Knowledge and perception of COVID-19 pandemic: Before-and-after online community survey.

DOI: https://doi.org/10.21203/rs.3.rs-28849/v1

Abstract

Background COVID-19 pandemic impacts many communities worldwide. In this study the Poles' knowledge about COVID-19 as well as people’s behaviours, attitudes and fears during the pandemic were assessed. Changes in these between the outset of the pandemic and the imposition of the strictest lockdown measures in Poland were investigated. Methods Physicians, nurses, students of medicine-oriented faculties, non-medical professionals, students of non-medicine-oriented faculties and secondary school students were surveyed by an anonymous online questionnaire two times: at the onset of the pandemic and in the second week of the strictest lockdown. Statistical analyses were performed using non-parametric tests - Chi square Persons, Kruskal-Wallis tests. Results In total 2618 responses were collected. At the beginning people knew that the respiratory system was attacked (97.9%); correctly identified the major symptoms of COVID-19 (95.0%) and ways to prevent infection: hand washing (99.8%), covering mouth (85.9%) and the need to call sanitary-epidemiological services if one experienced COVID-19-like symptoms (92.1%). The biggest changes between the first and second phase of the study concerned behaviours: more people wearing facial masks (+37.5%) and staying at home (+66.1%). Respondents in the second wave of the survey were also more scared of the pandemic (+19.6%), economic crisis (+64.1%), and worried about their families (+26.5%). However, they were less afraid of the quarantine (lockdown) (-18.2%). Nurses and physicians were the most worried groups. Conclusions The study showed that even at the outset of the pandemic Polish population had a good initial knowledge about symptoms, transmission, and preventive behaviours regarding COVID-19. People revealed more short-term concerns, such as the worries about coping with quarantine and isolation. After a month, the knowledge and the concerns among the respondents changed. A shift towards long-term pandemic management issues was observed. Respondents reported to experience more fears concerning the pandemic in general, as well as economic and healthcare crises. Medical professionals reported higher level of fear of the pandemic than other groups included in this study. This study uses before-and-after approach which highlights the changes in people’s knowledge and perception of the COVID-19 pandemic during the pandemic’s progression. Keywords online survey, COVID-19, medical personel, before-and-after study

Background

Coronavirus disease 19 (COVID-19) is the disease caused by the novel coronavirus 2019-nCoV (SARS-CoV-2). It is currently one of the biggest acute global threats to human health. The outbreak of the pandemic has affected many countries, causing problems concerning almost every aspect of everyday life. It has led to realignment in the world economy, deepened the medical crisis in many already vulnerable countries and it is currently the predominant topic covered by all media. The pandemic poses an unprecedented challenge for all health care systems worldwide. This is the first medical crisis in the recent history affecting different populations, countries and continents, requiring everybody to be aware and prepared for it. To assess the level of knowledge and attitudes regarding SARS-CoV-2 and COVID-19 a short survey was created to evaluate the knowledge about coronavirus in the Polish population as a spontaneous reaction to the situation. The survey also covered social aspects of the pandemic, its influence on everyday life and peoples’ attitude to information disseminated in the media.

The new coronavirus strain, discovered in December 2019 in the city of Wuhan in China [1], spread globally within few months. The first cases of COVID-19 in Europe were observed in January 2020 [2]. On March 4th, when the first case of COVID-19 was reported in Poland, there had already been more than 93,000 confirmed cases of infection and almost 3,200 deaths reported globally [3]. The first wave of the survey was launched on that day.

Within few days, the Polish government decided to implement precautions to stop the pandemic from spreading in Poland. Schools and universities were closed on March 12th [4].

Various public facilities and shops were closed on March 13th for a period of two weeks or longer. People were instructed to stay at home and refrain from travelling outside the country and the "state of epidemic threat" was declared nationally [5]. After a week, this official status was changed to the "state of epidemic" [6]. On April 1st, further restrictions amounting to a lockdown were introduced: leaving home was prohibited unless necessary, and only allowed individually or in groups of two. As a consequence of refusal to comply with the regulations a fine could be imposed [7].

The second wave of the survey began on April 9th, when there were about 5,600 confirmed cases of infection and 174 deaths in Poland [8]. Globally, there were over 1,430,000 confirmed cases of infection and more than 85,500 deaths [9]. At the time the second phase of the study began, after nearly a month of lockdown, the Polish government had not abolished any of the restrictions yet.

Aetiology and Pathogenesis

Coronavirus is zoonotic and probably spread to humans from bats or pangolins [10]. The disease is airborne, but indirect physical contact, such as touching a contaminated surface and then touching eyes, nose or mouth, can also lead to infection [1]. World Health Organisation (WHO) is assessing the ongoing research on the ways SARS-CoV-2 spreads. The symptoms of infection include fever, tiredness, and a dry cough. Other symptoms can include muscle pain, diarrhoea or nasal congestion. For some people, the infection takes the form of an abortive infection or is very mild. More than 80% of patients recover from the disease without any special treatment, but about 17% of the infected develop a serious/lethal form of the disease [1]. Severe cases require breathing support. This mostly affects older people and those with underlying medical conditions. The symptoms arise gradually and the incubation period lasts from 2 to 14 days [1].

Prevention and treatment

The infectious period for COVID-19 is not yet well established, and neither is the role asymptomatic infections plays in transmission [11]. It is estimated that the risk of transmission from someone with no symptoms is very low.

