautious or change their travel plans. The survey of MERS knowledge among pilgrimage travelers could insinuate a similar condition in SARS-CoV-2. SARS-CoV-2 is highly contagious, and essentially everyone is susceptible as there is no vaccination or natural immunity. Therefore, travelers should pay attention to the prevalence of SARS-CoV-2 in tourist destinations when arranging family travel or overseas study tours, especially while the SARS-CoV-2 epidemic is still ongoing. Two studies (43, 44) showed that health information from nonprofit, government and academic websites was more accurate than privately owned commercial websites and media websites. With the development of new media, people can now draw information from multiple sources, and through mobile devices basically at any time and place. Social media like Facebook, Twitter and WeChat are full of SARS-CoV-2 news and health education resources, which is convenient for the phone users. However, fake news and gossips are spreading fast, just like the virus. We appeal for the media and publishers to take deep consideration before post any information to the public. Official websites of the WHO and the national CDC are updating information about the epidemic and necessary preventive measures, and it is suggested for the publisher to cite and follow them. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 In the event of a public health emergency, professional agencies, government departments, and authoritative media should fully cooperate according to the information needed by the public at different stages of the crisis under the unified coordination of the government. This way the core information required by the public will transmit to the public in a timely, accurate, and appropriate manner (18). Although we have collected data on some health education and promotion campaigns or programs in the world, we still need a wide influenced and persistent-actioning campaign to face the outbreak of the novel infectious disease. The outbreaks of SARS， MERS, Ebola and COVID-19 have given us every time a lesson for solidarity and collaboration . Suffering from the pain of lost lives, health education campaigns should be launched as early as possible to slow down the spread immediately. Our rapid review provides evidence of the importance and urgency of health education. Boosting health education to improve public health awareness for infectious diseases is urgently needed, especially for some vulnerable groups. Considering that information from the social media may be unreliable, the public including parents should obtain information from the official websites of authorities such as the World Health Organization and national Center for Disease Control, or from other sources endorsed by these authorities, rather than from a general search of the internet or social media. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 For educating and cultivating children, parents need to educate their children on the importance of evidence-based information on COVID-19 and help them practice preventive measures and hygiene behaviors. We thank Janne Estill, from Institute of Global Health of University of Geneva, for providing guidance and comments for our review. We thank all the authors for their wonderful collaboration. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 April 19, . . https://doi.org/10.1101 April 19, /2020 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 19, 2020 . . https://doi.org/10.1101 /2020 . World Health Organization; c2020 [cited 2020 Apr 13] . Available online: www.epi-win.com/allresources/social-stigma-associated-with-covid-19. . 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