SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
Of the 691 responders that were retained after data curing, 514 (74.4%) filled the questionnaire in Arabic and 177 (25.6%) in English. Age was subcategorized into intervals of 20 years with 399 (57.7%) of the respondents between the ages of 21–40. A detailed overview of the socio-demographic data is reported in the appendix (supplementary table 1). The results showed that females comprised 68.7%, the majority 63.8% reside in Mount Lebanon, 35.2% have a bachelor’s degree and 47.2% are students. The household income assessment showed that 261 (37.8%) live in households with a monthly income of less than 200 US Dollars equivalence, and another 157 (22.7%) live with 200–400 US Dollars equivalence.
Most of the participants [430 (62.2%)] live in the rural areas of Lebanon. The mean crowding index was 1.01 (SD = 0.456). When stratified by crowding categories, 20.0% were found to live in households with crowding, of which 34.9% live in severely crowded households. The number of participants who had any children under the age of 5 living in the household was 134 (19.39%).
DESCRIPTION OF THE KAP SCORES
KNOWLEDGE
Respondents were asked questions to evaluate their level of knowledge of cholera and prevention. The majority of participants correctly identified the causative organism of cholera (64.9%), the characteristic symptoms of severe diarrhea (97.4%) and vomiting (53.0%), and the fact that children under the age of 5 are at an increased risk of complications (65.9%). Most of the respondents also correctly identified the transmission of the disease by unclean water (97.5%), undercooked food (66.9%), and fecal contaminants (70.8%), as well as the effective methods of preventing transmission and the treatment options at home. Vaccination was the least-chosen effective method of prevention (56.6%), whereas chlorination/boiling of water (91.3%), thorough cooking and washing of vegetables (91.0%), and appropriate hand washing before and after defecation (86.8%) were selected by a majority of respondents.
The mortality of untreated cholera was underestimated on average and only 32.0% of respondents answered correctly that untreated cholera has a mortality of more than 50%. 42.8% of participants correctly answered that mortality is reduced to < 1% when appropriate treatment is administered. A detailed distribution to the knowledge questions is provided in the appendix (supplementary table 2).
The mean knowledge score was calculated and found to be 18.27 ± 0.18 (SD = 3.23) with a minimum of 5 and a maximum of 24. When compared to a median of 19, a total of 52.41% of participants have a high knowledge score (Table 1).
ATTITUDES
The section included questions about personal attitudes toward the severity and outlook of the cholera situation in Lebanon, as well as attitudes towards known effective strategies of preventing the spread and contracting of cholera. Most respondents had a positive attitude towards effective measures and strategies, such as proper hand washing (93.2%), treating water with chlorine (91.9%), not sharing cups while drinking (80.4%), avoiding undercooked food (85.2%), unclean vegetables (96.3%), and food from public places (85.5%)
Only 17.3% of respondents were not worried at all about the cholera situation, whereas the rest expressed different degrees of worry. On that matter, 74.1% of participants agreed that the spread of cholera in Lebanon is a significant public health concern. Only half of the participants agreed that the vaccination campaign would be successful to halt the cholera outbreak in Lebanon. A detailed distribution to the attitude questions is provided in the appendix (supplementary table 3).
The mean attitude score was calculated and found to be 17.04 ± 0.06 (SD = 1.64) with a minimum of 6 and a maximum of 18. When compared to a median of 18, a total of 61.74% of participants have a high attitude score (Table 1).
PRACTICE SCORE
Respondents were assessed on their implementation of their practices toward preventing the spread of and contracting cholera. Most of the respondents practice appropriate protective measures in their daily life. 54.0% of participants would first go or take the family member to the hospital for care if they contracted cholera. 90.0% of respondents always wash their hands with soap and water before eating food and after defecating, 90.8% always cook food thoroughly, and 88.3% always wash their fruits and vegetables before consuming. When it comes to safe disposal of wastes, 93.6% of participants always defecate in the toilet. 20.7% of participants continue to eat raw meat. 89.4% of the participants do not share cups while drinking. However, only about half (55.2%) of the participants have chlorinated or plan to chlorinate their water supply (data is available in the appendix, supplementary table 4).
The mean practice score was calculated and found to be 21.21 ± 0.08 (SD = 2.01) with a minimum of 5 and a maximum of 23. When compared to a median of 22, a total of 56.60% of participants have a high knowledge score (Table 1).
BIVARIATE ANALYSIS OF THE KAP SUBSETS
KNOWLEDGE
The comparison of level of knowledge among the different socioeconomic and demographic variables revealed that higher mean knowledge scores were found in those aged 21–40 (18.63) compared to other age groups, in Bekaa (19.58) compared to other regions, in urban compared to rural areas (18.99 vs 17.79), and in those with medical degrees M.D. (20.43) compared to other categories of education. On the other hand, gender, marital status, job status, household income, and crowding have no statistically significant association with the knowledge score (Table 2 at the end of the document).