To protect oneself, the WHO recommends the following precautions:

cleaning hands with alcohol-based sanitizer or washing with soap and water;
maintaining at least one metre's distance away from other people (the Polish government encourages two meters [12]);
avoiding touching eyes, nose and mouth;
covering mouth and nose while coughing or sneezing with a bent elbow or tissue and disposing of used tissue immediately;
self-isolation while feeling ill and seeking medical help in advance by calling health care providers;
avoiding travelling [1].

No specific treatment has been found yet. Some findings have shown that plasma transfusion from convalescent donor or immunoglobulins can be used to improve patients’ condition [13]. To date, no vaccine exists.

Methods

Aims

1. To evaluate Poles' knowledge about COVID-19 as well as people’s behaviours, attitudes and fears during the pandemic in Poland, depending on the socio-educational profile of the respondent.
2. To compare responses at the beginning of the epidemic before the lockdown restrictions and during its peak, at the time when the number of COVID-19 cases in Poland was very high and the restrictions imposed by the government had already affected life of the respondents.

Materials

2,618 anonymous responses to the questionnaires were collected in two waves of the study: at the outset of the epidemic and during the most severe COVID-19 lockdown in Poland. Demographic characteristics of the sample are presented in Table 1. Due to the pandemic conditions, it was decided to collect data online. The following cohorts were distinguished among the respondents: medicine-oriented community: physicians, nurses, medicine-oriented students, and non-medicine-oriented community: non-medical professionals, non-medicine-oriented students, secondary school students (over 18 years old). Such division was introduced, as physicians, nurses, and non-medical professionals are mentioned in other studies on COVID-19 perception. Moreover, researches did not find many studies where the secondary or university students were asked about their knowledge and perception of the pandemic. These cohorts are also easily accessible for an online survey. Respondents were surveyed to evaluate their knowledge regarding coronavirus and awareness of the threats of the epidemic outbreak in Poland. Although every resident of Poland was eligible for this survey, the biggest number of the respondents hailed from the northern regions of the country.

Methods

The questionnaire was designed by the students of the Medical University of Gdańsk based on the WHO recommendations and information. Answers to the knowledge questions were based on the official WHO guidelines [14]. The survey consisted of twelve questions divided into four sections: demographics, knowledge, attitudes, and behaviours. The first section gathered data on the occupation, age, and the current place of residence of the respondent. The second part evaluated general knowledge about COVID-19 including its symptoms, routes of infection, and prevention methods. The third part measured the fear of the pandemic and which lockdown restrictions were the most difficult for people to cope with. The fourth part focused on sources of information on COVID-19. In the 4th question (infected body systems) a respondent could mark only one answer while the questions 5 to 11 (symptoms, transmission routes, prevention, what to do when experiencing symptoms, daily life difficulties, fears, knowledge sources) were multiple choice questions in which a respondent could pick more than one answer. The 12th question was a rating scale question. The research was conducted at two different phases of the epidemic in Poland. First questionnaires were collected in March (4/03/2020–11/03/2020), in the first week after the first case of COVID-19 had been announced in Poland. The survey was completed by 1,089 respondents. On March 15th the Polish government announced the state of epidemic emergency and imposed numerous limitations on the entire society, so the first wave of data collection was terminated. The questionnaires for the second wave of the survey were collected in April (9/04/2020-16/04/2020) during the strictest COVID-19 lockdown in Poland, when the Polish society had been living in a restricted isolation for approximately a month. During the second phase, 1,529 questionnaires were collected. The same questionnaire was used for both waves of the study (supplementary material). To increase the likelihood of obtaining a comparable sample, the survey was distributed by the same information channels in both rounds.

Data analysis

Demographic data are presented in Table 1 as counts and (for age data) means with standard deviations. The percentage rates of answers were calculated for questions 4 to 11 for each of the six cohorts and for the whole sample (Table 2, Table 4, Table 5). For question 12 (how well-informed respondents felt), mean scores (on a 1–5 scale) were calculated. All calculations were performed separately for both waves of the survey. All analyses of statistical significance were performed using non-parametric tests – Pearson's Chi squared and Kruskal-Wallis tests.

 
 
 

Data analysis

Demographic data are presented as means with standard deviations. Percentage rates of answers were calculated for questions 4 to 11 for each of the six cohorts and for the whole community. For the 12th question mean scores on the 1–5 scale were calculated. All calculations were performed for before and after surveys. All analyses were performed using non-parametric tests - Pearson's Chi squared and Kruskal-Wallis tests.

Results

In total, 2,618 surveys were collected, with about 80% of respondents residing in the Pomorskie (Pomeranian) voivodeship, Poland. Age and profession characteristics of the sample are presented in Table 1.

Table 1

Demographic characteristics of the sample.

