Telaah Kritis Jurnal Epidemiologi [PDF]

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TELAAH KRITIS HASIL PENELITIAN EPIDEMIOLOGI A CROSS-SECTIONAL SURVEY OF KNOWLEDGE, ATTITUDE AND PRACTICE (KAP) TOWARDS COVID-19 PANDEMIC AMONG THE SYRIAN RESIDENTS Untuk Memenuhi tugas mata kuliah Epidemiologi dan Kependudukan



Oleh: Aziz Nashiruddin Habibie Ananda Patuh Padaallah Yunidar



PROGRAM STUDI MAGISTER KEPERAWATAN FAKULTASS KEPERAWATAN UNIVERSITAS AIRLANGGA 2021



ii



DAFTAR ISI COVER ............................................................................................................................1 DAFTAR ISI....................................................................................................................ii BAB 1 PENDAHULUAN ................................................................................................1 BAB 2 TELAAH KRITIS ...............................................................................................3 2.1



Apakah kriteria inklusi dalam sampel didefinisikan dengan jelas?.....................3



2.2



Apakah subjek penelitian dan latarnya dijelaskan secara rinci?..........................3



2.3



Apakah eksposur diukur dengan cara yang valid dan andal?..............................3



2.4



Apakah kriteria standar yang obyektif digunakan untuk mengukur kondisi?.....3



2.5



Apakah faktor perancu teridentifikasi?...............................................................3



2.6



Apakah strategi untuk menangani faktor perancu dinyatakan?...........................4



2.7



Apakah hasil diukur dengan cara yang valid dan dapat diandalkan?..................4



2.8



Apakah analisis statistik yang tepat digunakan?.................................................4



2.9



Trias Epidemiologi.............................................................................................4



2.9.1



Host (Manusia)...........................................................................................5



2.9.2



Agent (Virus)..............................................................................................5



2.9.3



Environment (Lingkungan)........................................................................5



BAB 3 PENUTUP ............................................................................................................8 3.1



Kesimpulan........................................................................................................8



3.2



Saran..................................................................................................................8



DAFTAR PUSTAKA.......................................................................................................9 Lampiran........................................................................................................................10



ii



BAB 1 PENDAHULUAN 1.1. Latar Belakang Covid-19 merupakan penyakit menular yang muncul disebabkan oleh Novel Corona Virus jenis baru yang ditemukan dan menimbulkan wabah di Wuhan, Tiongkok pada bulan Desember 2019 dan telah menyebar ke seluruh dunia dan diumumkan sebagai pandemic oleh WHO hingga saat ini (WHO Indonesia, 2021). Mayoritas orang mengalami gejala ringan atau bahkan tanpa gejala (Kanu et al., 2021). Namun, pasien dengan komorbid mengalami tanda dan gejala yang paling berat, seperti demam, batuk kering, myalgia, dan kelelahan menjadi gejala yang paling banyak dikeluhkan (Kanu et al., 2021). Transmisi covid-19 mayoritas melalui droplets yang muncul akibat batuk, bersin atau berbicara dan virus tersebut dapat menginfeksi individu lain jika melakukan kontak langsung dengan membrane mukosa (Taye et al., 2020). Model transmisi lain yang mungkin yaitu Ketika individu menyentuh wilayah atau barang yang terkontaminasi kemudian diikuti menyentuh hidung, mulut ataupun mata (Taye et al., 2020). Minimalisasi transmisi resiko penting untuk dilakukan, sehingga komunitas perlu untuk mengikuti praktik pencegahan infeksi seperti mencuci tangan menggunakan sabun atau handrub, menjaga jarak, memahami tanda dan gejala covid-19, menggunakan masker dan menerapkan etika batuk dengan benar (Taye et al., 2020). Laporan WHO hingga Februari 2021 mengenai kasus terkonfirmasi positif covid-19 mencapai 113.076.707 kasus di seluruh dunia (WHO, 2021). Kasus konfirmasi positif di Indonesia sampai bulan Februari 2021 masih cukup tinggi yaitu 1.329.074 kasus penambahan mencapai 6.208 kasus per hari dan jumlah pasien meninggal mencapai 195 kasus per hari (KPCPEN, 2021). Jumlah kasus ini akan terus tertambah dan diperkirakan akan mencapai puncak pandemic pada bulan januari hingga juli tahun 2021 (Permana dan Sahadewo, 2020). Sementara itu, pemerintah telah menetapkan pembatasan sosial berskala besar (physical



1



2



distancing)



melalui



pemberlakuan



Work



from



Home



(WFH),



pembelajaran daring, dan pembatasan sarana transportasi. Kebijakan ini masih mendapatkan pro dan kontra dikarenakan informasi dan edukasi kesehatan di masyarakat masih belum terpusat dan kredibel (Nasir, Baequni dan Nurmansyah, 2020). Pengetahuan mengenai covid-19 yang baik memiliki hubungan dengan praktik penerapan pencegahan covid-19 (Taye et al., 2020). Berbagai upaya telah dilakukan pemerintah Indonesia untuk menekan kasus covid-19 di Indonesia, diantaranya pembatasan sosial berskala besar (PSBB) dan memberikan edukasi maupun ajakan untuk menerapkan



germas



dalam



masyarakat.



