key: cord-0754767-qrdjzeu6
authors: Al-Smadi, Ahmed Mohammad; Tawalbeh, Loai I.; Ashour, Ala; Shajrawi, Abedalmajeed; Gammoh, Omar; Abu-AL-Rous, Noor
title: Public knowledge, attitudes, and practice about COVID-19 pandemic
date: 2021-01-29
journal: J Public Health Afr
DOI: 10.4081/jphia.2021.1519
sha: 693f037eac6f64ff63922f6f0bf39920fee78413
doc_id: 754767
cord_uid: qrdjzeu6

COVID-19 is a newly discovered global pandemic that affected almost all countries, including Jordan. Knowledge, attitude and practices are fundamental to suppress the spread of the virus. This study aimed to examine knowledge, attitude and practices about COVID-19 in Jordan. A cross-sectional design was used to recruit a convenience sample of public from Jordan. An online instrument used to assess knowledge, attitude and practices about COVID-19, and was developed by the research team. The data were collected online through social media networks in Jordan. The data were collected during May 2020. 2470 participants participated and completed the study questionnaire. Results indicated good knowledge, practice, and attitude, about COVID-19 among the public in Jordan. Linear regression showed that female, aged 40 years or more, married, with Bachelor degree or higher, employed, and participants believe that Jordan will control COVID-19 had higher knowledge compared to their counterparts. Besides, linear regression showed that female, living in Amman city, with high knowledge about COVID-19, and believing that Jordan will control COVID-19 had higher practice compared to their counterparts. Knowledge, attitude and practices levels regarding COVID-19 among Jordanian population during the pandemic were high. However, health authorities and government have to implement and maintain educational programs to enhance the Jordanian population’s awareness regarding COVID-19 and to prevent its spread specially among male, aged less than 40 years, unmarried, with less than Bachelor degree, unemployed, and for participants believe that Jordan will not control COVID-19.

The novel corona virus is an enveloped positive single-strand RNA virus, has three glycoproteins E, M and S, with S protein ejecting from the viral envelope resembling solar corona that's where the name derived from. 1 Also this virus known as 2019-nCoV or COVID-19; it is a global health infection. 2 It was first recognized in China, December 2019 and emerged to almost every country. 3 By February 15, 2020 the epidemic ongoing virus has reached 26 countries, resulting in 51,854 infections and 1669 deaths. 4 The virus can be transmitted before even symptoms appear with an average of about 6 days. 5 The propagation of this virus has resulted in thousands of deaths and has affected people all around the world with various symptoms. 6 The virus infects mammals and was first transmitted from animals to humans in Wuhan on the Huanan seafood market. 2 The pathological aspects of COVID-19 are still under study. Health experts have found that it resembles those of SARS and MRSA but appears to be more infectious and sever than SARS and MRSA. 5 The clinical course of COVID-19 has shown asymptomatic illness in some patients at early stages, other patients developed mild fever, cough, myalgia, dyspnea, arthralgia, chest pain, runny nose and generalized weakness. 7 In later stages the primary outcomes where severe acute respiratory distress while the secondary was death during the ICU period as a result of organ dysfunction, hemorrhage and septic shock. 8 Intensive treatment, close monitoring and mechanical ventilation are required for those with complicated severe illnesses, some may still experience hypoxemia and increased breathing work even when oxygen is delivered through face mask reservoir bag. 9 Morbidity rate increases with age and patient with serious underlying medical conditions like hypertension, diabetes, cancer and coronary heart disease are associated with a higher risk of severe morbidity and mortality rate of COVID-19. 10 Public knowledge and awareness about COVID-19 are fundamental to suppress the spread of the virus. According to a study held in Jordan, Kuwait, Saudi Arabia targeting only unemployed, students and people with low level of education, the knowledge of middle east countries about prevention and control the transmission of the disease is low as some participants reported that it is no necessary for young adults and children to wear masks, and the highest knowledge score has found in Jordan. 11, 12 The variation in mortality rates between countries could be explained by the application of health measures including, social distancing, using masks, the lockdown of work organizations, shopping malls and airports, cancelling flights, traffic limits, avoid hand shaking and kissing at meetings, avoid surfaces touched by others such as tables, avoid direct contact with confirmed cases, avoid touching mouth or eyes, washing hands for no less than 20 sec-onds, avoid sharing cups, test for COVID-19 if feel any symptoms. 3 On 11 March 2020, WHO Director-General characterized COVID-19 as a pandemic. On 20 March 2020 the prime minister of Jordan had imposed a mandatory curfew from 6pm until 10am, people who breached the curfew were arrested and subjected to a fine of about 100-500JD. On 13 April Jordan suspended all coming and departing flights, screening of passengers and quarantine for coming travelers, Jordan also started distance learning, provided medication service for patients. Up to date statistics for 6 th June 2020 Jordan had recorded 784 cases (125 actives, 9 deceased and 571 recovered). 13 This virus has disrupted the economy and restricted daily life of countries worldwide. 14 There was a scarcity of studies that have been conducted to evaluate knowledge, attitude and practices about COVID-19 in Jordan. Therefore, study aimed to examine knowledge, attitude and practices about COVID-19 in Jordan. Furthermore, the difference in knowledge, attitude and practices about COVID-19 based on selected demographical characteristics was assessed.