Cohort

Wave of study

First

Second

n

Mean age

Standard deviation

n

Mean age

Standard deviation

Physician

147

36.4

9.0

123

38.3

13.1

Nurse

68

39.1

12.2

108

39.4

10.8

Student of medicine-oriented faculty

287

22.0

2.3

713

21.8

2

Non-medical professional

168

37.2

13.3

277

45.4

10.4

Student of non-medicine-oriented faculty

174

21.6

1.9

128

21.9

2.1

Secondary school student

245

17.7

1.9

180

17.8

2.8

All respondents (Mean)

1089

26.4

10.8

1529

28.2

10.7

Most of the respondents knew that COVID-19 attacked the respiratory system (97.9%, Table 2) and that it was an airborne disease (99.7%). They also correctly identified the main symptoms of COVID-19: fever (98.6%), cough (96.9%), shortness of breath (93.6%). Additionally, the medicine-oriented sub-population knew about muscle pain and tiredness. Respondents also knew the main prevention measures including hand washing (99.8%), covering mouth (85.9%), and social distancing (88.2%), as well as the need to call the sanitary-epidemiological service (92.1%) or to visit an infectious diseases ward (69.6%) if one experienced COVID-19-like symptoms. A small percentage of studied population said they would also visit a general practitioner (6.3%) or an emergency department (8.0%). People were worried about quarantine (69.1%), grocery price increases (61.2%), and their families (60.2%). Most of the questioned felt well informed about the virus (3.5/5, Table 3). The main sources of knowledge for non-medicine-oriented respondents were general news websites or social media, while medicine-oriented community chose science-oriented or governmental websites more often.

Table 2

Mean percentage rates of answers for questions of first phase surveys

Question

Answer

Rate of answers [%]

Statistically significant difference

Cohort

Physician

Nurse

Student of medicine-oriented faculty

Non-medical professional

Student of non-medicine-oriented faculty

Secondary school student

All respondents (Mean)

Which human organ system is usually infected by Coronavirus?

respiratory system

100.0

100.0

99.0

97.0

97.1

95.9

97.9

*

nervous system

0.0

0.0

0.3

1.2

1.7

2.0

1.0

digestive system

0.0

0.0

0.3

1.2

0.0

0.8

0.5

muscular system

0.0

0.0

0.3

1.8

1.1

1.2

0.8

genitourinary system

0.0

0.0

0.0

0.0

0.0

0.0

0.0

What are the symptoms of Coronavirus disease 2019?

fever

100.0

98.5

97.2

100.0

99.4

98.0

98.6

*

cough

98.0

98.5

97.2

95.8

96.6

96.3

96.9

breathlessness or breathing problems

98.6

98.5

95.5

94.6

87.4

90.6

93.6

muscle pain

72.8

60.3

62.4

66.7

56.3

55.9

61.9

fatigue

74.8

47.1

71.1

60.1

50.6

55.9

61.7

How does the virus spread to another person?

by droplet transmission: coughing/sneezing

99.3

100.0

99.7

100.6

98.9

100.0

99.7

*

by indirect contact: through items touched by the infected person

57.8

45.6

43.6

43.5

37.4

39.6

43.7

by fecal-oral transmission: eating food contaminated with the virus

24.5

8.8

18.1

26.2

25.3

32.7

24.1

by direct contact: touching infected person

41.5

32.4

35.9

38.1

24.1

26.1

32.7

How to protect yourself from the virus?

wear a standard ("surgical") mask

5.4

5.9

6.3

4.8

5.7

9.8

6.6

*

wear a mask with a HEPA filter

48.3

26.5

39.7

19.0

25.9

42.9

35.4

wash your hands often

100.0

100.0

99.7

100.0

100.0

98.8

99.8

cover your mouth when coughing or sneezing

89.1

98.5

87.8

83.3

83.3

81.6

85.9

keep at least 1 meter distance from others. 

96.6

92.6

87.5

86.9

85.6

85.3

88.2

do not leave the house / flat

27.9

14.7

27.2

12.5

18.4

21.6

21.6

contact the sanitary and epidemiological station after you came back from another country where Coronavirus disease 2019 has been reported

70.7

88.2

77.0

60.1

82.2

85.3

77.0

drink alcohol

1.4

2.9

3.1

4.8

5.2

3.7

3.6

avoid products made in China

2.0

2.9

4.5

5.4

5.2

8.2

5.1

What should I do if signs of infection appear?

notify the sanitary and epidemiological station

97.3

97.1

92.7

91.7

91.4

87.8

92.1

 

report to the emergency department in the nearest hospital

0.7

1.5

5.6

7.7

13.8

13.1

8.0

go to family doctor

0.7

2.9

3.5

9.5

8.0

10.6

6.3

report to an infectious disease ward or observation and infectious disease ward

74.8

76.5

72.1

56.5

70.1

70.2

69.6

What would be for you the biggest obstacle in everyday life due to Coronavirus disease 2019 pandemic?

inability to go to your workplace or place of study

49.7

26.5

61.7

39.9

57.5

55.9

52.5

*

cancelled mass events, such as performances, conferences, concerts

13.6

2.9

32.8

20.2

31.0

47.3

29.4

cancelled trips, flights

32.7

14.7

37.3

39.3

30.5

53.9

38.2

quarantine or isolation from loved ones due to quarantine

73.5

86.8

58.9

76.8

73.6

64.9

69.1

no products and food in shops or higher prices in stores

52.4

54.4

62.4

54.2

71.8

64.5

61.2

no personal protection equipment in stock

44.9

50.0

32.8

34.5

29.3

31.0

34.8

Does any of the following aspects worries you due to the spreading infection?

nothing worries me

10.2

5.9

32.1

27.4

21.3

28.6

24.2

*

my own health and life

26.5

42.6

11.1

25.0

26.4

17.1

21.1

health and life of my family

72.8

80.9

53.3

58.9

62.6

54.3

60.2

being quarantined

34.7

41.2

23.3

25.0

31.6

22.0

27.3

economic crisis

4.6

5.6

7.9

8.1

3.2

9.9

7.0

my education

4.5

1.9

2.2

3.3

5.1

4.5

3.6

Which of the following are your sources of knowledge about Coronavirus disease 2019?