Upaya



meningkatkan



pencegahan covid-19 dilakukan pemerintah melalui Kemenkes RI salah satunya dengan media video edukasi covid-19 dan flipchart maupun leaflet yang diharapkan dapat menjangkau seluruh lapisan masyarakat yang dapat dijumpai di fasilitas-fasilitas umum maupun di laman website Kemenkes RI. Untuk mengkonfirmasi efektifitas upaya praktik pencegahan dan menurunkan resiko covid-19, data pengetahuan, sikap dan praktik pencegahan menjadi sangat penting (Taye et al., 2020). Data tersebut akan sangat penting dalam menyediakan aplikasi pendekatan yang dibutuhkan dalam mengontrol penyebaran virus. Telaah penelitian melalui metode critical appraisal dalam bidang penelitian pengetahuan sikap dan praktik terhadap Covid-19. Critical appraisal adalah jalannya tindakan dalam memeriksa secara tepat dan sistematis dalam menilai keunggulanm nilai dan relevansinya untuk mengarahkan para professional dalam pengambil keputusan (Al-Jundi and Sakka, 2017). Telaah menggunakan cheklist CASP yang terdiri dari dari 8 pertanyaan untuk memahami jenis penilitian Crossectional Study. Penelitian ini dapat menjadi suatu rekomendasi untuk meneliti lebih lanjut mengnai pengetahuan sikap dan praktik masyarakat terhadap covid-19.



BAB 2 KRITIK ARTIKEL



2.1 Apakah kriteria inklusi dalam sampel didefinisikan dengan jelas? Tidak dijelaskan secara pasti kriteria inklusi dan ekslusi, tetapi di jurnal dijelaskan responden yang memenuhi syarat yaitu berumur 16 tahun dan selebihnya, untuk risiko atau tahap perkembangan penyakit belum ada. 2.2 Apakah subjek penelitian dan latarnya dijelaskan secara rinci? Sampel penelitian ini merupakan orang yang bertempat tinggal di Suriah, sebelumya dikumpukan terlebih dahulu data demografi dasasr tentang usia, jenis kelamin, tingkat pendidikan, status pekerjaan, dan usia 16 tahun hingga 60 tahun keatas. 2.3 Apakah eksposur diukur dengan cara yang valid dan andal? Penelitian ini menggunakan kuisioner yang sebelumnya telah digunakan serupa dengan kuisioner tentang H1N1 dan SARS. Analisis data statistik menggunakan uji-t sampel independen, uji signifikansi analisis varian satu arah dam regresi linier berganda digunakan untuk menguji hubungan karakteristik demografis dan variabel. 2.4 Apakah kriteria standar yang obyektif digunakan untuk mengukur kondisi? Dalam penelitian ini tidak dijelaskan secara pasti kriteria standar obyektif yang digunakan, tetapi di kalangan warga Suriah yang didiominasi wanita dengan berpendidikan tinggi sebagian besar menjawab pertanyaan dengan benar mengenai pengetahuan sederhana tentang Covid-19. Responden dilibatkan dalam pengambilan diagnosis, dengan cara melihat seberapa pengetahuan dari responden mengenai sikap dan praktik pencegahan dari Covid-19. 2.5 Apakah faktor perancu teridentifikasi? Penemuan skor pengetahuan sederhana mengenai Covid-19 didapat sejumlah 19 peserta, ini merupakah jumlah yang lebih rendah daripada pengetahuan sebelumnya, meskipun mayoritas berpendidikan tinggi. Temuan skorini kemungkinan disebabkan karena warga Suriah belum pernah mengalami pandemi seperti H1N1 atau SARS. Selain itu ditemukan pula



3



4



penyebab warga Suriah kurang optimis dalam pengendalian penyakit dibandingkan dengan nega lainnya. Alasannya karena kualitas sistem kesehatan yang kurang baik dipengaruhi oleh keadaan konflik perang selama sembilan tahun yang mengakibatkan kekurangan pekerja medis dan alat medis. 2.6 Apakah strategi untuk menangani faktor perancu dinyatakan? Penelitian ini memberikan tabel regresi linier berganda pada faktor yang berhubungan dengan pengetahuan, sikap, dan praktik Covid-19 yang buruk. Beberapa strategi yang efektif dalam pencegahan sikap warga Suriah terhadap penyebaran virus ini dilakukannya penutupan sekolah dan jam malam, menghindari tempat keramaian dan jabat tangan, menjaga kebersihan lebih baik daripada sebelum masa karantina, seperti mencuci tangan dengan sabun dan menggunakan desinfektan. 2.7 Apakah hasil diukur dengan cara yang valid dan dapat diandalkan? Penelitian ini mengunakan kuisioner yang berbasis web, pengumpulan data dilakukan selama lima hari, kuisioner diposting di sosial media berupa Facebook dan WhatsApp. Pengelompokkan responden didasarkan pada demografi kelompok usia dan tingkat pendidikan. 2.8 Apakah analisis statistik yang tepat digunakan? Analisis yang digunakan dalam jurnal ini adalah analisis regresi dimana variabel yang masuk dalam kategori adalah variabel pengetahuan, sikap, dan praktek. Penelitian ini memberikan wawasan tentang pengetahuan, sikap dan praktik warga Suriah terhadap Covid-19 selama karantina dalam konteks pasca konflik.



