A Crisis within a Crisis: COVID-19 Knowledge and Awareness among the Syrian Population—A National Survey Assessment

Background: COVID-19 is an infectious respiratory disease that emerged from a wet market in Wuhan China and quickly exploded into a global pandemic. This coronavirus has overwhelmed public health systems worldwide, and forced governments to impose draconian lockdowns of entire populations. With no vaccine or treatment to date, it is of paramount importance to assess the public’s awareness about COVID-19 so that knowledge gaps among the population can be targeted with prevention-focused educational campaigns. The aim of this study is to examine the Syrian public’s awareness and knowledge regarding COVID-19. Methods: This web-based cross-sectional study was distributed randomly in March 2020, nearly 10 year into the Syrian war crisis. The survey consists of a series of questions about socio-demographic characteristics, knowledge of the causative agent, incubation period, treatment, transmission pathways, clinical features, and prevention methods. Data was analysed 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 at college-educated. The study revealed good awareness regarding COVID-19 (mean 75.6%, SD±9.4%). Multiple linear regression analysis correlated knowledge scores with gender, education level, occupation, economic status, and the number of household members. Conclusion: This study revealed some potentially troubling knowledge gaps which underscore the need for a vigorous public education campaign. This campaign must reinforce the public's awareness, knowledge, and vigilance towards precautionary measures against COVID-19 and, most importantly aid in controlling the worldwide spread of the disease.

equipped and lacks the capacity to contain such a crisis. The estimated number of intensive care unit (ICU) beds with ventilators is mere 325, and the theoretical maximum number of cases that can be adequately treated is only 6,500. (6) Once this maximum threshold capacity is exceeded, drastic rationing decisions will have to be made. Therefore, cooperation with and response to guidance from the WHO are of utmost importance. Unprecedented measures have been adopted to control the spread of COVID-19 in Syria including: partial closure of borders; suspension of public transportation; closure of mosques, shops, parks, restaurants universities, and schools; isolation and care of suspected and infected individuals; curfews to limit social contact; and awareness campaigns. The public's adherence to these control measures-which is largely affected by their awareness, knowledge, and attitudes, towards COVID-19-is crucial to mitigating the further spread of the disease. (7,8) The Syrian con ict, now in its 10 th year, has resulted in the worst refugee crisis since World War II. (9) The devastating impact of war has placed the public health system under constant strain; the numbers of casualties continues to rise, 70% of health care workers have ed the country, the annihilation of healthcare facilities, and the "weaponization" of the healthcare are ongoing challenges. (6,10) These challenges along with dense residential areas, the growing prevalence of chronic illness, and 83% of the population living under the poverty line make Syria highly vulnerable to a severe outbreak. (6,11) While some studies have been conducted to assess the knowledge, attitude, and practices among populations during this pandemic, none have done so in Syria. (12)(13)(14)(15)(16)(17)(18)(19) To our knowledge this rst study that aims to measure the awareness and general knowledge of COVID-19 among the Syrian population at a time where ambiguity and misinformation are rampant. The objective of this study is to gauge speci c knowledge around clinical features, transmission pathways, and prevention methods, and to identify factors associated with poor knowledge to help facilitate outbreak management in Syria during this rapid global rise of the COVID-19 pandemic.