TV news

32.0

47.1

20.2

57.1

31.0

43.3

36.1

*

radio

13.6

23.5

8.7

31.5

14.9

22.4

17.9

newspapers

11.6

7.4

3.5

11.3

4.0

8.6

7.3

websites such as: onet, interia, wp, gazeta.pl, trójmiasto.pl

34.0

26.5

29.6

49.4

41.4

49.0

39.3

website of the Ministry of Health of the Republic of Poland

47.6

61.8

42.2

33.3

27.6

29.4

37.6

websites such as: onet.pl, interia.pl, wp.pl, gazeta.pl, trójmiasto.pl

87.1

66.2

75.3

36.3

46.6

50.6

60.1

family members and friends

14.3

7.4

35.9

31.0

33.9

41.6

31.4

social media: Facebook, Tweeter, Instagram

51.7

32.4

42.5

41.1

62.6

53.9

48.7

Table 3

Mean numbers of points given for the answer of 12th question

Wave of study

Cohort

Physician

Nurse

Student of medicine-oriented faculty

Non-medical professional

Student of non-medicine-oriented faculty

Secondary school student

All respondents (Mean)

First

3.4

3.6

3.6

3.7

3.3

3.4

3.5

Second

3.8

3.4

3.7

3.6

3.7

3.7

3.7

Difference

0.4

-0.2

0.1

-0.1

0.4

0.3

0.2

Legend: 1 means “not sufficiently informed” and 5 means “sufficiently informed”

When comparing the results from the first and second wave of the survey, more people reported wearing facial masks and staying at home (+ 37.5%, + 66.1%, Table 4, Table 5). Respondents were also more aware that they should not visit a general practitioner (2.2%, -4.2%) or an emergency department (1.6%, -6.3%) if symptomatic; that the SARS-CoV-2 could spread via direct (+ 18.1%) or indirect contact (+ 9.2%) and that tiredness was a symptom of COVID-19 (+ 9.1%). People were more worried about the pandemic generally (+ 19.6%), economic (+ 64.1%) and education (+ 37.3%) crises, and about their families (86.8%, + 26.5%). However, they were less afraid of being quarantined (-18.2%) or price increases (-36.7%). Among nurses and physicians not a single respondent selected "not worried about anything" answer, while only these two populations were not concerned about being absent at work (Table 4). More respondents in the second phase of the survey reported visiting governmental and science-oriented websites (+ 27.4%, + 9.6%, respectively), especially among the non-medical section of the sample, and watching TV (+ 16.4%) to learn about COVID-19. Non-medical professionals and nurses were the only cohorts that felt slightly worse informed about the COVID-19 in the second wave of the survey. In other groups, information confidence increased (Table 5).

Table 4

Mean percentage rates of answers for questions of second phase surveys

Question

Answer

Rate of answers [%]

Statistically significant difference

Cohort

Physician

Nurse

Student of medicine-oriented faculty

Non-medical professional

Student of non-medicine-oriented faculty

Secondary school student

All respondents (Mean)

Which human organ system is usually infected by Coronavirus?

respiratory system

100.0

100.0

100.0

100.0

100.0

98.9

99.9

 

nervous system

0.0

0.0

0.0

0.0

0.0

0.0

0.0

digestive system

0.0

0.0

0.0

0.0

0.0

0.0

0.0

muscular system

0.0

0.0

0.0

0.0

0.0

1.1

0.1

genitourinary system

0.0

0.0

0.0

0.0

0.0

0.0

0.0

What are the symptoms of Coronavirus disease 2019?

fever

100.0

100.0

99.0

99.3

98.4

95.6

98.8

*

cough

100.0

97.2

95.4

97.8

93.8

89.4

95.5

breathlessness or breathing problems

100.0

100.0

99.7

99.6

99.2

98.3

99.5

muscle pain

82.1

72.2

57.5

71.1

57.8

57.2

63.0

fatigue

87.0

79.6

68.9

77.6

65.6

55.6

70.8

How does the virus spread to another person?

by droplet transmission: coughing/sneezing

100.0

100.0

100.0

99.3

98.4

99.4

99.7

*

by indirect contact: through items touched by the infected person

72.4

64.8

57.1

66.1

67.2

61.1

61.8

by fecal-oral transmission: eating food contaminated with the virus

31.7

17.6

19.8

25.3

32.0

25.6

23.3

by direct contact: touching infected person

48.0

41.7

38.7

45.5

42.2

45.0

41.9

How to protect yourself from the virus?

wear a standard ("surgical") mask

63.4

52.8

47.4

56.0

57.0

47.2

51.4

*

wear a mask with a HEPA filter

83.7

76.9

73.4

70.0

68.0

68.9

72.9

wash your hands often

99.2

99.1

99.7

98.9

100.0

99.4

99.5

cover your mouth when coughing or sneezing

87.0

94.4

90.0

90.3

86.7

84.4

89.2

keep at least 1 meter distance from others. 