2.9 Trias Epidemiologi Penyakit yang berbeda memerlukan keseimbangan dan interaksi yang berbeda antara ketiga faktor ini, penting untuk menilai sepenuhnya dari tiap kompinen untuk dikembangkan dari kontrol dan langkah-langkah dari pencegahan yang efektif. Dan tiga faktor yang mempengaruhi adanya penyakit atau orang sakit adalah:



5



2.9.1



Host (Manusia) Host mengacu pada manusia yang rentan terkena penyakit. Memang host utama dari virus Corona ini awalnya disinyalir dari hewan oleh para ahli, tetapi sejak 2019 kemarin di Wuhan tejadi penularan ke manusia yang menyebabkan pandemi di seluruh dunia. Covid-19 akhirya menjadi penyakit yang penularannya dari manusia ke manusia. Berbagai faktor instrinsik pada inang, terkadang disebut dengan faktor risiko, dapat mempengaruhi paparan, kerentananm atau respon individu terhadap agen penyebab. Peluang terjadinya paparan dipengaruhi oelh kontak antar manusia. Sedangkan kerentanan dipengaruhi oleh faktor-faktor sepeti komposisi genetik, status gizi dan imunologi, struktur anatomi, adanya penyakit atau obat-obatan, dan susunan psikologis.



2.9.2



Agent (Virus) Awalnya agen ini disebut dengan mikroorganisme atau patogen infeksi dari :virus . bakteri, dan parasit, atau mikroba yang lain. Virus Covid-19 memiliki agen utama yang disebut dengan SARS-CoV-2. Virus ini tidak tahan untuk hodup diluar tubuh manusia terutama saat terkena oanas matahari, dan mati pada panas diatas 65 derajat celcius. Virus ini termasuk memiliki virulensi yang ganas dan sangat kuat. Masa inkubasi yang dimiliki virus ini antara 2 hingga 14 hari . Artinya rentang waktu tersebit jika masuk ke dalam tubuh maka akan muncul gejala penyakit Covid-19.



2.9.3



Environment (Lingkungan) Lingkungan mengacu



pada



faktor



ekstrinsik



yang



mempengaruhi agen dan peluang untuk terpapar, Faktor lingkungan meliputi faktor fisik yaitu geologi, iklim, faktor biologis seperti serangga yang menstranmisikan agen, faktor sosial ekonomi seperti crowding, sanitasi, dan ketersdiaan layanan kesehatan. Lingkungan fisik seperti area kimuh akan mempercepat penularan virus karena banyaknya



kontak



antar



kesehatan(laboratorium)



manusia. menjadi



Jumlah faktor



fasilitas yang



dan



alat



berpengaruh.



Lingkungan sosial dan budaya adalah cara yang menyebabkan



6



perkumpulan orang banyak. Penyakit Covid-19 akan muncul ketika ketiga dari faktor tersebut terpenuhi. Jika salah satu tidak ada, maka tidak akan muncul. 1) Host diseimbangkan Pencegahan utama dari penyakit ini adalah peran dari host yaitu manusia, host harus selalu menjaga kebersihan diri dan lingkungan agar terhindar dari virus. Perilaku masyarakat harus mampu menyeimbangkan host untuk memutus rantau penularan Covid-19 yaitu dengan cara physical distancing (menjaa jarak) , menggunakan masker, cuci tangan pakai sabun, tidak menyentuh area wajah sembarangan, memisahkan antara peralatan makan, serta menjaga daya tahan tubuh (imunitas). Jika host dapat menyeimbangkan kondisinya, maka viruus Covid-19 tidak akan muncul. Salah satu strategi untuk menyeimbangkan host adalah memantau status demam warga setiap hari,memberi arahan untuk beristorahat dirumah, membantu untuk proses siagnostik dini, membantu proses rujukkan dan memantau suhu Orang Tanpa Gejala (OTG) yang berasal dari daerahtertular. Proses pemantauan dapat memanfaatkan internet atau menggunakan simbol status kesehatan. 2) Agent diseimbangkan Menyeimbangkan agent yaitu virus Covid-19 termasuk hal yang sulit karena belum ditemukan vaksin dan obat yang mampu membunuh virus ini. Karakteristik dari virus tidak tahan terhadap suhu tinggi serta tidak mampu bertahan diluar tubuh manusiam cara efektif adalah menjaga lingkungan untuk tetap bersih. Terutama benda dan tempat yang paling sering disentuh oleh manusia untuk selalu dihaga kebersihannya. Karena sebagian orang yang terpapr Covid-19 tidak menunjukkan gejala sehingga tidak tahu keberadaan virus. 3) Environment diseimbangkan Lingkungan yang mendukung untuk pencegahan penularan virus Covid-19 adalah lingkungan yang bersih dan tidak ada kerumunan orang banyak. Perlu adanya kebijakan yang bersifat represif dan memaksa



7



masyarakat agar patuh dan aktif menjaga kondisi lingkungan mereka untuk tetap aman seperti tidak berkerumun untuk membersihkan dari virus Covid-19. Strategi yang bisa dilakukan untuk mengatasi kkekurangan kebutuhan fasilitas kesehatan, adalah mengurangi dampak sosial dan ekonomi yang terjadi, berdasarkan sumber daya yang sudah ada. Strategi yang dapat dilakukan selanjutnya adalah penyediaan tiga jenis fasilitas kesehatan dengan kebutuhan yang berbeeda yaitu pusat karantina untuk merawat ODP dan PDP. Perdayakan fasilitas layanan primer seperti puskesmas setempat dan tempat umum di daerah. Lalu pembangunan RS khusus Covid-19 dengan gejala ringan dan sedang. Terakhir RS rujukan untuk kasus gejala serius dan berat, Pusat karantina dapat memanfaatkan gedung yang ada di daerah untuk dialih fungsikan. Keseimbangan dari ketiga faktor ini (trias epidemiologi) akan efektif untuk memutus penyebaran dan penularan dari oenyakit virus Covid-19.



