key: cord-0701642-jdbwh9vp authors: Alaloul, Fawwaz; Alomari, Khaled; Al Qadire, Mohammad; Al‐Dwaikat, Tariq title: Public knowledge, attitude, practices, and level of anxiety toward the COVID‐19 pandemic among people living in Oman date: 2021-05-05 journal: Nurs Forum DOI: 10.1111/nuf.12592 sha: 345115a08d6e7297d1ce8bc94c333b6c7994b11e doc_id: 701642 cord_uid: jdbwh9vp The purpose was to examine knowledge, attitudes and preventive practices, as well as anxiety and stress of people living in a Gulf country with a diverse population toward the coronavirus disease 2019 (COVID‐19) pandemic. A descriptive cross‐sectional, exploratory design was used to meet the aims of this study. The target population was all individuals aged 18 years and older and who can read and write Arabic, English, or Hindi. The results showed that most individuals demonstrated a high level of knowledge regarding COVID‐19. Most individuals believed that COVID‐19 is not fatal and that countries can control the COVID‐19 virus. Despite the lower levels of anxiety and stress among this population, many individuals reported high levels of stress and anxiety. Higher levels of anxiety, higher levels of knowledge, and being married were associated with more preventive practices. This study showed that the level of knowledge is positively associated with compliance with preventive measures. Providing the public with accurate and consistent information regarding COVID‐19 may enhance their compliance with preventive measures. Using different risk communication strategies will ensure collaboration from the public and encourage them to be active members when facing contagious diseases 58.3% of people in Oman are Omanis, with the remaining 41% being expats from many countries all over the world. 2 Oman is considered an ethnically diverse country as expats come from different cultures and ethnicities. Therefore, Oman is considered a good example for understanding public knowledge, attitudes, behaviors, and practices, as well as levels of anxiety and stress, in a country with a diverse population. The first case of coronavirus infection was reported in December 2019 in China; this was later named coronavirus disease . COVID-19 is an infectious disease caused by a novel type of coronavirus. 3 On March 11th, 2020, the World Health Organization (WHO) declared COVID-19 to be a pandemic disease. By April 2nd, 2020, COVID-19 had spread to more than 203 countries, territories, or areas, infecting over a million individuals and killing more than 56,000. 4 As of March 14th, 2021, COVID-19 has caused more than 119 million cases and more than 2.6 million deaths worldwide. 5 On April 2nd, 2020, the total number of confirmed COVID-19 cases had reached 231. 6 As of March 28th, 2021, the number of cases exceeded 156,000 cases, while 1662 individuals have died due to COVID-19 in Oman. COVID-19 is a highly contagious disease that spreads mainly from person-toperson contact through respiratory droplets produced when an infected person coughs, sneezes, or talks. The virus can also spread from contact with contaminated surfaces and objects. The incubation period of COVID-19 is reported to range from 1 to 14 days, meaning that the disease can easily spread globally. 7 To prevent the spread of COVID-19, the WHO has recommended preventive measures including strict hand hygiene, personal protective equipment, social distancing, quarantine, and seeking medical help when needed. 8 As a result, countries have implemented physical distancing measures, such as lockdown to limit the spread of the disease; this includes closing public places, limiting or banning travel, closing borders, and staying at home orders. 9 Successful control efforts by countries are based on an individual's and the general public's knowledge and perception, behaviors, and practices. 10 Previous studies on controlling and limiting epidemic infectious diseases have emphasized the importance of understanding community members' responses, readiness, and actions. 11, 12 Understanding gaps in general public knowledge, perception, practices, and behaviors can help with identifying strategies and measures to deal with contagious diseases. Understanding the influence of psychological status during an epidemic disease can help with identifying strategies to change behaviors and help individuals comply with preventive measures. 13, 14 In the Netherlands, Bults, et al., 14 found that a higher level of anxiety during the H1N1 pandemic was associated with complying with protective measures. They also found that the level of anxiety was high during the early stages of the pandemic. Consistent with this finding, Leung, et al., 15 found that anxiety was high during the outbreak peak and was associated with complying with preventive measures. Inconsistent with this finding, Liao, et al., 16 found that levels of anxiety among individuals in Hong Kong were not associated with adhering to preventive measures toward the H1N1 pandemic. Therefore, it is important to describe the level of anxiety of the public during the COVID-19 pandemic and its relationship to complying with protective measures. Some sociodemographic and health factors may be negatively associated with an individual's compliance with treatment and instructions. 17 A descriptive cross-sectional, exploratory design was used to describe COVID-19 related knowledge, attitudes, and practices, as well as levels of anxiety and stress, in adult individuals in Oman. The outcomes of this study will form the foundation for a later interventional study to identify strategies and programs to deal with current and future contagious outbreaks. The target population is all individuals aged 18 years and older and who can read and write Arabic, English, or Hindi. The researchers used non-probability convenience sampling to recruit participants. Snowballing was via Facebook and WhatsApp groups in Oman. The estimated total number of adult individuals in Oman is 3.7 million. With an alpha error of 0.05, 95% confidence, and 50% response distribution, the estimated sample size was 470. 