90.2

89.8

93.3

91.0

86.7

91.1

91.6

do not leave the house / flat

80.5

79.6

90.6

82.3

88.3

93.9

87.7

contact the sanitary and epidemiological station after you came back from another country where Coronavirus disease 2019 has been reported

76.4

92.6

92.1

83.4

88.3

86.1

88.3

drink alcohol

0.8

0.0

0.6

2.2

1.6

3.3

1.2

avoid products made in China

0.8

2.8

2.7

2.5

2.3

6.7

2.9

What should I do if signs of infection appear?

notify the sanitary and epidemiological station

97.6

98.1

99.4

96.8

100.0

98.9

98.7

 

report to the emergency department in the nearest hospital

2.4

2.8

1.0

0.0

1.6

5.6

1.6

go to family doctor

1.6

2.8

1.1

4.0

0.8

4.4

2.2

report to an infectious disease ward or observation and infectious disease ward

63.4

75.9

46.1

50.2

43.8

48.9

50.5

What would be for you the biggest obstacle in everyday life due to Coronavirus disease 2019 pandemic?

inability to go to your workplace or place of study

31.7

15.7

76.2

43.3

67.2

68.9

60.8

*

cancelled mass events, such as performances, conferences, concerts

15.4

9.3

30.2

16.2

35.2

50.6

27.8

cancelled trips, flights

39.0

19.4

32.4

38.6

36.7

37.8

34.1

quarantine or isolation from loved ones due to quarantine

77.2

71.3

73.9

73.3

70.3

82.8

74.6

no products and food in shops or higher prices in stores

12.2

28.7

27.9

21.3

28.1

19.4

24.5

no personal protection equipment in stock

56.9

61.1

39.4

42.6

33.6

22.2

40.4

Does any of the following aspects worries you due to the spreading infection?

nothing worries me

0.0

0.0

4.9

4.3

6.3

8.9

4.6

*

my own health and life

28.5

46.3

21.9

35.7

25.0

22.8

27.0

health and life of my family

92.7

93.5

87.7

87.0

83.6

77.2

86.8

being quarantined

20.3

29.6

6.6

6.1

4.7

6.1

9.0

economic crisis

74.8

57.4

71.9

73.3

75.8

66.7

71.1

my education

22.8

11.1

53.6

23.1

46.9

43.9

40.9

Which of the following are your sources of knowledge about Coronavirus disease 2019?

TV news

32.5

61.1

50.8

59.6

50.8

57.8

52.5

*

radio

10.6

24.1

15.0

23.1

15.6

24.4

17.9

newspapers

11.4

13.9

4.5

12.6

2.3

7.2

7.3

websites such as: onet, interia, wp, gazeta.pl, trójmiasto.pl

39.8

43.5

39.8

59.9

47.7

57.2

46.4

website of the Ministry of Health of the Republic of Poland

58.5

77.8

69.8

61.4

59.4

51.7

64.9

websites such as: onet.pl, interia.pl, wp.pl, gazeta.pl, trójmiasto.pl

91.1

75.0

75.6

58.8

64.8

49.4

69.8

family members and friends

16.3

13.0

32.4

24.2

41.4

55.0

31.7

social media: Facebook, Tweeter, Instagram

33.3

43.5

46.4

35.0

56.3

56.1

45.1

Table 5

Difference between mean percentage rates of answers for questions of first and second phase surveys

Question

Answer

Rate of answers [%]

Cohort

Physician

Nurse

Student of medicine-oriented faculty

Non-medical professional

Student of non-medicine-oriented faculty

Secondary school student

All respondents (Mean)

Which human organ system is usually infected by Coronavirus?

respiratory system

0.0

0.0

1.0

3.0

2.9

3.0

2.0

nervous system

0.0

0.0

-0.3

-1.2

-1.7

-2.0

-1.0

digestive system

0.0

0.0

-0.3

-1.2

0.0

-0.8

-0.5

muscular system

0.0

0.0

-0.3

-1.8

-1.1

-0.1

-0.7

genitourinary system

0.0

0.0

0.0

0.0

0.0

0.0

0.0

What are the symptoms of Coronavirus disease 2019?

fever

0.0

1.5

1.8

-0.7

-1.0

-2.4

0.1

cough

2.0

-1.3

-1.8

2.0

-2.8

-6.9

-1.4

breathlessness or breathing problems

1.4

1.5

4.2

5.0

11.9

7.7

6.0

muscle pain

9.3

11.9

-4.9

4.5

1.5

1.3

1.1

fatigue

12.2

32.6

-2.2

17.5

15.1

-0.4

9.1

How does the virus spread to another person?

by droplet transmission: coughing/sneezing

0.7

0.0

0.3

-1.3

-0.4

-0.6

-0.1

by indirect contact: through items touched by the infected person

14.5

19.2

13.5

22.6

29.8

21.5

18.1

by fecal-oral transmission: eating food contaminated with the virus

7.2

8.8

1.7

-0.9

6.7

-7.1

-0.8

by direct contact: touching infected person

6.5

9.3

2.8

7.4

18.0

18.9

9.2

How to protect yourself from the virus?

wear a standard ("surgical") mask

58.0

46.9

41.1

51.2

51.3

37.4

44.8

wear a mask with a HEPA filter

35.4

50.4

33.6

51.0

42.1

26.0

37.5

wash your hands often

-0.8

-0.9

0.1

-1.1

0.0

0.7

-0.3

cover your mouth when coughing or sneezing

-2.1

-4.1

2.2

6.9

3.4

2.8

3.4

keep at least 1 meter distance from others. 