BAB 3 PENUTUP 3.1



Kesimpulan Penggunaan artikel ilmiah sebagai sumber referensi perlu ditingkatkan dengan mempertimbangkan berbagai aspek. Diantaranya adalah kualitas dari sebuah artikel yang dipublikasi. Kesesuaian isi yang selaras dengan metode yang digunakan merupakan salah satu hal yang perlu diperhatikan. Dalam pemilihan sebuah artikel yang dijadikan referensi, harus memperhatikan kriteria dalam penetapan sampel, subjek penelitian, pengukuran harus secara jelas serta valid, kriteria standar yang objektif, berbagai variabel perancu, dan analisis statistic yang tepat. Selain itu, dalam penelitian epidemiologi harus menerapkan trias epidemiologi yaitu Host, Agen, dan Environment. Penggunaan trias Epidemiologi sebagai pendekatan penelitian merupakan standar yang digunakan dalam penelitian epidemiologi.



3.2



Saran Dalam Sebuah penelitian maka sehendaknya penggunaan refrensi yang memiliki kredibilitas yang tinggi harus diupayakan. Dalam memilih artikel yang memiliki kredibilitas yang tinggi maka diperlukan pula sebuah metode atau sebuah tools dengan berbagai indikator dalam menunjang proses telaah kritis sebuah artikel yang mudah serta memberikan hasil yang lebih akurat.



8



9



DAFTAR PUSTAKA Kanu, S. et al. (2021) ‘Healthcare workers’ knowledge, attitude, practice and perceived health facility preparedness regarding covid-19 in sierra leone’, Journal of Multidisciplinary Healthcare, 14, pp. 67–80. doi: 10.2147/JMDH.S287156. KPCPEN



(2021)



‘Peta



Sebaran



COVID-19’.



Available



at:



https://covid19.go.id/peta-sebaran-covid19. Taye, G. M. et al. (2020) ‘COVID-19 knowledge, attitudes, and prevention practices among people with hypertension and diabetes mellitus attending public health facilities in Ambo, Ethiopia’, Infection and Drug Resistance, 13, pp. 4203–4214. doi: 10.2147/IDR.S283999. WHO (2021) Coronavirus Disease (COVID-19) Pandemic. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. WHO Indonesia (2021) Pertanyaan dan Jawaban terkait Coronavirus. Available at: public.



https://www.who.int/indonesia/news/novel-coronavirus/qa/qa-for-



10



Lampiran ahdab BMC Public Health (2021) 21:296 https://doi.org/10.1186/s12889-021-10353-3



RESEARCH ARTICLEOpen Access



A cross-sectional survey of knowledge, attitude and practice (KAP) towards COVID- 19 pandemic among the Syrian residents Sanaa Al ahdab1,2 Abstract Background: Effective COVID-19 pandemic management requires adequate understanding of factors that influence behavioral changes. This study aims to assess knowledge, attitudes and practices towards COVID-19 among Syrians in a post-conflict context. Method: A cross sectional web-based survey was conducted on the Syrian residents of 16 years and above. It contains questions on knowledge, attitudes and practices (KAP) with respect to COVID-19. Participants’ demographic characteristics are recorded and analyzed. The study is conducted during the global outbreak of COVID-19. Results: A total of 706 participants (female, 444; male, 262) were enrolled. This study included 405 participants aged between 16 and 29, 204 aged between 30 and 49, and 97 aged above 60 years. There were 642 who have a university degree and 61 who have high school degree. Among the participants 253 were students, 316 were employed, 75 work as freelancers, and 62 were unemployed. Results showed that overall knowledge score towards the disease was about 60% (mean score 3.54 ± 1.20; range 0–6). Knowledge scores significantly differed across age groups (P < 0.05), education levels (P = 0.001), and occupations (P < 0.05). Attitude and practice scores were 2.45 ± 0.81 (range 0–4), 5.90 ± 1.52 (range 0–8), respectively. Attitude scores were significantly different between males and females (P < 0.05), whereas practice scores varied significantly across gender (P < 0.05), age groups (P = 0.01), education levels (P = 0.015), occupations (P < 0.05), and according to knowledge score (P = 0.000). Results from multiple linear regression indicated that lower knowledge scores were significantly associated with lower education level (P < 0.05), whereas poor preventive practices were common among male, young and unemployed participants with significance levels of P < 0.01, P = .000, P < 0.01, respectively. Conclusion: The findings of this study suggest that the Syrian residents demonstrate modest knowledge, attitudes and practices towards COVID-19 at the time of its global outbreak. Efforts should be directed towards raising the awareness of the disease to improve their practices in the current COVID-19 pandemic, as well as for future epidemics. Keywords: COVID-19, Knowledge, Attitude and practice, Syria, Pandemic Correspondence: [email protected]; [email protected] 1 Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Rasheed International University for Science and Technology, Ghabagheb, Daraa’, Syrian Arab Republic 2 Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Baath University, Homs, Syrian Arab Republic © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.



