Psychological Impacts and Attitudes of the Syrian Population Regarding the COVID-19 Pandemic and Face Masks During the First Syrian Lockdown

Background This study assesses the attitudes and psychological impacts regarding COVID-19 and face masks among the Syrian population during the current pandemic and war. A web-based cross-sectional Arabic survey design was employed. The survey was distributed in May 2020 during the COVID-19 pandemic and civil war in Syria. The survey contained items relating to socio-demographic characteristics and items assessing attitudes regarding COVID-19, and face masks. The chi-square test was applied to the questions against socio-demographic variables. Results Of the 4148 participants, 3053(73.6%) were female, and 3238(78.1%) were single. 423(10.2%) and 1573(37.9%) stated they had poor and moderate economic status respectively. Home quarantine has led to an increase in family problems 3016(72.7%) and has had a negative psychological impact upon 1666(40.2%) Syrians. 538(13.0%) are shy about wearing face masks in public.

Having an inferior view of those who wear a face mask signi cantly differed across gender (p<0.001), age group (p<0.001), and education level (p<0.001) ( Table 7).
Worrying about what people would say about you if you wear a face mask signi cantly differed across age group (p<0.001), social status (p<0.001), education level (p=0.013), and occupation (p<0.001) ( Table 8).

Discussion
To the best of our knowledge, this is a rst report assessing Syrians Attitudes and psychological impacts regarding both COVID-19, and face masks during the current pandemic.
Our results showed that approximately half of the participants believed that the pandemic will be nally controlled. This nding is lower compared with studies conducted in China and Malaysia. (21,22) This attitude could be attributed to the severely under-equipped Syrian healthcare system that lacks the capacity to contain such a pandemic. The estimated number of intensive care unit beds with ventilators is a mere 325, and the theoretical maximum number of cases that can be adequately treated is only 6,500.(23) In the absence of a vaccine, effective treatment protocol for COVID-19 and medications at the time of the survey, the hope of such a crisis to be tamed has diminished.
The majority of participants supported wearing face masks publicly. Since the outbreak of COVID-19, the importance of using face masks has become ubiquitous. Previous studies conducted at the same institution reported a high level of awareness, 89.3% knew that wearing a face mask outside was a preventive measure against the spread of COVID-19; however, only 39.1% of the Syrian population wore face masks publicly.(24, 25) Face masks can break the transmission cycle of respiratory microorganisms.(5) However, effectiveness can be limited by the lack of any of the following 3: knowledge, practice, and attitude.
Almost all participants did not have an inferior view of those who wear a face mask. Despite that, a small proportion of participants stated they will stop wearing face masks if they are embarrassed or bullied by individuals. This result re ects the lack of national bullying helplines and organizations to support victims in Syria.
The quarantine negatively affected participants' psychological state, with the majority suffering from an increase in family problems, and feeling lazy and inactive. This is not surprising as the majority of them were abiding by home quarantine rules. A study conducted during the COVID-19 pandemic revealed that most Syrians suffer from depressive (83.4%) and anxiety (69.6%) symptoms.
This novel pandemic parallels a deteriorating Syrian economy and has increased demand for many products including face masks resulting in a supply shortage-driving the nation into a hyperin ation crisis.(26) Millions of Syrians are in poverty, forced to choose between buying food to escape starvation and face masks to escape morbidity and mortality.(27)

Strengths and limitations:
A major strength of this study lies in its large sample recruited during a critical period, the early stage of the COVID-19 pandemic and the civil war. On the other hand, this study has several limitations. First, due to the over-representation of the well-educated Syrians of good socio-economic status, in the sample, the ndings may not generalize to other groups of the Syrian population especially those who lack access to the internet. Elderly and rural residents that have limited access to the internet represented a minority in this study. Second, self-reporting has certain limitations compared with structured interviews. Third, Credible published national data regarding the socio-demographic characteristics of Syrians are not available to evaluate the representativeness of our sample.

Conclusion
This study has revealed varying attitudes and signi cant psychological impacts regarding both the COVID-19 pandemic and face masks. Based on the ndings the Syrian government must put efforts into providing national helplines for Syrians and reach out to targeted groups to provide further support.

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 following relevant guidelines and regulations.
Consent for publication: Not applicable.
Availability of Date and material: All data generated or analysed during this study are included in this published article and its supplementary information les.
Competing interests: The authors declare that they have no competing interests. Funding: This research did not receive any speci c grant from funding agencies in the public, commercial, or not-for-pro t sectors.
Authors' contributions: BB conceptualized the study, participated in the design, wrote the study protocol, performed the statistical analysis, did a literature search, and drafted the manuscript. FM participated in study design, did a literature search, and drafted the manuscript. DM, SA, and AN conceptualized the study and participated in the design. MM participated in statistical analysis. JK and YL did a literature search and revision of the draft. All authors read and approved the nal draft. the COVID-19 Pandemic. 2021:1010539521997261.   Table 3 Attitudes of participants by socio-demographic characteristics, n(%)   Table 5 Attitudes of participants by socio-demographic characteristics   Table 7 Attitudes of participants by socio-demographic characteristics, n(%) 9. Are you shy about wearing a mask and/or gloves in the street in front of people?

Supplementary Files
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