-6.4

-2.8

5.8

4.1

1.1

5.8

3.4

do not leave the house / flat

52.6

64.9

63.4

69.8

69.9

72.3

66.1

contact the sanitary and epidemiological station after you came back from another country where Coronavirus disease 2019 has been reported

5.7

4.4

15.1

23.3

6.1

0.8

11.3

drink alcohol

-0.5

-2.9

-2.6

-2.6

-3.6

-0.3

-2.3

avoid products made in China

-1.2

-0.2

-1.9

-2.8

-2.8

-1.5

-2.2

What should I do if signs of infection appear?

notify the sanitary and epidemiological station

0.3

1.1

6.8

5.1

8.6

11.1

6.6

report to the emergency department in the nearest hospital

1.8

1.3

-4.6

-7.7

-12.2

-7.5

-6.4

go to family doctor

0.9

-0.2

-2.4

-5.6

-7.3

-6.2

-4.2

report to an infectious disease ward or observation and infectious disease ward

-11.4

-0.5

-26.0

-6.4

-26.4

-21.3

-19.1

What would be for you the biggest obstacle in everyday life due to Coronavirus disease 2019 pandemic?

inability to go to your workplace or place of study

-18.0

-10.7

14.5

3.4

9.7

13.0

8.2

cancelled mass events, such as performances, conferences, concerts

1.8

6.3

-2.6

-4.0

4.1

3.2

-1.6

cancelled trips, flights

6.4

4.7

-4.9

-0.7

6.3

-16.1

-4.1

quarantine or isolation from loved ones due to quarantine

3.8

-15.5

15.0

-3.5

-3.3

17.9

5.6

no products and food in shops or higher prices in stores

-40.2

-25.7

-34.5

-32.9

-43.7

-45.0

-36.7

no personal protection equipment in stock

12.0

11.1

6.7

8.1

4.3

-8.8

5.6

Does any of the following aspects worries you due to the spreading infection?

nothing worries me

-10.2

-5.9

-27.1

-23.0

-15.0

-19.7

-19.6

my own health and life

1.9

3.6

10.7

10.7

-1.4

5.6

5.9

health and life of my family

19.9

12.6

34.3

28.1

21.0

22.9

26.5

being quarantined

-14.4

-11.5

-16.8

-18.9

-26.9

-15.9

-18.2

economic crisis

70.2

51.8

64.0

65.2

72.6

56.8

64.1

my education

18.3

9.2

51.4

19.8

41.8

39.4

37.3

Which of the following are your sources of knowledge about Coronavirus disease 2019?

TV news

0.5

14.1

30.6

2.4

19.7

14.5

16.4

radio

-3.0

0.5

6.3

-8.4

0.7

2.0

0.0

newspapers

-0.2

6.5

1.0

1.3

-1.7

-1.3

0.1

websites such as: onet, interia, wp, gazeta.pl, trójmiasto.pl

5.8

17.0

10.2

10.5

6.3

8.2

7.1

website of the Ministry of Health of the Republic of Poland

10.9

16.0

27.7

28.0

31.8

22.3

27.4

websites such as: onet.pl, interia.pl, wp.pl, gazeta.pl, trójmiasto.pl

4.0

8.8

0.3

22.5

18.3

-1.2

9.6

family members and friends

2.0

5.6

-3.5

-6.8

7.5

13.4

0.2

social media: Facebook, Tweeter, Instagram

-18.4

11.2

3.9

-6.1

-6.4

2.2

-3.6

Discussion

The COVID-19 pandemic is a rapidly spreading global threat that in one way or another affects everyone, regardless of their profession and age. The study reported in this paper was a spontaneous and quick response to a unique and new social situation, designed to gain a measure of understanding of Poland's population knowledge of and reactions at two very different phases of the epidemic's development in Poland. Due to the crucial role of medical professionals in tackling the pandemic, the sample was divided into the two main cohorts, medical and non-medical.

The pandemic is a new, ongoing and rapidly changing phenomenon. There are no long-term studies about COVID-19 or social reactions to either the threat or the restrictions and, therefore, this study can be compared only with the currently published cross-sectional studies, ongoing COVID-19 studies and studies regarding previous epidemics of the 21st century: SARS-CoV-1, Ebola and MERS [15].

Communities’ knowledge about COVID-19

Even at the beginning of pandemic in Poland, nearly all of the respondents knew that the SARS-CoV-2 attacked the pulmonary system. Moreover, this level of knowledge was maintained a month later.

The three main symptoms of the infection (cough, fever, shortness of breath) were well known, similarly to other studies [16]. Only the three main symptoms of the infection were shown on the governmental posters [17] and that is probably the reason why the non-medical respondents were mostly aware just of those. At the beginning of the epidemic, muscle pain and tiredness were mentioned only by specialised sources of scientific knowledge [1, 11] and that is the reason why only physicians knew about them. After a month, an overall increase in the awareness of other symptoms was observed.