ahdab BMC Public Health



(2021) 21:296



Background Since the discovery of the novel coronavirus disease 2019 (abbreviated as COVID-19) in China in December 2019, the disease has spread quickly across the globe. Despite its strong foothold in the region, particularly in Lebanon, Jordan, and Iran, the spread of COVID-19 in Syria was late. The first COVID-19 laboratory-confirmed case was reported on 22 March [1], with the first fatality reported a week later [2]. The disease has spread quickly, and by July 03, 2020, there were 328 laboratoryconfirmed cases and 10 deaths as reported by the Syrian Ministry of Health. There were some concerns on the accurateness of these figures, partially due to limited testing capacity of COVID-19 owing to limited resources and sanctions imposed on Syria [3]. Syrian health authorities used purchased and gift kits to conduct approximately one hundred tests daily in Damascus [4] that reached around 2.700 tests as of May 8 [5]. Moreover, many cases were probably not reported because tests were available only to people who showed clear symptoms or had contact with confirmed cases or deaths. COVID-19 is expected to be of a great challenge to the Syrian war-torn health system because of its fragile health system aggravated by the lack of sufficient equipment [6] and the loss of around 70% health workers [7]. In 2018, the Syrian government spent less than 1% of its total expenditure on health [8]. In 2019, the number of beds was disproportionally distributed between cities and among private and government hospitals with an average number of population of 699 per bed [8]. The total number of intensive care unit (ICU) beds was approximately 650 in hospitals all over Syria (excluding the city of Idlib) [8]. Although private hospitals provide relatively better healthcare services compared to public hospitals, they suffered from similar shortages and problems as government hospitals did. To stem the spread of the disease, the Syrian government has imposed similar measures to those adopted by other countries. On March 24, a curfew was declared from 6 pm to 6 am, in addition to the closure of shops, markets, parks, and public transport. Classes at schools and universities were curtailed, travel between cities was banned, and all incoming and outgoing flights were also suspended. In addition, lockdown was imposed on areas where confirmed or suspected infections or deaths were reported. On May 26, the government decided to gradually loosen curfew restrictions in order to bring people back to work and salvage the economy. Prior evidence on good knowledge, attitudes and practices (KAP) among the public are essential for successful control and outbreak prevention of pandemics; such as severe acute respiratory syndrome (SARS) in 2003 [9–13], H5N1 epi- demic [14], Swine Flu [15, 16], H1N1 [17, 18], and COVID-



Page 2 of 7



19 [19–21]. To the best of our knowledge, there is no published study among the Syrian residents about KAP towards pandemics. This paper aims at investigating the KAP of the Syrian residents towards COVID-19 pandemic in a post- conflict context. While the Syrian health authorities aspire to curtail the spread of the pandemic with their control mea- sures, their effectiveness will depend on the individual and societal awareness and practices. It is interesting to find out how similar measures can be perceived differently in differ- ent contexts; particularly in the Syrian special case where the underdeveloped health system associates the conflict.



Materials and methods Design and settings



To measure the KAP towards COVID-19 of the Syrian residents, a web-based questionnaire was developed for this study and used for data collection from 5 April to 9 April, during the second week after the lockdown of the Syrian territories. The questionnaire was posted on social media platforms (Facebook and WhatsApp). Privacy of the original post was set as “public” to enable more people to participate in the questionnaire. Participants



Persons who were aged 16 years or more, agreed to participate in the study. Although the target participants were local Syrian citizens, Syrians who reside outside Syria were also eligible for this survey. However, the latter’s answers were excluded because this study focused only on people who reside in Syria. Questionnaire



The questionnaire was based on a similar questionnaire on COVID-19 [19] and other questionnaires on H1N1 [16, 22], and Severe Acute Respiratory Syndrome, SARS [11] as well as concepts theories of health behaviors [23]. The questionnaire takes about 5 min to complete. The questionnaire language is Arabic. This questionnaire [see Additional file 1] collected basic demographic data on age, gender, education level, employment status, and residents above 60 or younger than 16 in the house. Questions on knowledge aimed to assess general knowledge on clinical presentations of COVID-19 and the se- verity of the disease (Q1-Q6). These questions were answered as on a yes/no basis with an additional “maybe” option. Questions on attitudes (A1-A4) were about the agreement with the measures adopted to prevent the spread of the pandemic COVID-19 and the confidence in winning the battle against COVID19. Questions on practices were used to assess the individuals’ compliance and behaviors during the quarantine (P1-P8). A summary of questions assessed is shown in Table 2.



Statistical analysis



Independent sample t-test, one-way analysis of variance (ANOVA) test of significance, and multiple linear regression were used to examine the relation between the demographic characteristics and variables. A Pearson correlation analysis was used to compare correlations between variables. All statistical analysis was performed using IBM SPSS 24 for Windows.