Study design, setting and participants
This web-based cross-sectional survey was conducted between March 3 rd and April 4 th . Ethical approval was obtained from the Institutional Review Board (IRB) of the Faculty of Medicine, Syrian Private University. All participants residing in Syria with no known history of COVID-19 infection were included in the study. The authors designed questions that were modelled after existing surveys. (12,13) We conducted a pilot study on 20 people to assess clarity, relevance, and the acceptability of the survey; these were excluded from the nal sample to avoid bias. Modi cations were made based on feedback received to facilitate better comprehension before distributing the nal survey to the general population. The Arabiclanguage survey was posted on various social media platforms including WhatsApp, Telegram, Instagram, and Facebook targeting various social groups. Participants con rmed their voluntarily participation by answering a yes-no question, were informed of the option to opt-out of the survey at any time, and were assured of the con dentiality and anonymity of their responses. After con rmation, participants were directed to the rst part of the survey to complete questions about socio-demographic information including, age, gender, residence, education level, occupation, and economic status. Participants under the age of 18 required informed parental consent, as well as submission of parent/guardian contact information. The researchers were responsible for contacting the parents/guardians to obtain consent before the child was given access to the survey. The selfadministered survey contained 40 questions divided into 4 sections: general knowledge (10 questions), transmission pathways (7 questions), clinical features (12 questions), and prevention methods (11 questions). The survey is available in appendix 1.

Statistical analysis
Data was analyzed using the Statistical Package for Social Sciences version 25.0 (SPSS Inc., Chicago, IL, United States) and reported as frequencies and percentages (for categorical variables) or means and standard deviations (SD) (for continuous variables). One-way analysis of variance (ANOVA), t-test, or Chisquare test was applied to compare mean knowledge scores against socio-demographic variables. Multivariable linear regression analysis using the socio-demographic variables as independent variables and mean knowledge score as the outcome variable was conducted to identify factors associated with knowledge. P-values<0.05 was considered statistically signi cant.  (Table 4).
Participants acquired their information from the following source(s): Social media, 1998(55.7%); health websites, 2823(78.7%); television/radio, 1572(43.8%); family members/friends, 528(14.7%); magazines/books, 266(7.4%); and lectures, 517(14.4%). Participants with the lowest awareness acquired their information from family members/friends (74.0%), whereas those with the highest awareness acquired their information from lectures (78.2%), (p-value=0.000), (Figure 4). When participants were asked if they were likely to share new information with friends and family, 3513(98.0%) answered "yes". There was a signi cant difference in mean knowledge between those who were inclined to disseminate new information about COVID-19 to friends and family (75.7%) compared with those who were not (72.3%) (p-value=0.002). On exclusive use of personal belongings, 2692(75.1%) answered "yes". We found no signi cant correlation between mean knowledge and participant tendency to share personal belongings with others (p-value=0.112). Participants who knew someone infected with COVID 19, 65(1.8%) answered "yes". There was no signi cant difference in mean knowledge between those who knew an infected individual (75.9%) compared with those who did not (75.6%) (p-value=0.816).

Multiple linear regression:
Multiple linear regression analysis results: male gender (vs. female, p=0.005); education of secondary school or lower (vs. college/university and above, p=0.000); careers in government, private, business, military, and "other" sectors, as well as unemployment (vs. health care workers, p=0.000); poor and moderate economic status (vs. good and excellent, p<0.040), and over 5 household members (vs. of 1-5, p=0.000) were associated with signi cantly lower knowledge scores (Table 7). Careers in health care (vs. Unemployed, p-value=0.000), and the 31-45 age group (vs. 16-30, p-value=0.005) were associated with signi cantly higher knowledge scores.

