General public Knowledge of coronavirus disease 2019 (COVID-19) at early stages of the pandemic: results of a random online survey in the Kingdom of Saudi Arabia

Abstract Background: A novel coronavirus was identied at the end of 2019 in Wuhan City, China. Later, the World Health Organization (WHO) named the disease caused by the virus coronavirus disease 2019 (COVID-19) and declared a pandemic in March 2020. Saudi and global health agencies have provided various COVID19 knowledge tools and facts to the general public. Therefore, this study aims to assess COVID-19 knowledge among the general public in Saudi Arabia at the early stages of the pandemic, including knowledge of prevention practices, home quarantine measures, and compliance with governmental restrictions. Subjects and methods: A cross-sectional study was conducted in March 2020 during the COVID-19 pandemic in Saudi Arabia. The study included 1006 participants who responded to a random online COVID-19 public knowledge questionnaire that included ve sections: demographic characteristics, general knowledge, prevention practices, home quarantine measures, and knowledge of governmental restrictions. Data were collected from a random sample recruited through the circulation of the questionnaire on social media platforms and were then analysed by descriptive statistical methods. Three levels of knowledge were established: excellent, intermediate, and poor. Differences in the percentages of participants with different knowledge levels by the demographic variables were analysed using the chi-square test. Results: Regarding overall general knowledge of COVID-19, 75%, 24%, and 1% of the participants had excellent, intermediate, and poor knowledge levels, respectively. Knowledge levels were signicantly different by nationality and age (P=0.027 and 0.008, respectively). The majority of participants (98.4%) reported excellent knowledge of prevention practices, with no statistically signicant differences among groups (P>0.005). Older age groups reported higher knowledge of home quarantine measures (86.6% and 86.4% of the 51-60 and older than 60 age groups, respectively, P=0.001). Approximately 50% of Saudis reported excellent knowledge of the restrictions imposed by the Saudi government to control the spread of COVID-19, while approximately 45% of non-Saudis had an excellent level of knowledge (P= 0.009). Conclusion and recommendations: High levels of knowledge about the virus, including prevention

However, the two epidemic CoVs that have emerged in humans in the last 2 decades, SARS-CoV in 2003 and MERS-CoV in 2012, had devastating consequences. Notably, both epidemic CoVs belonged to beta CoV subgroups, and the outbreaks resulted in high case fatality rates. SARS-CoV affected at least 8000 individuals with a case fatality rate of approximately 10% [8], whereas MERS-CoV affected more than 2000 people, and the case fatality rate was approximately 35% [9].
Recently, a more virulent CoV was identi ed at the end of 2019 in Wuhan, a city in Hubei Province of China [7]. The virus was temporarily named 2019 novel coronavirus (2019-nCoV) by the World Health Organization (WHO) [10]. On February 11, 2020, the WHO named the virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease caused by the virus coronavirus disease 2019   [11]. In a short period, SARS-CoV-2 spread rapidly and resulted in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world. Based on this global spread of SARS-CoV-2, a pandemic was declared by the WHO on March 11, 2020 [12].
SARS-CoV-2 can be transmitted by both symptomatic [13] and asymptomatic individuals [14]. Although the extent of infection is unknown among asymptomatic individuals, it is reported to be from 0.45% to 5% among symptomatic individuals. SARS-CoV-2 is reported to have an incubation period of 14 days [15,16], with a median incubation period of 4 days [16] to 5.1 days [17]. The severity of COVID-19 symptomatic infection ranges from mild to critical. Most infections are not severe [16]. The severity depends predominantly on advanced age or underlying medical comorbidities. Various clinical studies have reported COVID-19 case fatality rates from 0.7 to 7.2% [13,18,19] with notably increased mortality rates associated with older age. Among the clinical manifestations, pneumonia appears to be the most frequent, primarily accompanied by fever, fatigue, dry cough, anorexia, myalgias, dyspnoea, and bilateral in ltrates on chest imaging [7,20,21].
Saudi Arabia reported the rst case of COVID-19 on March 2nd, 2020, for a person who arrived from Iran through the Kingdom of Bahrain [22]. Consequently, newly recorded cases of COVID-19 continued to increase, and the rst reported death in Saudi Arabia was recorded on March 24th, 2020 [23]. Due to the rapid spread of COVID-19 across countries and the increasing number of reported cases and deaths, the Saudi government imposed extreme restrictions to control the spread of COVID-19, which included closing schools and universities, banning domestic and international travel, and temporarily suspending group prayers at mosques, including Umrah at the holy mosque in Makkah. Moreover, local and global health agencies started to provide various COVID-19 knowledge tools and information for the general public. Therefore, this study aimed to assess COVID-19 knowledge among the general public in Saudi Arabia, including knowledge of prevention practices, home quarantine measures, and compliance with governmental restrictions.