Results A total number of 825 participants completed the survey questionnaire. After excluding 119 respondents who live outside Syria, the final sample consisted of 706 participants [see Additional file 2]. Among the final sample, 444 (62.9%) were female, 405 (57.4%) aged between 16 and 29 years, 642 (90.9%) were either at higher education level or above, 316 (44.8%) were employed in private or public occupations and 516 (73.1%) had residents in their houses aged above 60 and/ or younger than 6 years. Demographic characteristics are shown in Table 1. This study shows that the Syrians’ Basic knowledge of COVID-19 is moderate. The correct answer rates of the 6 questions on the COVID-19 knowledge questions ranged between 22.7–85% (Table 2). The mean knowledge score was 3.54 (SD: 1.20, range: 0–6) suggesting an overall 59% (3.54/6*100) correct rate on this knowledge test. Knowledge scores significantly differed across age groups (P < 0.05), education levels (P = 0.001), and occupations (P < 0.05) (Table 1). Knowledge regarding COVID19 symptoms was the highest (85.1%), whereas perception of the severity of COVID-19 was the lowest (22.7%). Having a child under 16 or aged persons above



60 did not make a statistical difference in the COVID-19 knowledge. Furthermore, no statistical difference was found between genders with regard to knowledge scores (Table 1). For the attitudes, the majority of respondents believed that school closure and curfew were effective in controlling the spread of COVID-19; scores were 91.5 and 78.2%, respectively (Table 2). Only 15.4% of the respondents expected the pandemic to spread in Syria, whereas about 60% had confidence that COVID-19 will eventually be controlled. Attitude scores were significantly different between males and females (P < 0.05) (Table 3). In addition, the mean practice score was 5.90 (SD: 1.52, range from 0 to 8). The highest practice score was 75% (6/8*100) by participants aged over 50 years. Practice scores varied significantly across gender (P < 0.05), age groups (P = 0.01), education levels (P = 0.015), occupations (P < 0.05), and according to knowledge score (P = 0.000) (Table 4). More than 90% of participants avoided crowded places and practiced better hygiene after than before the quarantine, whereas only 27.9% of participants wore facemasks during the quarantine (Table 2). The results from multiple linear regression analysis of variables that score poor on KAP indicators show that the education level of elementary school (β: -1.70, P < 0.05) was significantly associated with lower knowledge score, whereas females had lower attitude score (vs. males, β: -0.14, P < 0.05). Furthermore, male gender (vs. female, β: -0.36, P < 0.01) aged between 16 and 29 years (β: -0.42, P = 0.000), and unemployed (β: -0.66, P < 0.01) were predictors of poor practice score (Table 5).



Table 1 Demographic characteristics of participants and the score of COVID-19 knowledge by demographic variables Characteristics



Number of participants (%)



Knowledge score (mean ± standard deviation)



P value > 0.05



Gender



Male



262 (37.1)



3.46 ± 1.25



Female



444 (62.9)



3.59 ± 1.17



Age-group (years)



16–29



405 (57.4)



3.43 ± 1.16



Education



Occupation



30–49



204 (28.9)



3.71 ± 1.29



50+



97 (13.7)



3.62 ± 1.15



Elementary School



3 (0.4)



2.00 ± 1.73



High school



61 (8.6)



3.08 ± 1.26



Degree



642 (90.9)



3.59 ± 1.18



Unemployed



62 (8.8)



3.54 ± 1.36



student



253 (35.8)



3.39 ± 1.10



75 (10.6)



3.76 ± 1.25



Employed



316 (44.8)



3.62 ± 1.23



No



190 (26.9)



3.52 ± 1.12



Yes



516 (73.1)



3.55 ± 1.23



706 (100)



3.54 ± 1.20



Free lancer Residents above 60 or younger than 16 in the house Knowledge of COVID-19 score



< 0.05



0.001



< 0.05



> 0.05



Table 2 Summary of Questions for Knowledge, Attitudes and Practices towards Pandemic COVID-19. Percentages represent the correct answers Questions Knowledge Q1.The main clinical symptoms of COVID-19 are fever, fatigue, dry cough, and myalgia (85.1%) Q2. Symptoms of COVID-19 are similar to the common symptoms of flu (55.2%) Q3. COVID-19 infection causes severe symptoms in all patients (22.7%) Q4. Persons with COVID-2019 can infect the virus to others when a fever is not present (56.2%) Q5. COVID-19 infection causes serious disease (44.6%) Q6. Although there is no proven cure for Corona disease, the available treatments lead to recovery (35.3%) Attitudes A1. Do you think school closure is an effective way of preventing the spread of the disease? (91.5%) A2. Do you think curfew is an effective way of preventing the spread of the disease? (78.2%) A3. Do you think that COVID-19 will spread widely in Syria? (15.4%) A4. Do you think that COVID-19 will be successfully controlled? (60.1%) Practices during quarantine Avoidance behavior P1. Avoid crowded places (92.5%) P2. Avoid travel by taxi (80%) P3. Avoid shaking hands (82%) Personal Habits Practice P4. Practice better hygiene than before (90.8%) P5. Use disinfectants (ethanol) (73.5%) P6. Wear facemasks (27.9%) P7. Wash hands more often (95.8%) P8. Have a balanced diet (47.9%)



There was positive and significant correlation between knowledge-practice, knowledge-attitudes, and attitudepractice. The correlation coefficients were (0.198, 0.204, and 0.210, respectively. P < 0.01) as shown in (Table 6).