The Ethical approval to conduct the study was obtained from the Institutional Review Board (IRB) at the American University of Madaba. The study protocol approval number is H20004. A consent form was available to all participants at the beginning of the questionnaire and includes information about the purpose, objectives of the study. The participants were assured that their participation was confidential. A code number was provided for each participant to protect their confidentiality during data collection and analysis. Data were maintained in a secured computer to keep it private and confidential. The participants weren't asked to fill their names in the online survey during the data collection.

A cross-sectional design was used to assess knowledge, attitude and practices about COVID-19 among Jordanian population.

A convenient sampling technique was utilized to recruit a convenience sample of the public from Jordan; individuals had access to the social media such as fakebook and what's were invited to participated in the study. Researchers for this study sent the link to their social network through WhatsApp, and Facebook page that include the link and invitation to participate through Google forms. For the purpose of increase visibility for the link by potential participants in Jordan; a paid service to Facebook was done, which made the link available for higher number of individuals. The target population was all public in Jordan, while the accessible population was public who have social media and able to complete the survey online. The inclusion criteria are: persons who aged 18 years or above, can read and write Arabic or English language. Potential participants were asked about their age initially, only participants with 18 years old and above were able to proceed in completing the questionnaire.

An online instrument that was developed by the research team was used online and built using Google forms. The instrument consists of two parts. The first part of the study is the demographical details which are age, gender, marital status, city, education level, and employment status. The second part of the instrument is the questions that assess an individual's knowledge, attitudes, and practice related to COVID-19. It was developed based on previous literature review and it was initially in the English language. It consists of 22 questions. The first 15 questions assess participants' knowledge about COVID-19 with three options true, false, and I don't know; the answers were recoded to be true answer, false answer, and I don't know; this followed by recoded true answer to 1 and both false and I don't know the answer to zero. The mean score for each 15 items was calculated (with possible score ranged from 0 to 1) and then a total mean score for knowledge was calculated with possible scores ranged from 0 to 15. The next six questions assess participants practice towered COVID-19 (questions 16-21) with three options; always (coded 2), sometimes (coded 1) and never (coded 0) and question 16 has revised coded. A mean score for each item were calculated with a possible score ranged from 0 to 2, and then a total mean score for the practice was calculated with a possible score range from 0 to 12.

The data were collected online though social media networks, mainly Facebook, and WhatsApp. The online survey was built using Google forms. The research team developed the questionnaire through the google forms. The online link for the questionnaire distributed through social media such as Facebook and WhatsApp. The data collection lasted for one month; during May 2020.