18 Proportional quota sampling will be used to ensure representation of the Omani population, stratified by age, geographical area, and gender. COVID-19 survey. The survey was developed based on previously published studies conducted with similar contagious diseases. 10, 14, 19, 20 The COVID-19 survey consists of 39 items divided into four sections: (1). Sociodemographic and health variables including age, gender, level of education, income, marital status, employment, place of residence, smoking, number of children, number of chronic diseases, type of health insurance, and family members with chronic diseases (12 items). (2). Knowledge regarding COVID-19 (10 items). Respondents were asked to answer questions regarding clinical manifestations, transmission, and prevention. A score of one point was given for a correct answer. The overall score for knowledge combines the scores of the 10 items. A higher score indicates a higher level of knowledge. (3). Attitudes towards COVID-19 (6 items). Respondents were asked to indicate how much they agree or disagree, or were not sure, with six statements related to COVID-19. (4). Practices to prevent the spread of COVID-19 (11 items). Respondents were asked to indicate how often they adhere to COVID-19 instructions regarding handwashing, wearing a mask, social distancing, and visitation on a five-point Likert-type scale ranging from 1 (never) to 5 (always). The overall compliance practice score combines the scores of the 11 items. A higher score indicates a higher level of compliance. The survey was checked for face validity by two researchers and piloted using a random sample of 20 participants. The survey was made available in Arabic, English, and Hindi. The depression anxiety stress scale (DASS-21) is a set of selfreporting scales that is used to measure the intensity of depression, anxiety, and stress over the previous week of administration. The Anxiety refers to physiological hyperarousal, while stress refers to persistent levels of tension, frustration, and irritability. The degree of anxiety and stress (normal, mild, moderate, severe, extremely severe) was classified according to the scores, where the higher the score, the more severe the stress and anxiety. The survey's reliability was measured by using Cronbach's alpha and found to be good; it was 0.80 for the AS and 0.84 for the SS. 22 The reliability of the Arabic version was measured by alpha coefficients and found to be 0.75 for anxiety and 0.77 for stress. 23 To adhere to the mitigation efforts and social distancing recommendations, an anonymous online survey was used to assess sociodemographic and health variables, knowledge, attitudes, and practices regarding COVID-19 disease, as well as levels of stress and anxiety, using Google Forms. This survey link was sent to potential participants in Oman using secure social media platforms (Facebook, WhatsApp) and email. Using an anonymous online survey will help to minimize social desirability bias and increase response rates. 14 Potential participants received an online survey with an explanation of the purpose of the study, along with the study consent form. Potential participants were asked about their age. Participants older than 18 years were able to access the study survey. The survey was administered in Arabic, English, and Hindi. Ethical approval was obtained from the first author's institution. To ensure the validity and reliability of this survey, a pilot study was conducted with 20 participants to assess feasibility and question validity. The average time to complete the study survey was about 20 min. Sample characteristics are presented in Table 1 The mean score for knowledge was 7.96 (SD = 1.38, range 1.0-10.0). Table 2 shows that most participants answered the questions correctly. Most know the clinical manifestations, differences from the common cold, mode of transmission, available treatment, and prevention methods. Table 3 shows individuals' attitudes toward COVID-19. Most participants will seek additional information, believe in the importance of handwashing, and will seek testing when needed. Most participants believed that COVID-19 is not fatal and they have confidence in countries' efforts in dealing with COVID-19. The mean score for practice was 50.66 (SD = 4.53, range 25.0-55.0). Finally, the Pearson correlation test was used to examine the relationships between knowledge level and preventive practices. There was a significant relationship between the level of knowledge and preventive practices: r(474) = 0.19, p < 0.001. Levels of anxiety and stress are presented in Table 4 . Most participants expressed normal levels of anxiety (73.8%) and stress (74.4%). Many participants reported severe to extremely severe levels of anxiety (8.2%) and stress (8.6%). There were no significant changes in the levels of anxiety and stress scores among participants by the month in which the survey was completed. Multicollinearity was not a problem as VIF values were close to 1. 24 For the knowledge score, the best fit model that emerged Furthermore, this study showed that being male, having a high level of anxiety, and the absence of chronic diseases in the family were associated with lower levels of knowledge. Previous studies showed that older age, a lower level of education, low income, and unemployment were associated with a lower level of knowledge. [28] [29] [30] Therefore, using different educational methods by policy-makers and health workers that target specific groups of people may improve knowledge and consequently improve compliance with preventive using reliable sources of information is important, especially in an era of false information due to the use of social media as an information source. Being anxious was also associated with greater compliance with preventive measures, thus supporting previous studies. 