Discussion
We found an overall mean knowledge score of 75.6%, indicating that most participants were relatively knowledgeable about COVID-19, though less so compared to their counterparts in China (90%). (12) This level of knowledge was unexpected given that when we carried out the survey, only 10 cases of COVID-19 had been con rmed in Syria. (20) We found that poor knowledge was associated with males, non-post-secondary education, nonhealthcare occupations, unemployment, poor and moderate economic status, and households exceeding 5 members (Table 5). Similar trends were observed in China. (12) Correlating socio-demographic variables with awareness is critical to public health efforts to mitigate the spread of COVID-19. This data obtained can be leveraged by the Syrian Ministry of Health to tailor prevention and educational campaigns to populations with the widest knowledge gaps.
In the general knowledge section (67%), the majority of the participants 3383(94.3%) knew that COVID-19 is caused by a virus, similar to a Pakistani study (93.3%). (17) Low awareness of the 2 to 14 day incubation period was found, (21) among dentists (36.1%), and health care workers (HCW) (36.4%). (13,19) Our study showed a higher level of awareness 2535(70.7%) among the population. Syria has a relatively young population; 2018 showed that only 4.5% of the population was over 65. (22) 3489(97.3%) knew that COVID-19 infection can be severe and lead to death in elderly, chronically ill, and immunode cient patients. This is higher than studies conducted in China (73.2%), and India (88.37%). (12,23) 40.6% of Syrians are hypertensive, yet a staggering 79.8% of them are unaware of their condition. Diabetes is also prevalent, affecting 11.9% of the population. (24,25) Such a rampant lack of awareness about chronic disease in the population can be fatal, and underscores the need for targeted awareness campaigns.
Only 2597(72.4%) participants knew that there is currently no available treatment; this is higher than a Kenyan study (40%) but signi cantly lower than a Chinese study (94%). (12,15) A minority 103(2.9%) participants thought there was a vaccine available against COVID-19; by contrast, Coimbatore District (18.6%) and Pakistan (11.6%) were misinformed. In the absence of a vaccine or effective treatment protocol for COVID-19, controlling the spread of the disease is the best line of defense. We observed a considerable knowledge gap in 1268(35.3%) with regards to ibuprofen as a treatment option. There is no available evidence to suggest that ibuprofen is effective against COVID-19. (26) Participants showed a fair level of awareness regarding transmission pathways (70.7%), very similar to a Pakistani study (70.8%). (17) The majority 3521(98.2%) of participants were aware that respiratory droplets are common transmission vectors this is similar to a Chinese study (97.8%), but much higher than an Indian study (29.5%). (12,16) WHO advise on physical distancing include: using greetings that replace physical contact with a wave, nod, bow, peace sign, sign language, friendly words or smiles. (27,28) 3330(92.9%) participants identi ed handshaking as a transmission pathway, higher than a study among dentists (85.6%). (13) A good level of awareness was found regarding the clinical features of COVID-19 (76.0%), similar to a Pakistani (77.7%). (17) A very high level of awareness of the most common symptoms was found: fever 3563(99.4%), dry cough 3466(96.7%), fatigue 3405(95.0%), and myalgia 3019(84.2%), similar to ndings from Chinese (96.4%) and Indian (95.4%) studies. (12,23) When asked about sore throat, a higher level of awareness 3037(84.7%) was found compared to studies from India (15.2%) and among dentists (28.5%). (13,16) Knowledge about diarrhea as a symptom was lacking: only 1972(55.0%); a study among dentists also showed low awareness (39.9%). (13,16) While infected individuals are frequently asymptomatic, or present with mild symptoms, around 1 in every 5 infections can be serious enough to require hospitalisation. (4,29) Only 2221(61.9%) participants were aware that infected individuals can be asymptomatic, while a study among dentists (34.5%) reported much lower awareness. "Silent spreaders" may signi cantly contribute to the transmission of COVID-19, and so increasing public awareness of this particular point is crucial We found a high level of awareness in the preventive methods section (88.8%), similar to a study in Pakistan (85%). (17) Hand hygiene is considered an important element of infection control dating back to the revolutionary work of Ignaz Semmelweis. (30) Implementing hand-washing techniques can break the transmission cycle and reduce the risk of infection by 6%-44%. (31) Almost all 3574(99.7%) participants were aware that washing hands with soap and water is an important preventive measure against COVID- 19. This nding is in accordance with India (97.0%), and other studies (96.2%, and 87%). (13,16,19) This year the WHO recommended that the following mitigation measures be implemented during the holy month of Ramadan: cancelling social and religious gatherings, holding events outdoors for adequate ventilation, physical distancing of at least 1 meter between people, and the use of technology to broadcast ceremonies on television. (27,28) The majority 3574(99.7%) identi ed avoiding mass gatherings as a preventive measure; studies in China (98.6%) and Coimbatore District (97.7%) reported similar awareness. (12,23) Cheap and e cient interventions such as N95 ( ltration capacity=95%) have a 91% effectiveness of blocking pathogen transmission. (32) 3204(89.3%) participants considered wearing a face mask when leaving home as an effective prevention method, compared with a Coimbatore District study (93.02%). (23) Since Syrian society is particularly vulnurable to COVID-19, this knowledge gap is potentially dangerous and should be addressed to mitigate disease spread. Only 2482(69.2%) knew that the u vaccine offers no protection against COVID-19; this is similar to a Coimbatore District study (67.4%), but lower than a study amongst HCWs (90.7%). (19,23) Mixing ash with bleach is highly toxic and caustic to the respiratory tract. Only a minority of participants 158(4.4%) believed that this method of cleaning is a sound preventive measure. 3305(92.2%) were aware that individuals showing symptoms should quarantine themselves, lower than in China (98.2%) and India (95.8%). (12,16) North-East Syria (NES) has a population of over 4 million people, 600,000 of whom are internally displaced refugees, 100,000 of whom live in overcrowded camps: only 2 of NES's 11 hospitals are currently functioning. NES consists of 3 governorates: Ar-Raqqah, Deir-ez-Zor and Al-Hasakah. With only 22 ICU beds, (18 in Al-Hasakah, 4 in Ar-Raqqah and none in Deir-ez-Zor), the maximum capacity threshold is only 80 COVID-19 cases. Ar-Raqqa and Deir-ez-Zor, the most vulnerable governorates, also showed the lowest awareness in the study (71.7%), and (71.8%). This is a potentially catastrophic situation, and a concern to the international community, as an unmonitored, uncontrolled outbreak in NES can prolong the global pandemic.