Discussion This study is expected to be the first to examine the KAP towards COVID-19 among the Syrian residents. In this predominantly female and well-educated population, the overall correct rate of around 60% on the knowledge questions indicated that most respondents have modest knowledge about COVID-19. The majority of the participants believed that the school closure and curfew were effective in preventing the spread of COVID-19. However, 15.4% of participants believed that the virus would spread in Syria and only 60% had confidence that COVID-19 will eventually be



successfully controlled. Despite this, the practices of the Syrian residents were cautious: 92.5% avoided crowded places and shaking hands and 90.8% practiced better hygiene than before the quarantine, like washing hands and using disinfectants. Surprisingly, however, only 27.9% wore facemasks when leaving homes. This study also analyzed the characteristics of KAP towards COVID19 and identified some demographic factors as- sociated with KAP; these findings are useful for public health policy-makers and health workers to identify and target people for COVID-19 prevention and health edu- cation in case of future outbreaks. The finding of a modest knowledge score of COVID19 of participants, although the majority were welleducated, was unexpected. Their scores were lower than their counterparts in China [19] and in Iran [20] which showed an overall correct rate of 90% among the Chinese and Iranian populations, respectively. However, Syrians scored higher in terms of their COVID-19 knowledge compared to the population of northern Thailand in the early period of the outbreak [21]. In Thailand, 73.4% had poor knowledge towards COVID19 [21]. The finding of moderate knowledge score was probably because Syrian residents have not experienced previous pandemics such as H1N1 or SARS. In addition, this survey was conducted during the very early stages of COVID-19 in Syria when the country was not seriously affected by the outbreak, with the number of laboratory confirmed COVID-19 cases of only 19 (Ministry of Health), the lowest among other countries in the region. This underlines the importance of the Syrian health authorities providing consistent clear updates and information about the emerging virus as well as the need to continuously assess whether their messages are being understood within the community. Since the World Health Organization declaration of the COVID-19 outbreak to be pandemic on March 12, 2020 [24], countries around the world have implemented different measures to prevent further spread of the virus. Many countries have applied school closure as a response to COVID-19 according to UNESCO [25]. Other restrictions also included curfews and stay-at-home orders. Similarly, the Syrian government has also closed schools and enforced curfew while allowing some essential businesses to open. The vast majority of Syrians included in this survey believed that these measures were effective against COVID-19. Furthermore, compared to KAP studies in China and Iran, Syrians under study were less optimistic about the disease control than the Chinese [19] and Iranians [20]. The underlying reason could be related to the quality of the Syrian health care system that has seriously been af- fected by the nine-year war, and further deteriorated due to sanctions [26]. Moreover, efforts to aid the COVID-



Table 3 Attitudes towards COVID-19 by demographic variables Characteristics Gender Age-group (years)



Education



Attitude score (mean ± standard deviation) Male



2.54 ± 0.87



Female



2.40 ± 0.77



16–29



2.49 ± 0.77



30–49



2.40 ± 0.85



50+



2.40 ± 0.90



Elementary School



2.33 ± 0.57



High school Occupation



< 0.05 > 0.05



> 0.05



2.38 ± 0.93



Degree



2.46 ± 0.80



Unemployed



2.29 ± 0.87



Student



2.48 ± 0.76



Free lancer Residents above 60 or younger than 16 in the house



P value



> 0.05



2.55 ± 0.82



Employed



2.44 ± 0.84



No



2.49 ± 0.76



Yes



2.44 ± 0.84



Attitude score



> 0.05



2.45 ± 0.81



19 control were limited due to shortages of medical workers and medical materials [4]. Although attitudes towards COVID-19 were unassertive, Syrians took precautions to prevent infection by COVID-19: not going to crowded places and practiced better hygiene with an overall practice score of about 74%. This may be attributed to their doubts on the ability of the health care system to accommodate them if they are infected. However, this score was lower than other practice scores towards COVID-19 documented among Chinese [19] and Iranians [20]. Unfortunately, the present study showed that only approximately 30%



wore facemasks when going outside home. This could be primarily attributed to the unavailability of quality facemasks and the surge in their prices which increased by 6 to 10 folds particularly during the time of this survey. The potentially poor documented practices were associated with younger age males. This is in agreement with the findings of similar COVID-19 studies in China [19] and Iran [20]. The finding that women were more likely to practice non-pharmaceutical health behavior (e.g., hand washing) is also consistent with a previous study on SARS pandemic [27]. Furthermore, this study is in agreement with previous evidence that late adolescents



Table 4 The score of practices towards COVID-19 by demographic variables Practice score (mean ± standard deviation)



P value



Male



5.75 ± 1.64



< 0.05



Female



6 ± 1.44



16–29



5.76 ± 1.55



30–49



6.04 ± 1.49



50+



6.22 ± 1.42



Elementary School



5.33 ± 2.30



High school



5.38 ± 1.82



Degree



5.96 ± 1.48



Unemployed



5.47 ± 1.77



Student



5.81 ± 1.55



Free lancer



5.99 ± 1.61



Employed



6.04 ± 1.42



No



5.92 ± 1.42



Yes



5.90 ± 1.56



Characteristics Gender Age-group (years)