ATTITUDE
The comparison of level of attitude among the different socioeconomic and demographic variables revealed that higher mean attitude scores were found in females compared to males (17.1 vs 16.7), and in participants living in households with children under 5 years of age (17.3). On the other hand, age, marital status, job status, residence by governorate and type, educational level, crowding, and household income were not associated with statistically significant differences in attitude score (Table 2 at the end of the document)
PRACTICE
The comparison of level of practice among the different socioeconomic and demographic variables revealed that higher mean practice scores were found in those aged above 60 (21.70) compared to other age groups, in females compared to males (21.20 vs 21.07), in those who are married (21.60) compared to other groups, and those who are homemakers (21.90) compared to other occupations. On the other hand, there are no statistically significant differences in practice scores by different governorates, type of residence, educational level, crowding index, number of children under 5 years of age living in the household, and household income (Table 2 at the end of the document).
RELATIONSHIP OF KAP SUBSETS
The Spearman’s correlation test was used to identify associations between the Knowledge, Attitudes, and Practice scores. Spearman’s rank correlation coefficient was calculated to determine the strength and direction of the association between the three subsets. Among the participants, the knowledge score was positively correlated with the attitude score with a Spearman’s correlation coefficient of r = + 0.163 (P < 0.001). The knowledge score was also positively correlated with the practice score with a coefficient of r = + 0.120 (P < 0.002), Finally, the attitude score was found to correlate positively with the practice score with a coefficient of r = + 0.259 (P < 0.001). This shows a weak, positive correlation between all three subsets of the KAP scores, the highest of which is the association between attitude and practice (Table 3).
MULTIVARIATE ANALYSIS
KNOWLEDGE
The first linear regression model, taking knowledge as the dependent variable, showed that higher attitude scores (B = 0.346, P < .001) were significantly associated with higher knowledge scores. Similarly, those with higher levels of education like having a bachelor's degree (B = 4.29, P = 0.041) and medical degree (B = 6.514, P = 0.002) were significantly more likely to have higher knowledge scores compared to those with less formal education. (Table 4, Model 1)
ATTITUDE
The second linear regression model, taking attitude as the dependent variable, showed that both higher knowledge scores (B = 0.092, P < .001) and higher practice scores (B = 0.171, P < .001) were significantly associated with higher attitude scores. On the other hand, being male (B=-0.393, P = 0.004) was significantly associated with having lower attitude scores. (Table 4, Model 2)
PRACTICE
The third linear regression model, taking practice as the dependent variable, showed that higher attitude scores (B = 0.284, P < .001) and being a homemaker (B = 1.546, P = 0.001) compared to other job statuses were associated with higher practice scores (Table 4, Model 3).
VACCINATION
DESCRIPTION OF VACCINATION-RELATED KNOWLEDGE AND ATTITUDE
In the setting of the recent COVID-19 mass vaccination campaign, respondents were asked for information about their vaccination history. The survey included questions to assess the respondent’s knowledge and attitude towards the cholera vaccine, on a background of their COVID-19 vaccination status. The majority 75.4% of participants have received at least one COVID-19 vaccine, whereas 24.6% of participants have received none.
Only 30.2% of participants correctly identified the vaccine administration method (oral). A freely available cholera vaccine would be accepted by 55.5% and possibly considered by 30.3% of respondents. Vaccination willingness is defined as accepting or considering the vaccine. Of those who display vaccination willingness, an economic follow up question showed that 77.5% would accept or consider a paid vaccine, of which the majority 78.6% would only pay if the vaccine cost 10 dollars or less. A minority of respondents 14.2% would not receive a freely available vaccine. To identify the reasons for vaccine refusal or hesitancy, follow up responses were collected. The results showed that the two most commonly listed reasons, both at 44.0%, were low trust in the vaccine and preference of natural immunity to the disease. 16.5% of respondents cited previous personal experience with the COVID-19 vaccine. Only 1 respondent cited religious reasons for vaccine refusal. A detailed distribution to the vaccination questions is provided in the appendix (supplementary table 5).
BIVARIATE AND MULTIVARIATE ANALYSIS
VACCINATION WILLINGNESS
Overall, 55.50% of respondents are willing to take the cholera vaccine if available for free. The comparison of vaccination willingness among the different socioeconomic and demographic variables revealed that higher vaccination willingness was found in those below 20 (59.1%) compared to other age groups, in students (63.9%) compared to other job statuses, and those who have a medical degree (66.3%). Similarly, having higher knowledge scores and higher attitude scores was significantly associated with higher vaccination willingness. Notably, practice score is not associated with willingness. There is also no statistically significant correlation between vaccination willingness and the rest of the sociodemographic variables (Table 5 at the end of the document).
A chi square test showed a disproportionate association between respondent cholera vaccination willingness and having increasing number of COVID-19 vaccination status (P < 0.001). A linear regression taking vaccination willingness as the dependent variable showed that those with higher knowledge score were more likely to be willing to take the cholera vaccine (B = 0.091, P = 0.002) (Table 6).
SOURCES OF INFORMATION
The respondents receive their information and news about cholera from a wide range of sources of information. Social media outlets were found to be the most commonly used medium (22.6%) followed by healthcare professionals, television channels, the World Health Organization (WHO), the Ministry of Public Health of Lebanon (MOPH), and family and friends. The newspaper was only used by 3.7% of participants (Table 7).