Study design
A cross-sectional study was conducted in March 2020 during the early stages of the COVID-19 pandemic. Data were collected using Google Forms, through which an online questionnaire was randomly circulated on social media platforms such as Twitter, Facebook, and WhatsApp in the Kingdom of Saudi Arabia with no consideration as to the geographic location of participants. The study collected responses from the general public regardless of their demographic characteristics or their degree of risk for acquiring COVID-19. Responses were collected for one week until no more responses were received. Raosoft [24] sample calculation software recommended a minimum of 385 subjects using the total Saudi population size of people aged 15 years or older of 25,828,206 [25], response distribution of 50%, con dence interval of 95%, and margin of error of 5%. A total of 1363 responses were received, including responses from 357 healthcare workers, which were excluded from this study. The nal sample consisted of 1006 random responses from the Kingdom of Saudi Arabia. The study included subjects of both genders who were at least 15 years old. Ethical approval was obtained by the research ethics committee at King Khaled University in Abha, Saudi Arabia. Participants were asked to take part in the study voluntarily and to not provide personal or identity-revealing information.

Study tools
Data were collected using a questionnaire that was designed based on the latest general public information on COVID-19 published by the Centers for Disease Control and Prevention, the Saudi Ministry of Health, and the Saudi Center for Disease Prevention and Control [10,26,27]. The questionnaire comprised ve sections: demographic data, general COVID-19 knowledge, prevention practices knowledge, home quarantine knowledge, and knowledge of governmental measures to stop the spread of COVID-19. Questions were prepared and arranged according to pretested available questionnaires designed to assess public knowledge and awareness of infectious diseases [28]. Furthermore, except for the high-risk group question, which had four choices with one most appropriate answer, all the other questions had three options: as "Yes", "No", and "I do not know". The most appropriate answers were considered the correct responses and scored "one", while inappropriate answers and "I do not know" answers were considered incorrect responses and scored "zero". The reliability of the questionnaire's sections was evaluated by conducting a pilot study on 87 participants. Cronbach's alpha coe cients were as follows: general knowledge=0.82, prevention knowledge=0.76, home quarantine knowledge =0.69 and governmental restrictions knowledge=0.76). Similarly, the scienti c credibility and validity of the tool was evaluated by three independent public health preventive medicine experts, who provided feedback on the accuracy, relevance, and simplicity of the included questions and statements with reference to the knowledge sources used to create the questionnaire, which resulted in the improved clarity and presentation of all items.

Statistical analysis
Three levels of knowledge were established: excellent, intermediate, and poor.
Moreover, the scores were classi ed in three close intervals as follows: two-thirds and more correct responses was considered "excellent", one-third to less than two-thirds correct responses "intermediate," and one-third and less correct responses "poor" [29].
Demographic variables were analysed using the frequency distribution for categorical variables. The chisquare test was used to test the differences in knowledge levels by selected independent demographic variables for categorical and proportion data. The statistical signi cance level was set at a P-value < 0.05. All analyses were performed using the statistical software package STATA (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX).

