Respondents participating in our study answered correctly at an overall average of 67.1% to the questions regarding knowledge of SARS-Cov-2 and COVID-19. However, we found significant deviation from the average depending on the questions asked. Questions about mode of transmission, symptoms, population groups at higher risk and the difference between COVID-19 and the flu were around average (61.5, 54.7, 62.7 and 77.5%, respectively). Questions about the incubation period and the date of the first cases were answered correctly significantly below the overall average (15.4% and 34.2%, respectively). While questions regarding the cause of COVID-19, the target body system and its recovery rate were answered correctly at a much higher rate (96, 97.4 and 94.4%, respectively). It might be worth noting that at the time of the collection of data for this study, the predominant opinion about the body system affected in COVID-19 was the respiratory since very scarce information was out implicating other body organs or systems such as blood coagulation [16] and the digestive system [17]. Hence, the appropriate knowledge regarding the afflicted organ was marked based on the widely accepted target system at that time. Even if we excluded the answers to the incubation period, our overall average for the knowledge questions will still be at 73% which could be considered as good especially when we compare our averages with similar studies done elsewhere. For example, the overall correct rate of the knowledge questions in China is 90% [18]; in Malaysia the average was 80.5% [19] and in Saudi Arabia it was 81.64% [20]. Our knowledge averages were lower than the aforementioned studied although in our case the data collection was done at a much later time, a time at which global public awareness towards COVID-19 was on the rise. On the other hand, a similar study in Bangladesh found that the correct knowledge average was 54·87% which was less than our findings [21] while another study conducted in Egypt obtained almost the same correct knowledge percentage (71.2%) [22].
Our participants had positive overall attitude towards COVID-19; particularly, the isolation of the COVID-19 cases, optimism about finding a treatment and developing a vaccine (97.1, 90.3, and 88.2%, respectively). This is similar to the attitude of participants in relevant studies [18.19]. However, our sample showed concern about catching the disease (83.3%) and did not seem to have trust in the measures taken by the Lebanese government to manage the COVID-19 epidemic (only 52.7% showed positive attitude towards this question). This latter finding was in sharp contrast with other results where the trust in the country/government of China and Malaysia were 97.1 and 89.9%, respectively [18,19].
Our sample participants did not exhibit in high percentages good practices. Only 76.6% washed their hands frequently with soap and water which is less than what others have found in similar studies [19]. Regarding the use of personal protective equipment (PPE), such as gloves, masks or face shields, we found that only 39.2% of our sample always used them. This is a low percentage when compared to the 98.0% of people always wearing facemasks when going out in the Chinese study [18]; 95.45% in Bangladesh [21] and even the 51.2% that was found by Azlan et al. 2020 [19]. Such a low percentage in our study could be attributed to the lack of clear public policy by the Lebanese government which did not impose PPE’s at the time our data was collected (the government implemented the lock down and prevention campaign at the time where this survey was conducted but the control of the implementation of this strategy was not strict). Similar to what others have found regarding social distancing [19], our sample did observe acceptable social distancing with 74.3% avoiding crowded places and only 15.1% stating that they always went out in spite of the epidemic. At the same time, we found that around half of our sampled participants did disinfect personal items after being out such as their clothes, shoes, and money; while we found 66.4% to disinfect packaged food items they would bring home.
The levels of knowledge and practices we found were significantly higher in people who were ever married, older, with higher education levels, worked in the healthcare sector or related areas and with how much they worry about getting COVID-19. People living in urban areas had significantly better knowledge than those in rural areas without showing a significant difference in practices. Also, gender was not found as a significant factor for knowledge in our studies sample; however, practices were found to be significantly better in males. In most of the studies conducted in this subject, males typically showed less knowledge, and attitudes as well as exhibited less cautionary practices compared to females [18, 20, 21, 23]. Although one of these studies was done in a culturally similar environment to the one we have here, we cannot be certain to why we would find that males and females showed insignificantly different knowledge levels with males having better practices. Although this finding needs further investigation, we think that the fact that during the time of data collection, most of the males in this survey may have been obliged to go out to work since many families in Lebanon rely mainly of males for income in the absence of any financial assistance from the government. If accurate, this would explain why in this study men were found to have good knowledge compared to females and significantly better practices.
Our findings indicate that the educational background and occupation (the different healthcare fields) correlated positively with knowledge and practices. This finding is not surprising since higher educational degrees (in medical areas) and healthcare professions are associated with good KAP in most epidemic diseases including COVID-19 [18, 23, 24, 25 & 26]. Although the number of healthcare workers surveyed in this study was not very significant, this was to our knowledge the first study to include healthcare workers and none healthcare workers in the same questionnaires being asked the same questions and the data analysed with the same parameters. In spite of the aforementioned shortcoming in numbers, we here cautiously say that healthcare workers exhibited better KAP regarding COVID-19.
One final parameter we looked at regarding knowledge and practices towards COVID-19 was the attitude parameter of how worried our participants were about getting infected. Indeed, we found that being worried about the possibility of being infected with the COVID-19 causing virus does significantly associate with higher knowledge and better practices as has been found elsewhere [27]. On the other hand, it was found that people with health complications and serious concern about getting COVID-19 did not have better knowledge and attitude [28].
Limitations of the Study
This study had few limitation, the main ones being the selection bias related to the surveying method which excluded all uneducated, illiterate, and less technologically savvy individuals. As such, our study included the population sample composed of individuals who were mostly young adults, educated and literate. At the same time, since most participants had a good level of education (95.4% had at least high school degrees or above) and had a second language (English, as a second language) our results may have been skewed towards these two factors. This is unfortunate since the uneducated and elderly might be more susceptible to this disease and therefore should be investigated using a different method.
Policy implications
Based on the preceding, we suggest further studies into the mechanisms of transmission and dissemination of information to the Lebanese population to try to assess the points of weakness that need to be improved in order to enhance the knowledge of the general populace towards COVID-19 or pandemic level diseases. This should include a detailed analysis of the different media tools and their access by the different socio-demographic tiers of the population.
We would also recommend that governments work towards gaining more trust among the population by putting in place a transparent and a more reassuring public health plan to ensure public safety. It will be interesting to study the comparative KAP of populations in different governments with different economic capabilities to see if having a stronger economy would affect the attitude and eventually the practices of the population in pandemics. Since the world has seen two different examples of how governments supported their people through financial assistance or the lack of it – as happened in Lebanon where the government proposed but barely distributed a very small financial assistance, coupled with unemployment reaching 11.4% many were forced to work in conditions even if they didn’t observe the recommended social distancing [29]- it would, therefore, be recommended for organizations such as WHO to direct more effort towards countries with suffering economies.
Finally, it is our opinion that practices should have been better in Lebanon had the governing bodies in this country been more adamant about enforcing the implementation of rules such as the mandatory wearing of PPE’s and social distancing in public places. We did personally know about cases of social gatherings (weddings, funerals and others) taking place without having any intervention by any of the law enforcement agencies in Lebanon.