Education



Occupation



Residents above 60 or younger than 16 in the house Practice score



5.90 ± 1.52



0.01



0.015



< 0.05



> 0.05



Table 5 Results of multiple linear regression on factors associated with poor COVID-19 knowledge, attitude and practice P value



95.0% Confidence Lower Bound



Upper Bound



−1.65-



> 0.05



– 0.41-



0.04



0.70



−2.44-



< 0.05



−3.06-



−0.33-



0.12



−1.06-



> 0.05



– 0.36-



0.11



−0.14-



0.06



−2.25-



< 0.05



−0.27-



– 0.02-



Gender (male)



−0.36-



0.12



−2.97-



< 0.01



−0.59-



−0.12-



Age (16–29)



−0.42-



0.12



−3.59-



.000



−0.65-



−0.19-



−0.45-



0.88



−0.51-



> 0.05



−2.18-



1.29



−0.66-



0.21



−3.17-



< 0.01



−1.06-



−0.25-



Variable



Coefficient (β)



Standard error



t



– 0.19-



0.11



−1.70−0.13-



Interval for B



Knowledge Age (16–29) Education (Elementary School) Occupation (Students) Attitude Gender (female) Practices



Education (elementary school) Occupation (unemployed)



were also more likely to engage in risk taking behaviors [28]. It is unsurprising that unemployment was also associated with poor practices because of having less exposure to the COVID-19 virus. Therefore, the unemployed are expected to be less adherent to health safety measures of keeping social distancing and wearing facemasks. This study provides evidence on the positive and significant correlations between knowledge-attitudes, knowledgepractice, and attitudes- practices among the respondents (Pearson correlation coefficient approximately 0.2). This reaffirms that better knowledge and attitudes associate with bet- ter practices. Similar levels of association between these variables were documented in a previous study on H1N1 pandemic [29]. Therefore, health authorities should not only intensify their efforts to improve health services but also give equal importance to raising people awareness and knowledge towards COVID-19.



Conclusion In summary, this study provides insights into Syrians’ knowledge, attitudes and practices towards COVID-19 during the quarantine in a post-conflict context. This is expected to help Syrian health authorities formulate suitable measures to counter the spread of COVID-19 and develop best practices for future epidemics. Yet, the successfulness and impact of current measures on controlling COVID-19 are still unclear and debatable. Table 6 correlations between scores of knowledge, attitudes and practices towards COVID-19 Variable(s)



Knowledge



Attitudes



Practices



Knowledge



1



–



–



This study has some limitations. First, the use of an internet-based survey may overlook people who do not have internet access or Facebook/WhatsApp accounts. Second, the sample may be over-representative by respondents with higher education levels compared to others with lower education levels. This may inflate the overall results, as these groups are probably more knowledgeable and have better practices towards pandemics in general. Third, this study does not distinguish between different income groups while investigating KAP. Nevertheless, par- ticipants’ income could have important impact on their at- titudes and practices towards the pandemic. Fourth, this study does not examine the impact of knowledge on both attitude and practices. All these limitations represent venues for further new research. Future research could also focus on how different sources of information affect respondents’ knowledge. That is, future research can try to find the best source that delivers reliable information to avoid panic or false sense of security among the general public. In addition, it may be worth investigating how infected people react to re-infection news and if they would change their attitudes and practices in response to this news. The results of this study may not be generalizable to other countries or cities that have experienced previous severe epi- demics such as SARS. This study presents a unique reference for pandemic cautious behavioral response to COVID-19 in a post-conflict context. Nevertheless, it was challenging to finish data collection within a short period (5 days) before lockdown measures were eased off.



Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12889-021-10353-3.



Attitudes Practices a



a



0.204



a



0.198



1



– a



0.210



Correlation is significant at the 0.01 level (2-tailed)



1



Additional file 1. Questionnaire-English version. This table represents an English version of the questionnaire



Additional file 2. Resopnse.variables.scores. Description of data: Data related to demographic characteristics, responses to KAP questions, and KAP scores. Responses are represented as 0 or 1. KAP scores represent the sum up of responses to each group questions.



9. 10. 11.



Abbreviation COVID-19: Coronavirus disease 2019 12. Acknowledgments I would like to acknowledge Dr. Sulaiman Mouselli for his invaluable assistance in conducting the statistical analysis. Author’s contributions This paper is a sole contribution of AAS. The author(s) read and approved the final manuscript. Funding No funding was required. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request.



13.



14. 15. 16. 17.



Ethics approval and consent to participate The present study was approved by the ethics committee at the Faculty of Pharmacy and the Faculty of Pharmacy council at Al-Rasheed International University for Science and Technology. The purpose of this research was ex- plained to all participants and were assured of confidentiality by the re- searcher. The survey also included an informed consent form, which allowed participants to tick to confirm their consent. Completion of this form followed by completion of the survey showed that participant consented to the study. Participation in the study questionnaire was optional. A statement in the introductory section of the questionnaire clearly indicated the volun- tary nature of participation, and declared the anonymity, confidentiality and the fact that the study results would be used for research purposes only. Consent for publication Not applicable. Competing interests I know of no conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome. Received: 12 May 2020 Accepted: 28 January 2021



18. 19.



20.



21.



22. 23. 24.



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