Limitations
Our ndings can only be generalized about well-educated Syrians of good socio-economic status. Syrians vulnerable to COVID-19, such as the elderly and rural residents, are more likely to exhibit poor knowledge and awareness due to limited internet access. As such, reaching out to these populations must be prioritized. Even though all Syrian governorates were represented in this study, the majority of participants lived in Damascus and Rural Damascus. Furthermore, assessment of attitudes and practice towards COVID-19 is needed, which should be developed as either a web-based survey, or phone interviews, and constructed using multi-dimensional scaling.
Conclusion  has been a dire warning to humanity about the fragility of its social, economic, and healthcare institutions. Our study revealed good public awareness of clinical features and preventive measures. However general knowledge and knowledge about transmission pathways was suboptimal. Syrians of good socio-economic status, in particular young well-educated women, have shown good knowledge. Our national response must adapt to the growing threat of COVID-19 by adopting public awareness strategies and behaviours to contain the disease both within and beyond our borders. We are thankful to the management of the Syrian Private University for the support in the eld of medical training and research. We are thankful to everyone who participated in this study and for Mrs. Marah Muarrawi for her statistical help.

Funding:
Syrian Private University funded the study. No contribution to data design, collection, analysis, or interpretation was made by the funding resource. No other funding sources.
Availability of data and materials: All data related to this paper's conclusion are available and stored by the authors. All data are available from the corresponding author on a reasonable request.
Ethics approval and consent to participate: This study was approved by the Institutional Review Board (IRB) at the Syrian Private University (SPU). All Participants con rmed their written consent by answering a yes-no question. 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.

Consent for Publication:
Not applicable.

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

Authors' contributions:
FM conceptualized the study, participated in the design, wrote the study protocol, performed the statistical analysis, did a literature search and drafted the manuscript. BB participated in study design, did a literature search and drafted the manuscript. HA, and NA did a literature search, and revision of the draft. All authors read and approved the nal draft.  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.      Relationships between both genders and mean knowledge.

Figure 3
Relationship between place of residence and mean knowledge.