In March 2020, Poles knew the COVID-19 was an airborne disease, similar to the UK and US populations [16]. After a month, they also knew that the virus could spread via direct and indirect contact. Researches marked answers pointing to these three ways of transmission as correct, as the preventive measures promoted by the government [17] to limit the spread of COVID-19 were: hand washing that limits indirect contact, covering mouth to reduce airborne transmission and social distancing, which reduces direct contact. People were highly aware of these prevention steps.

At the beginning of the epidemic, Poles knew they should call sanitary-epidemiological services or visit an infectious diseases ward if experiencing COVID-19 symptoms. Unfortunately, some people would also visit a general practitioner clinic or an emergency department. This would be a fundamental mistake as these places were not taking sufficient anti-COVID-19 preventive measures [18]. The same behaviour was noticed in Italy during COVID-19 and in South Korea during the MERS epidemics [19]. This is most likely due to the typical way the healthcare systems operate, including the Polish one. If one needs to see a physician, one goes to a general practitioner (mild cases) or an emergency department (severe cases). This changed during the pandemic as the healthcare system had to adapt to the new conditions. Fortunately, during the second assessment, a threefold and fourfold drop was observed in the percentage of respondents mentioning a general practitioner or emergency department visit with COVID-19 symptoms, respectively. This is an excellent improvement in the society's knowledge that limits the COVID-19 spread. This happened as the “do not’s” were added on posters, too [20].

Why did the Poles have such high levels of knowledge about COVID-19 that further increased later on? At the beginning, the most crucial information (transmission routes, prevention, what to do if one has symptoms) was broadly disseminated via leaflets, posters [17, 20], and mass media news reports, and repeated multiple times so people had a chance to encounter and learn it. A similar pattern was observed in other countries affected by the pandemic [21]. What is more, before the virus arrived in Poland in March, the pandemic had already been ongoing for several weeks (months, if counting from the first Wuhan infections) and had already affected many other countries worldwide (China, South Korea) and in Europe (Italy) [3]. Thus, people in Poland had more time to prepare for the new threat. Searching for information using various media could be used to reduce anxiety levels by helping people to understand the upcoming, unprecedented situation [21–23]. On the practical level, increasing one's knowledge helps to avoid infection [16].

The differences between medical and non-medical populations are understandable in the light of the requirement for continuous professional education among medical professionals. Furthermore, medical professionals form the first line of defence against COVID-19. Thus, this group had naturally more interest and a larger need to prepare early and more effectively to protect themselves.

COVID-19 information sources and their evaluation

In general, people felt quite well informed to start with, and after a month the information confidence had slightly increased further. This is a result similar to other studies [24]. General news websites and social media were the main sources of knowledge for non-medicine-oriented respondents, which explains why at the beginning of the pandemic many people were not familiar with the up to date events and findings presented in scientific knowledge sources. Conversely, medicine-oriented community preferred science-oriented or governmental websites. Again, this group choose these sources to educate themselves as they were the first line of defence against COVID-19.

In the second wave of the study the respondents indicated using other sources of knowledge than they had used a month earlier. More respondents visited governmental and science-oriented websites. This difference was particularly noticeable among the non-medical cohort. Additionally, due to the lockdown restrictions and isolation [12], people were spending much more time at home. Thus, more people had time to watch television and learn about COVID-19 from TV broadcasts, which explains the greater popularity of this information source in the second round of the study.

Pandemic-induced fears and their changes

At the beginning of the pandemic in Poland the virus had already spread to all inhabited continents and clearly affected societies worldwide. In general, insecurity was the most alarming factor for the Poles, who felt more threatened with COVID-19 compared to, for example, people in China [21]. The probable reason was that at the beginning of the epidemic in China, the residents were not aware of the gravity of the situation and the consequences that the pandemic would bring. Moreover, media were devoting a lot of coverage to the epidemic in China [25]. All these induced additional fears among the Poles.

A month after the first survey was conducted, the situation in Poland had changed dramatically. Numerous governmental restrictions were imposed on the citizens in order to stop COVID-19 from spreading [4–6]. As a result, more than 95% of the respondents surveyed in the second wave of the study were scared of something (picked at least one item in the 10th question) and a 20% increase in this measure was observed between the first and the second wave of the study (Table 4, Table 5).

More specifically, however, at the beginning people were worried about the quarantine (69.1%), rising grocery prices (61.2%), and their families (60.2%) (Table 2). Later on, the main fears included economic crisis (+64.1%), education system crisis (+37.3%), and families’ health (+26.5%). On the other hand, the respondents were less often afraid of quarantine (-18.2%) or price increases (-36.7%) (Table 5).

The quarantine and isolation

As quarantine and isolation cause a separation from the family, loss of freedom, and boredom, it is understandable [23] that people would like to avoid it and that at the beginning of the epidemic they were scared of it. However, the quarantine and isolation is crucial in preventing the pandemic from spreading [26]. Due to their concerns quarantine and isolation some people might not comply with the lockdown rules, which could result in higher incidence rate in the population. After a month, the quarantine became widespread and many people themselves or their family members had to undergo quarantine. This familiarity may be the reason why, after a month of the lockdown, the respondents were less afraid of being quarantined.