Results
The total cohort consisted of 1006 participants after we excluded healthcare workers, who might have introduced bias due to the main study objective, i.e., to test the knowledge of the general public. There were no missing data, as the questionnaire was designed to capture complete responses to all questions. Data were collected after the WHO declared COVID-19 as a pandemic and a threat to the world's public health [12]. During the period of data collection, the number of con rmed positive COVID-19 cases in Saudi Arabia ranged from 500 to 1200, with four reported cases of death [23]. Participants were categorized according to their gender, nationality, age group, and level of education. Male participants accounted for 61.7% of the total sample, and the 21-30 and 31-40-year-old age groups were the largest two segments, representing 34.3% and 29.1% of the participants, respectively. Moreover, Saudi nationals accounted for 92.3% of participants, and participants with a college or university degree accounted for 72.4% of the total respondents (Table 1).
General knowledge of COVID-19 was assessed by 14 questions on high-risk groups, transmission, availability of a vaccine and treatment, signs and symptoms, and possible complications ( Table 2). Regarding overall knowledge of COVID-19, 75%, 24% and 1% of the participants had excellent, intermediate, and poor knowledge levels, respectively.
Speci cally, the differences in the reported levels of knowledge by gender and level of education were not statistically signi cant. In contrast, we found that older participants were signi cantly more likely to have excellent knowledge levels than younger participants (P-value of 0.008). Moreover, Saudi nationals had signi cantly higher levels of knowledge than non-Saudi nationals (P-value of 0.027).
Knowledge of COVID-19 prevention practices, such as the avoidance of crowded places and close contact with people who had tested positive, correct practices for coughing and sneezing, social distancing, cleaning and disinfection of surfaces, and stay at home measures, was measured through another set of questions and statements (Table 3). Most participants (98.4% of all respondents) reported an excellent level of knowledge of COVID-19 prevention practices regardless of their demographic characteristics.
There were no statistically signi cant differences across categories. Table 3 presents the percentages of participants with different levels of prevention knowledge by demographic characteristic.
Participants were asked questions related to what they should do if they were in home quarantine due to a de nite or suspected case of COVID-19, and 75.8% and 22.5% of participants reported excellent and intermediate knowledge, respectively. Participants in the older age groups reported higher knowledge of home quarantine knowledge and compliance, as the age groups of 51-60 years old and more than 60 years old were the two age groups with the highest percentages of excellent responses (86.6% and 86.4%, respectively) (P-value of 0.001) ( Table 4).
As the government of Saudi Arabia took extreme measures to control and stop the spread of COVID-19, participants' knowledge of measures required by the government was assessed. Table 5  Currently, there are no speci c vaccines or treatments for COVID-19. However, scientists from all over the world are evaluating potential treatments, as evidenced by the many ongoing clinical trials. Consequently, focusing on strategic prevention measures by educating the public about the disease caused by the virus and how the virus spreads seems to be an important proactive measure. The majority of participants in our study showed an excellent level of knowledge of prevention practices. The fact that there are no available vaccines and treatments should enhance people's compliance with prevention measures such as social distancing and personal hygiene practices.
Excellent knowledge of prevention was reported by approximately 95% of participants in this study. These results on knowledge of prevention practices demonstrate two ndings. First, an excellent level of knowledge was the dominant outcome. Second, there were no signi cant differences among the demographic groups, which illustrates consistency in practices related to COVID-19 prevention measures and practices by the general public. In contrast to our ndings, an online survey of respondents in the United States and the United Kingdom showed inappropriate conceptions of COVID-19 transmission and prevention among participants that was mainly caused by false social media content [32]. Furthermore, high knowledge levels of COVID-19 prevention might help limit the spread of the virus as the world, including Saudi Arabia, races to control COVID-19 by working on potential vaccines and treatments. Meanwhile, high levels of prevention knowledge should be sustained with more and frequent simpli ed guiding information and tools, which will help minimize the spread of COVID-19 by increasing individuals' knowledge until an effective vaccine and treatment become available.
The questions related to knowledge of home quarantine were constructed based on the latest WHO recommendations for persons who have been exposed to people who tested positive for COVID- 19 [33]. Compliance with home quarantine relies on good knowledge of its requirements. In addition, our ndings showed acceptable levels of home quarantine knowledge considering that home quarantine was an uncommon practice in Saudi Arabia until COVID-19 became a global pandemic. More speci cally, older participants reported higher levels of knowledge than younger participants less than 30 years old. This nding emphasizes the need to focus on young people using relevant content and platforms, which will enhance their knowledge and compliance with COVID-19 home quarantine requirements.
Reported knowledge of the measures required by the government to prevent the spread of COVID-19 was the lowest among all types of knowledge in this study. Overall, approximately 50% of participants reported excellent knowledge, and we observed differences in knowledge levels by nationality and level of education. Additionally, the study illustrates that high levels of knowledge of the disease and its prevention measures might not be enough to support compliance with the imposed restrictions by the government, such as complete or partial lockdowns. In addition, non-Saudi nationals reported knowledge levels of governmental measures that were clearly below those reported by Saudi nationals, which is consistent with the higher rates of infection among non-Saudi nationals [34].

Conclusion
Knowledge of COVID-19 in general was excellent, including knowledge of prevention practices and home quarantine measures. However, knowledge of governmental restrictions to stop the spread of COVID-19 was excellent only among half of the participants. The study recommends that ongoing updates on COVID-19 information, directions, and prevention measures continue to be provided with enhanced clarity and emphasis of messages related to governmental restrictions to control COVID-19.

Limitations of the study
This study has various limitations, such as a lack of other comparable studies, as the topic is still evolving. Consequently, this limitation was addressed through the comparison of our outcomes with the results of studies related to SARS-CoV or MERS-CoV instead.
Furthermore, some answers to the questions included in the study tool might have been easily guessed, and a future study that includes distracting answers might be helpful in determining levels of COVID-19 knowledge. Moreover, data collection for this study was carried out through the random circulation of the questionnaire on social media covering a random sample of people in Saudi Arabia, which did not ensure equal representation across all demographic variables and regions. Although the sampling procedure and the results do not present a nation-wide outcome, researchers might nd this study useful when conducting studies of the same or a similar concept in a nationally representative sample. Finally, the outcomes of this study might be relevant only to Saudi Arabia due to differences in the circulation of COVID-19 information in other countries. For instance, populations in Saudi Arabia rely heavily on social media as a source of information, which might not be the case in other locations. https://www.who.int/docs/default-source/searo/whe/coronavirus19/the-guideline-for-homequarantine---quarantine-in-non-health-care-settings-is-intended-for-anyone-who-believes-they-havebeen-exposed-to-covid-19-and-are-required-to-be-home-quarantined-to-prevent-community-trans.pdf?