34, 36 Being anxious regarding the consequences of a pandemic may enhance preventive compliance. Anxiety is experienced by individuals on a daily basis. A higher or lower level of anxiety during a pandemic can result in negative consequences. 39 People with low levels of anxiety may be less likely to comply with preventive measures, while people with high levels of anxiety may impact healthcare systems due to their frequent visits to emergency departments and clinics. 39 On the other hand, some people with high levels of anxiety are reluctant to seek medical help out of fear that they will become more susceptible to infectious diseases in healthcare settings. 39, 40 Therefore, policymakers and healthcare providers are required to deliver a reasonable message to the public to ensure appropriate compliance during pandemic events. Study limitations should be noted. Most of our study population were highly educated people. Therefore, study findings may not reflect the entire population of the Gulf region. Another potential limitation is the use of a generic tool to assess anxiety and stress. Using a specific tool to measure stress and anxiety during the pandemic may be more beneficial for capturing the psychosocial burden. This study showed that the level of knowledge is positively associated with compliance with preventive measures. Providing the public with accurate and consistent information regarding COVID-19 may enhance their compliance with preventive measures. Using different risk communication strategies will ensure collaboration from the public and encourage them to be active members when facing contagious diseases. Using these simple strategies may save lives and save the economy. Toward a collaborative model of pandemic preparedness and response: Taiwan's changing approach to pandemics Expatriates make up 41.7 percent of total population of the Sultanate. Oman News Agency. 2020. https:// omannews.gov.om/NewsDescription/ArtMID/392/ArticleID/ 12456/Expatriates-Make-up-417-percent-of-Total-Population-ofthe-Sultanate World Health Organization. Coronavirus disease (COVID-19) weekly epidemiological update and weekly operational update. World Health Organization Weekly epidemiological update on COVID-19 -16 Worldometer. Coronavirus: Oman. Worldmeter website. 2021 World Health Organization. Coronavirus disease (COVID-19) pandemic World Health Organization. Coronavirus disease (COVID-19) advice for the public World Health Organization. 6 steps every country must take now to prevent coronavirus deaths: WHO Director-General Public knowledge, risk perception, attitudes and practices in relation to the swine flu pandemic: a cross sectional questionnaire-based survey in Bahrain Monitoring community responses to the SARS epidemic in Hong Kong: from day 10 to day 62 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 Demographic and attitudinal determinants of protective behaviours during a pandemic: a review Perceived risk, anxiety, and behavioural responses of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands: results of three consecutive online surveys Longitudinal assessment of community psychobehavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in Hong Kong Anxiety, worry, and cognitive risk estimate in relation to protective behaviors during the 2009 influenza A/H1N1 pandemic in Hong Kong: ten crosssectional surveys Sense of community-belonging and healthbehaviour change in Canada Sample size calculator University life and pandemic influenza: Attitudes and intended behaviour of staff and students towards pandemic (H1N1) Assessment of knowledge and practices towards swine flu: a cross-sectional study among rural housewives Manual for the Depression Anxiety Stress Scales. Psychology Foundation Psychometric evaluation and normative data for the depression, anxiety, and stress scales-21 (DASS-21) in a nonclinical sample of US adults Spiritual well-being, depression, and stress among hemodialysis patients in Jordan Multicollinearity and misleading statistical results Knowledge, attitudes and practices towards COVID-19: an epidemiological survey in North-Central Nigeria 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, attitudes, and practices towards COVID-19 among Ecuadorians during the outbreak: an online cross-sectional survey Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: a cross-sectional study A cross-sectional survey of knowledge, attitude, and practices (KAP) toward pandemic COVID-19 among the general population of Jammu and Kashmir, India. Soc Work in Public Health Knowledge, attitude, and practices (KAP) towards COVID-19 and assessment of risks of infection by SARS-CoV-2 among the Bangladeshi population: an online cross sectional survey The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong Pandemic influenza in Australia: using telephone surveys to measure perceptions of threat and willingness to comply A survey of knowledge, attitudes and practices towards avian influenza in an adult population of Italy Psychological correlates of COVID-19 pandemic in the Austrian population Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China Factors associated with increased risk perception of pandemic influenza in Australia Predictors of tuberculosis knowledge, attitudes and practices in urban slums in Nigeria: a cross-sectional study Knowledge, attitudes and practices (kap) regarding influenza A (H1N1) among a population living along Thai-Myanmar border Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: the importance of gender How health anxiety influences responses to viral outbreaks like COVID-19: What all decision-makers, health authorities, and health care professionals need to know Public knowledge, attitude, practices, and level of anxiety toward the COVID-19 pandemic among people living in Oman The authors declare that there are no conflict of interests. Data available on request from the authors. Tariq Al-Dwaikat https://orcid.org/0000-0002-6859-1623