Worry about family members

At the beginning many people were worried about the health of their family, similarly to the results noted in other studies [24]. Such concerns increased as the government imposed physical distancing, quarantine and isolation, especially for the elderly who have the greatest mortality risk [27]. Over time, the number of cases of COVID-19 in Poland increased [8].Additionally, many healthcare systems could not manage COVID-19 without being overwhelmed (lack of hospital beds and medical personnel) which resulted in a high death toll, for example in Italy [9]. These may be among possible reasons why concerns about the health of respondents' families considerably increased and were the most frequently selected reason for worry in the second wave of the survey.

Financial crisis

People expected that in the short time, the prices for products in shops would rise [28] as an effect of decreased and prolonged delivery services, for example due to border controls. Such thinking caused many people to stockpile for the upcoming pandemic [29].

Many people have lost their only sources of income [30] and some businesses will not survive the pandemic [31]. The fear of job loss is experienced by 26% of the Poles [32]. Moreover, as the pandemic spread globally, a threat of a worldwide economic crisis has emerged [33]. As a result, the threat of an economic crisis registered the greatest increase among all reasons for worry listed in the survey.

Education crisis

Relatively low fear rate at the beginning of pandemic in three surveyed "student" cohorts was observed. With introduction of the lockdown restrictions, students could no longer attend their educational facilities. With time, students started to worry about their future and their fear rates increased in the wave two of the study. Students of medicine-oriented faculties reported this worry most frequently, likely because their courses included practical classes like laboratory classes or clinical workshops that cannot be taught online.

Fears among medical professionals

Being the first line of defence against COVID-19 for over a month, there was no respondent among nurses and physicians who did not pick at least one reason for worry. This shows that as the pandemic spread, medical professionals felt more and more endangered, possibly due to rising stress levels and tiredness. Moreover, in the second wave of the study medical professionals were the only group who did not indicate their absence at work as a worrisome problem. There is a likelihood that they would rather not go to work if they had any choice. This interpretation is consistent with the results from other studies, where physicians reported reluctance to work and even considered resignation [34]. Moreover, doctors experience high levels of posttraumatic stress [35], which suggests a need to pay more attention to psychological problems of the medical professionals, especially as members of this population suffer from vicarious traumatization [22] and seek increased social support during the pandemic [36].

The significant advantage of this survey is the fact that the first phase of the survey was conducted at the onset of the pandemic in Poland [3]. This allowed for monitoring of the change in level of knowledge and attitudes to COVID-19 among the Poles by repeating the same survey after a month. Furthermore, an online survey is an optimal method for collecting data during this dynamically changing situation, since it is faster and requires no contact between people, thus being more convenient than traditional methods.

Due to the shortness of time available for creating an ad hoc spontaneous survey, the interpretation of the findings from the study was subject to methodological limitations. It should be mentioned that some facts about the virus have not yet been scientifically proven and they change over time. Moreover, the samples in wave one and wave two of the study were not matched, and their demographic and professional composition differed to some extent, as the researchers did not conduct  a follow-up survey and, as a result, anyone could fill in the survey in either or both waves – thus it is possible that some of the responses in wave two were from respondents who completed wave one, and some responses were from new respondents. Regardless of this methodology limitation, the samples were treated as independent samples coming from the same population. To increase the likelihood of obtaining a comparable sample, the survey was distributed by the same information channels in both waves. It is also problematic to assess whether respondents looked up answers to any of the knowledge questions while completing an online questionnaire.

Conclusions

Due to their good initial knowledge about symptoms, transmission, and preventive behaviours regarding COVID-19, the Polish population appears to have been prepared for the peak of pandemic’s cases. People had more short-term concerns, like the possibility of rising grocery prices or worries about coping with quarantine and isolation. Over time, the knowledge and the fears among the respondents changed and at the end of the study they reflected long-term pandemic management issues. After a month, more people reported being scared of the pandemic in general, as well as economic and healthcare crises. The quarantine was not perceived as being as stressful as often as in the first wave. Students concerns were related to the education crisis. Medical professionals reported higher level of fear of the pandemic than other groups included in the study. Over time, a transition from the use of popular mass-media to more scientific sources of information was observed among the non-medical sub-population.

Compared to other studies, this study used before-and-after approach, which highlights the changes in people’s knowledge and perception of the COVID-19 pandemic over a period of time and the progression of the pandemic. It shows Polish communities’ transition between the onset of the epidemic and the time of the most extreme lockdown provisions against the COVID-19 pandemic in Poland.

List Of Abbreviations

Coronavirus disease 2019 (COVID-19)

World Health Organisation (WHO)

novel coronavirus 2019-nCoV (SARS-CoV-2)

Declarations

Ethics approval and consent to participate

All participants had to read a written consent form for purposes of this study before fulfilment of the survey. Fulfilment of the survey by the participant was an equivalent to his or her consent to take part in this study. The Bioethics Committee of the Medical University of Gdańsk had given its approval to carry out this study. Bioethics Committee of the Medical University of Gdańsk approval number: NK BBN/157/2020.

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

Not applicable

Authors' contributions

WN and KN created the survey and wrote abstract, results, discussion and conclusions. JL wrote the introduction section and helped in survey development. AP wrote the methods and material section, helped in survey development, and applied for approval of the Bioethics Committee of the Medical University of Gdańsk. AS and MB reviewed the manuscript. MB analysed the data statistically. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

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