key: cord-0796927-ben8a47p
authors: Saadatjoo, Saeede; Miri, Maryam; Hassanipour, Soheil; Ameri, Hosein; Arab-Zozani, Morteza
title: Knowledge, attitudes, and practices of the general population about Coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis with policy recommendations
date: 2021-03-24
journal: Public Health
DOI: 10.1016/j.puhe.2021.03.005
sha: a9f7dada3d02da273b3f802d4b9660f4546ae8a0
doc_id: 796927
cord_uid: ben8a47p

Objectives This study aimed to investigate and synthesize the current evidence on knowledge, attitudes, and practices (KAPs) of the general population regarding COVID-19. Study Design Systematic review and meta-analysis. Methods We conducted a systematic search on PubMed/LitCovid, Scopus, and Web of Sciences databases for papers in the English language only, up to 1 January 2021. We used the Joanna Briggs Institute (JBI) checklist developed for cross-sectional studies to appraise the quality of the included studies. All stages of the review conducted by two independent reviewers and potential discrepancies were solved with a consultation with a third reviewer. We reported the result as number and percentage. A meta-analysis conducted using a random effect model with a 95% confidence interval. Results Forty-eight studies encompassing 76848 participants were included in this review. 56.53% of the participants were female. The mean age of the participants was 33.7 years. 85.42% of the included studies were scored as good quality, 12.50% as fair quality, and the remaining (2.08%) as low quality. 87.5% examined all three components of the KAPs model. The knowledge component was reported as good, and poor in 89.5%, and 10.5% of the included studies, respectively. Of the studies that examined the attitude component, 100% reported a positive attitude. For the practice component, 93.2% reported satisfactory practice, and 6.8% poor practice. The result of the meta-analysis showed that the overall score of KAPs components about COVID-19 were 78.9, 79.8, and 74.1, respectively. Conclusions This systematic review and meta-analysis showed that the overall KAP components in the included studies were at an acceptable level. In general, knowledge was at a good level, the attitude was positive and practice was at a satisfactory level. Using an integrated international system can help better evaluate these components and compare them between countries.

Coronavirus disease 2019 was reported on 31st December 2019 from Wuhan, 43 China, and announced by the World Health Organization (WHO) as a pandemic on 11th March 44 2020 1, 2 . To date (27 January 2021), it was estimated that about 100 million people were infected 45 with COVID-19 worldwide, of which about two million have died 3 . 46 COVID-19 is characterized by several flu-like symptoms including fever, respiratory problems 47 (dry cough, shortness of breath or difficulty breathing, sore throat), chills, headache, and loss of 48 taste. Also, this disease is much more severe with men, higher age groups, and patients with 49 other pre-existing conditions, such as cardiovascular disease, chronic respiratory disease, 50 diabetes, and hypertension 4, 5 . Based on existing evidence, about 81% of COVID-19 cases are 51 mild, 14% are severe and 5 % are critical. The median time from symptoms onset to clinical 52 recovery is approximately two weeks for mild cases and three to six weeks for severe or critical 53 cases 6 . The incubation period for this disease was reported as 2-14 days based on WHO reports. 54 The mortality rate for this disease is different among countries and was reported between 2% and 55 5% 7, 8 . The most important ways to prevent this disease are to use a mask and maintain social 56 distance 9-11 . So far, there have been several cases of infection in the general public, especially 57 doctors and medical staff, some of which have led to death [12] [13] [14] . 58 Considering the extent and progress of COVID-19 disease and its major effects on economic, Having enough knowledge about a disease can always affect people's attitudes and practices, 64 and on the other hand, negative attitudes and practices can increase the risk of disease and death. 65 Therefore, understanding the general population' KAPs and knowing potential risk factors can 66 help to achieve the outcomes of planned behavior 17, 18 . 67 Given the importance of the issue, conducting a review of studies that have examined the KAPs 68 of individuals and summarizing the results can provide solid evidence for decision-makers in all 69 countries to better manage the disease. Thus, this study aimed at conducting a systematic review 70 to synthesize current evidence on KAPs of the general population with COVID-19 worldwide.

Protocol and registration 73 We conducted a systematic review of the existing evidence related to KAPs of COVID-19 74 patients worldwide following Preferred Reporting Items for Systematic Reviews and Meta-75 analyses (PRISMA) statements (Appendix Supplementary file 1) 19 . We also registered a 76 protocol for this systematic review in the International Prospective Register of Systematic 77 Reviews 20 . 78 Eligibility criteria 79 We included all studies which met the following inclusion criteria: 1) cross-sectional survey; 2) 80 investigate at least one component of the KAPs model regarding COVID-19 disease worldwide; 81 3) published or in-press original paper; 4) in English; 5) with a sample representative general 82 population. No restrictions were applied to the setting, time, or quality of the study. The answer to each questions is yes, no, unclear, and not applicable. Potential 107 discrepancies were resolved by consultation with a third researcher.

Descriptive analyses are carried out in most sections and report the pooled data as a or 110 percentage for similar data items. We used Microsoft Excel software to design the charts. We Q-value was applied to discover between-study heterogeneity, and the I 2 statistic was calculated 115 to assess statistical heterogeneity 24 . Based on Cochrane criteria if the heterogeneity was ≥50 we 116 used the random-effect model 25 . Although there was heterogeneity between the studies above, 117 this was negligible due to differences in settings as well as the use of different questionnaires.

However, we used subgroup analysis based on regions to reduce this heterogeneity 26 . Also, a 119 meta-analysis using a random effect model with a 95% confidence interval (CI) was conducted We contacted ten experts in the related field including health promotion, public health, health 125 policy, epidemiology, and behavioral science via email and asked for their opinions on how to 126 increase the levels of these components in the community. Comments were translated verbatim Forty-two studies encompassing 76848 participants were included. Also, 56.53% of the 138 participants were female. The mean age of the participants was 33.7 years. Most studies were 139 from Asia, Africa, and America, (Fig 2A) . The most important method of data collection was 140 online questionnaires ( Fig 2B) . Most studies examined all three components of the KAPs model, Table 1 . The overall mean quality score of the included studies was 5.70. Of the included studies, 41 149 studies (85.42%) were scored as good quality (score ≥6), 6 (12.50%) as fair quality (score 3-5), 150 and remaining (2.08%) as low quality (score <3) (Fig 3) . The lowest and highest quality scores in Good (59) Positive (63) Satisfactory (67) According to experts, the policy recommendations for promoting the KAP components were as We found that about 90% of the samples had good knowledge of COVID-19 (overall score: mentioned in the studies were television, social media, the internet, radio, and friend and 220 relatives.

Our result showed a high percentage of knowledge, attitudes, and practices in Asian countries.

The probable reason for these higher percentages could be related to the factors such as the initial muscle pain, sore throat, and loss of taste or smell 28, 33, 34, 41, 49, 50, 57, 63 . More than 90% of the 233 participants considered air droplets as a way to spread. This good level of knowledge can be due 234 to widespread information through various means such as public media (television and radio), -19 28, 29, 37, 45, 50, 53, 60, 69 . 

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