A Crisis within a Crisis: An Assessment of COVID-19 Attitude and Practice among Syrians - A Cross-sectional Study

Introduction: COVID-19 has overwhelmed public healthcare systems worldwide, exacted substantial economic burden, and forced governments to impose partial or complete lockdowns of entire countries with stringent infection control measures to curb the spread of the virus. This study aimed to reect the Syrian public’s adherence to infection control measures by assessing their attitude and practice during this outbreak embedded within the war in Syria. Methods: This web-based cross-sectional study was distributed randomly in March 2020, nearly 11 years into the Syrian war crisis. The survey consists of 3 sections: socio-demographic characteristics, attitude, and practice. Multivariable logistic regression analysis was performed to identify factors associated with good practice, and negative attitude. Data were analyzed using the Statistical Package for Social Sciences version 25.0. Results: Of the 3586 participants, 68.2% were females, 50.8% were unemployed, and 79.2% were college-educated. Only 1402(39.1%) participants were wearing face masks when leaving their homes. Multiple logistic regression analysis revealed that female gender, age, and residence were factors associated with good practice towards avoiding mass gatherings, wearing face masks, and maintaining a 1-meter interpersonal distance; however, age and occupation were factors associated with a negative attitude towards the closure of universities and schools, travel ban, and quarantine for travelers. Conclusion: This survey sheds light on the need for multiple measures to address targeted populations; there must be a specialized method of prevention for each occupation, age group, and place of residence to prevent the outbreak of COVID-19.

contacting the parents/guardians to obtain consent before the child was given access to complete the survey. The second part of the survey contained 16 questions divided into 2 sections: attitude (8 questions) and practice (8 questions). Ethical approval was obtained from the Institutional Review Board (IRB) of the Faculty of Medicine, Syrian Private University. The survey is available in appendix 1.

Statistical analysis:
Frequencies and percentages (for categorical variables) or means and standard deviations (SD) (for continuous variables) were reported. The t-test was applied to compare attitude and practice questions against both genders. The chi-square test was applied to compare attitude and practice questions against socio-demographic variables (age, social status, residence, education level, occupation, economic status, and household members). Binary logistic regression analysis using the socio-demographic variables as independent variables was conducted against attitude (disagree with the travel ban and disagree with quarantine for travelers) and practice (avoiding crowded places and wearing face masks) questions as the outcome variable to identify factors associated with negative attitude, and good practice. Data analysis was conducted with Statistical Package for Social Sciences version 25.0 (SPSS Inc., Chicago, IL, United States). Statistical signi cance was considered at p-values < 0.05.

Practices towards COVID-19 by demographic values:
The practice towards avoiding crowded places and mass gatherings signi cantly differed across gender, age, social status, residence, education, occupation, and economic status (p<0.001). The practice of wearing a face mask when leaving the house signi cantly differed across gender (p<0.001), age group (p=0.004), area (p=0.007), occupation (p<0.001), and the number of household members (p=0.008) ( Table 4).