Data were analyzed using the Statistical Package for Social Science (SPSS) version 23 (IBM Corp., Armonk, NY, USA). Descriptive statistics including frequency mean (M), and standard deviation (SD) were utilized to describe the sample characteristics. Data for the outcome variables were normally distributed as indicated by the level of skewness. No missing data were detected in the analysis. Independent sample t-test was used to examine differences in COVID-19 knowledge, attitudes, and practices scores based on demographical details. In addition, multiple-linear regression was used to examine each knowledge and practice possible predictors. Significance level was set at P<0.05. 

A total of 2470 individuals completed the study questionnaire. However, 34 refused to participate. As shown in Table 1 ; the majority of participants were female (N=1688, 68.3%), between 18 and 39 years old (N=1879, 76.6%), living in Amman city (N=1699, 68.6%), married (1487, 60.2%), had a bachelor's degree or higher (N=2107, 85.3%), and 1442 (58.4%) were unemployed.

As shown in Table 2 the total mean score for the knowledge questions was 12.04 out of 15 indicating high knowledge related to COVID-19. Examining the mean score for each knowledge questions showed that the majority were above 0.8 out of 1 except four questions. The questions that showed mean scores lower than 0.8 were; "Not all persons with COVID-2019 will develop to severe cases. Only those who are elderly, have chronic illnesses, and are obese are more likely to be severe cases" with a mean score of 0.79, and "Ordinary residents can wear general medical masks to prevent the infection by the COVID-19 virus" with a mean score of 0.78, and "Unlike the common cold, stuffy nose, runny nose, and sneezing are less common in persons infected with the COVID-19

virus" with a mean score of 0.73, and the least mean score for the question "It is not necessary for children and young adults to take measures to prevent the infection by the COVID-19 virus" with a mean score of 0.06. Examining the total mean score for COVID-19 practice-related questions showed that the total mean score for the six questions was 9.37 out of 12, indicating good practice as shown in Table 2 . Examining the mean score for each practice questions showed that the majority were above 1.6 out of 2 except one question; "In recent days, have you gone to any crowded place" with a mean score of 0.13. The last question was a general asked respondent about their attitude towered their confidence that the country they reside in Table 2 . Descriptive statistics for knowledge, practice, and attitude items toward COVID-19 in Jordan, May 2020 (N=2470).

True answerFalse answer, Don't knowMean (SD) N (%) N (%) N (%) 

An independent sample t-test was used to examine differences in total mean score for each knowledge and practice towered COVID-19 based on their demographical details and their attitude towered the Jordan can control COVID-19. As shown in Table  3 there were significant differences in knowledge total mean score based on participants' gender, age, marital status, education level, employment status, and country control. The results indicated that female had significant t(2468)=-3.26, p=0.001 higher knowledge mean score (M=12.12, SD=1.70) compared to male (M=11.87, SD=2.03); participants' with age group from 40 and above years old had significant t(2468)=-6.82, p=0.001 higher knowledge mean score (M=12.49, SD=1.51) compared to participants aged 18-39 years old (M=11.90, SD=1.88). In addition, non-married had significant t(2468) =-8.88, p=0.001 higher knowledge mean score (M=12.44, SD=1.57) compared to married (11.78, SD=1.92); participants' with bachelor degree and above had significant t(2468) =-7.04, p=0.001 higher knowledge mean score (M=12.15, SD=1.75) compared to participants' with associate degree or below (M=11.42, SD=2.05). Furthermore, employed participants' had significant t(2468) =7.28, p=0.001 higher knowledge mean score (M=12.35, SD=1.56) compared to unemployed (M=11.82, SD=1.96); and participants' believe that Jordan will control COVID-19 has significant t(2468)=-9.26, p=0.001 higher knowledge mean score (M=12.15, SD=1.60) compared to those believe the contradictory (M=10.98, SD=1.23). As shown in Table 3 there were significant differences in practice total mean score based on participants' gender, age, city, education level, employment status, and country control. The results indicated that female had significant t(2468) =-5.09, p=0.001 higher practice mean score (9.45, SD=1.46) compared to male (M=9.19, SD=1.46); participants' with age group from 40 and above years old (M=9.48, SD=1.09) had significant t(2468) =-2.66, p=0.005 higher practice mean score compared to participants aged 18-39 years old (M=9.33, SD=1.22). Also, participants' living in Amman city had significant t(2468) =1.96, p=0.049 higher practice mean score (M=9.40, SD=1.12) compared to those living outside Amman city (M=9.30, SD=1.28); participants' had bachelor degree and above had significant t(2468) =-3.02, p=0.002 higher practice mean score (M=9.40, SD=1.15) compared to participants' with an associate degree or below (M=9.19, SD=1.29); employed participants' had significant t(2468) =2.24, p=0.025 higher practice mean score (M=9.43, SD=1.10) compared to unemployed (M=9.32, SD=1.23); and participants' believe that Jordan will control COVID-19 had significant t(2468) =-8.36, p=0.001 higher practice mean score (M=9.43, SD=1.06) compared to those believe the contradictory (M=8.74, SD=1.93).

Multiple-linear regression was used to identify the significant predictors of knowledge. To determine knowledge predictors; demographical details as well as the country control question were included as possible predictors. The full model was significant F (7,2462) =34.05, p=0.001, and as a whole explained 8.6% of the variance in knowledge. As shown in Table 4 , gender t(2462)=3.32, P=0.001, age t(2462)=2.40, P=0.01, marital status t(2462)=3.96, P=0.001, education level t(2462)=5.31, P=0.001, employment status t(2462)=-3.63, P=0.001, and country control t(2462)=9.26, P=0.001 were the significant predictors. This indicated that female, aged 40 years or more, married, with Bachelor degree or higher, employed, and participants believe that Jordan will control COVID-19 had higher knowledge compared to their counterparts. Multiple-linear regression was used to identify the significant predictors of practice. Demographical details, knowledge and country control were included as possible predictors for practice. The full model was significant F (8, 2461)=26.01, p=0.001, and as a whole explained 7.8% of the variance in practice. As shown in Table 5 , gender t(2462)=4.52, P=0.001, city t(2462) =-2.08, P=0.03, knowledge t(2462)=9.27, P=0.001, and country control t(2462)=6.45, P=0.001 were the significant predictors. This indicated that female, living in Amman city, with high knowledge about COVID-19, and believe that Jordan will control COVID-19 had higher practice compared to their counterparts. In addition, linear regression to predict Practice showed that female, living in Amman city, with high knowledge about COVID-19, and believe that Jordan will control COVID-19 had higher practice compared to their counterparts. 