Discussion
In the absence of an effective treatment or availability of vaccines against COVID-19 in Syria, the public's attitude and practice regarding preventive measures towards COVID-19 infection control are crucial to mitigating the spread of this virus. Therefore, it is important to assess the practice and attitude of the Syrian population, to provide baseline data for public health policymakers and health professionals to target speci c populations, plan effective measures and awareness campaigns.
The majority of Syrian participants showed cautious practice towards the COVID-19 pandemic; (81.3%) avoided crowded places and public gatherings, (71.4%) washed hands for at least 30 seconds, and (76.8%) abstained from shaking hands and kissing. These ndings observed in our study were lower compared with other studies conducted in India, China, and Malaysia,(10, 12, 13) but were higher than a study conducted in Sudan. (14) WHO and the centers for diseases control and prevention (CDC), recommended a set of public health interventions, physical distancing, staying at least two meters from people, avoiding mass gatherings in groups, and other protective measures to break the transmission cycle of COVID-19. (15,16) Syrians knowledge regarding preventive measures have been shown to be high including avoiding crowded places (99.7%), and washing hands (99.7%), which shows a lack of adherence by our participants towards infection control. (9) The present study showed low adherence to wearing face masks similar to a study conducted in Sudan and Egypt. (14,17) In other studies conducted in China, Malaysia, Ecuador, and KSA, the number of people who wore face masks was much higher. (10,13,18,19) In this novel pandemic where the economic status in Syria has deteriorated, signi cant price increases in personal sterilization items (face masks, hand sanitizers -up to 5,000% increase) have been reported across Syria. (20) The drastic increase in price and demand for masks due to shortage of supplies not just in Syria, but even worldwide can be the reason behind participants not wearing face masks. (21) Data revealed that female participants were associated with good practice compared with male participants. A study conducted in China found an association with male gender and hazardous practice. This could be attributed to the fact that males are burdened with the responsibilities towards providing for their families, making them forced to nd means of work to secure their livelihoods, which keeps them away from social media, awareness announcements on television and radio. Therefore, the government should target this group for education on preventive control measures to cut the spread of COVID-19.
On 12 March 2020, the Syrian government implemented precautionary measures to prevent the spread of the virus, concurrent with the declaration provided by WHO regarding the COVID-19 outbreak evolving into a worldwide pandemic. (22,23) The vast majority (92%) of participants considered the COVID-19 pandemic to be a serious public health issue, much higher than in a Thailand study. Similarly, two other studies in China showed that the majority of people thought that the COVID-19 outbreak was very severe. The reason behind this attitude can be attributed to the high number of cases and mortality worldwide with the absence of treatment or vaccine at the time of the survey. (2) Shockingly only 65.5% of participants agreed that infected individuals have the right to marry where the rest did not know and disagreed. This kind of stigma re ects negative beliefs and attitudes towards patients with COVID-19. 20.6% of the participants agreed that lack of faith/religion is the cause of this pandemic. A study conducted in Poland revealed that 64% of catholic women believed that faith will protect them from the COVID-19 and 67.6% declared that faith/spirituality was important for facing the COVID-19 pandemic. Approximately 90% of the population are Muslim, which can be the reason behind the stigma of negative views. (24) Multiple logistic regression analysis showed that females; age group of ≥45 years; residence in Hama, Aleppo, Homs, Tartous, Lattakia, and Dar'a; were signi cantly associated with avoiding crowded places, wearing face masks, and maintaining a 1-meter interpersonal distance. The ndings regarding the age group ≥45 years, can be attributed to the participants being more cautious as COVID-19 infection can be severe and lead to death in elderly, chronically ill, and immunode cient patients. 40.6% and 11,9% of Syrians are hypertensive and diabetic, respectively. (25,26) This high prevalence of chronic diseases is alarming and underscores the need for targeted awareness campaigns towards younger generations through encouraging the use of face masks and avoiding meeting with older people to protect them from infection.
Multiple logistic regression analysis showed that the age group of 16-30 and occupation of government, private, business, military, unemployed, and other sectors were signi cantly associated with negative attitudes with regards to the travel ban and quarantining travelers. This age group lies in the productive population where a large fraction of the economy depends on this group, commuting to work and universities require transport to be open freely, and quarantine can have negative effects on people who rely on their daily work to earn a living. (20) Syrians that depend on daily work, such as taxi drivers and small store owners, cannot afford to quarantine, especially after the huge rise in food prices because of war and COVID-19 related factors like panic buying, and reduced store hours. (20) Non-healthcare occupations have not received the same education compared with HCW, educating the community about the impact of traveling and not quarantining travelers on the spread of COVID-19 infection is crucial. As this country has no capacity to withstand a pandemic, targeting these groups with awareness campaigns is cost-effective in the long run.
Limitations Some limitations are found in this study, young, well-educated female participants were overrepresented in this study. Therefore, the results can only be generalized concerning these groups. The elderly and rural residents, who are vulnerable to COVID-19 making them at increased risk of getting the infection, are more likely to exhibit bad practices due to limited internet access. The study included participants from all Syrian governorates, but participants who live in Damascus/Rural Damascus were over-represented in our sample.

Conclusion
The world is facing a pandemic that threatens public health and humanity's existence. Our study revealed a lack of adherence to certain practices especially with regards to wearing face masks. Face masks should not be worn by choice, enforcing the mandatory wearing of face masks in public should be a fundamental law, and failure to do so is liable to pay a ne. Awareness should not only be restricted to social media platforms but also the Ministry of Public Health should come forth with new strategies to target groups associated with bad practices and negative attitudes.

Declarations
Ethics approval and consent to participate: This study was approved by the Institutional Review Board (IRB) at the Syrian Private University (SPU); however, we were not given a reference number. Informed consent was obtained from all participants. Participants under the age of 18 required verbal informed parental consent, as well as submission of parent/guardian contact information. The researchers were responsible for contacting the parents/guardians to obtain verbal consent before the child was given access to the survey. The verbal and written form of consent was approved by the IRB at SPU. Participation in the study was voluntary and participants were assured that anyone who was not inclined to participate or decided to withdraw after giving consent would not be victimized. All information collected from this study was kept strictly con dential. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for Publication:
Not applicable.

Availability of data and materials:
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests.

Funding:
This research received no speci c grant from SPU or any other funding agency in the public, commercial or non-pro t sectors.  (22) 1 Poor: income does not provide essential needs for the family. 2 Moderate: income provides essential needs for the family but no more. 3 Good: income provides essential needs and some luxury requirements. 4 Excellent: income provides luxury requirements.