In this cross-sectional study, we presented an insight into the knowledge, attitude and practice measures of the Jordanian population towards COVID-19 pandemic. To the best of our knowledge, this is the first study in its kind implemented to examine knowledge, attitude and practices about COVID-19 pandemic and investigate the difference in knowledge, attitude and practices about COVID-19 pandemic based on selected demographical characteristics in Jordan. The study resulted that the overall knowledge about the COVID-19 pandemic was high among the participants. These results are consistent with other a Chinese, Malaysian and Saudi Arabia studies reported that high levels of knowledge among the study group despite being conducted during the COVID-19 pandemic. 4, [15] [16] [17] In addition, the high level of knowledge of COVID-19 pandemic among Jordanian population is reflected in controlled COVID-19 pandemic status and with a number of total COVID-19 pandemic, total cases 1,071 and total deaths (9 cases) discovered in Jordan from 15 February until 24 June 2020, 13 which is considered a very good pandemic level in comparison with other Middle Eastern countries and other countries in the world. Only 5.5% of participants were found had knowledge about "It is not necessary for children and young adults to take measures to prevent the infection by the COVID-19 virus". This result is similar to Azlan et al. 15 which indicated that 3.7% have knowledge about "children and young adults to take measures to prevent the infection by the COVID-19 virus". This could be related to false information were distributed by different social media in Jordan that children don't be infected by COVID-19, particularly, for persons had taken Mycobacterium Tuberculosis vaccine during the childhood period. The study showed that female participants, aged above 40 years, educated and married associated with higher knowledge level toward COVID-19. This is study is consistent with the study by Al-Hanawi et al. 17 showed that male gender, age-group of 16-29 years, and education of secondary or lower were significantly associated with lower knowledge level toward COVID-19 in Malaysia. Several factors influence the level of medical knowledge. For example, according to the study Assaf et al. 18 among the Jordanian society, the transmission of medical knowledge is primarily acquired by the family, friends and the social media platforms. Indeed, the high level of knowledge is a result of the high traffic on the social media platforms which has dramatically increased during the lockdown period in Jordan that lasted for more than two months from 18 March until 29 May 2020 with lockdown time 16 hours from 6 pm -10 am. And then from 30 May until this moment lockdown time 6 hours from 12 am -6 am. The study also reported a high rate of optimism that Jordan can control the spread of COVID -19 on its territories. The optimistic attitude of the Jordanian residents could be related to the unprecedented COVID-19 control measures. This result is congruent with another study in Saudi Arabia by Al-Hanawi et al. 17 which found that the Saudi population have a high level of knowledge, optimistic attitudes and good practices towards COVID -19 pandemic as a result of governmental enormous effort to prevent COVID -19 pandemic through social media and strict lockdown which includes all sectors such as tourism, restaurants, shopping malls, industries, transportation, religious centers, universities and schools, with keeping open only groceries stores, and hospitals. In the current study, the Jordanian population showed a positive practice towards the ongoing COVID-19 pandemic to prevent spread. The majority of participants reported that they were adherent with preventive measure toward COVID -19 pandemic such as, washing hand frequently, avoidance of hand shaking, wearing a mask and gloves, social distancing (at least 1.5 meters between individuals), cleaning fruits and vegetables and preventive techniques during coughing and 

This is the first study to examine the knowledge, attitude and the practice towards COVID-19 pandemic among Jordanian population. However, it is important to highlight that this online survey had limitations, the first, due to the very limited time for developing the questionnaire with simple questions only during the rapid COVID-19 pandemic. The research team utilized quick assessment of knowledge, attitudes and practices towards COVID-19 pandemic, which should be developed through a structured interview, direct observation or focus group discussion methods and developed as multi-dimensional measures. Second, the minor focus on the specific group such as elderly population, vulnerable groups and the individuals who don't have capability to use social media who are more likely to have less knowl-edge, negative attitudes, and inappropriate preventive practices towards COVID-19 pandemic.

The health authorities and the government have to pay more efforts in increase awareness and educating the people about COVID-19 pandemic on different social media through mobile messages and television. Moreover, providing awareness about the COVID-19 pandemic in large Jordanian population may help in rectifying some false information regarding the knowledge, practice or attitudes towards the COVID-19 pandemic. Moreover, the study results should be cautiously considered within the cultural context of Jordanian population, as the tradition, beliefs and culture may be different from other countries. Finally, replicating the study with different the method to confirm study results is required.

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Acknowledgements: The authors would like to thank the study participants.Contributions: Study conception, Data collection, Writing the paper: LT, AMAS, AA, AS, OG; Methodology, Data analysis: LT, AMAS, OG.

The knowledge regarding COVID-19 among Jordanian population during the pandemic was high, attitudes were good and the practices were mainly appropriate. Health education about COVID-19 should be directed more toward males, aged less than 40 years, less than bachelor education, unmarried and unemployed. Measures and the efforts that were implemented by the Jordanian government during this pandemic may had positive impact on public knowledge, practice, and attitude toward COVID-19 in Jordan. However, further follow-up assessment and research for these factors and COVID-19 impact are highly recommended, as the COVID-19 pandemic in Jordan and worldwide is changing.