Knowledge, Attitude and Practice Assessment on COVID-19 Infection: A Systematic Review Protocol

Background: The coronavirus disease 2019 (COVID-19) is an emerging respiratory disease caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has been declared a public health emergency of international concern (PHEIC) by the World Health Organisation (WHO) on 30 January 2020. We aim to systematically review the tool used for the assessment of the knowledge, attitude, and practice (KAP) on Covid-19 infection. Methods: We will conduct a systematic review of knowledge, attitude, and practice assessment on COVID-19 infection. The search will cover the period December 2019 to January 2021. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality will be assessed using the STROBE checklist for a cross-sectional study. Data will be analysed using descriptive statistics. The numerical outcome will be analysed using mean and standard deviation. The categorical outcome will be analysed using absolute number and percentage. The range number of items, reliability, and validity of each domain will be assessed descriptively. Discussion: This systematic review of KAP measurement tools will provide a detailed summary of the existing tools used to assess the KAP levels towards COVID-19 and its’ reliability and validity in different settings and populations. Also, the review will provide evidence on the importance of the reliability and validity of the assessment tools in ensuring quality data from future research.


Background
The coronavirus disease 2019 (COVID-19) is an emerging respiratory disease caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). Since then, it has spread very fast to more than 200 countries and has been declared as a public health emergency of international concern (PHEIC) by the World Health Organisation (WHO) on 30 January 2020 (2). For more than a year, the global has lived with the SARS-COV-2 virus. Yet, this infection is continued to spread with more than 158 million cases, with 3.2 million deaths reported globally (3). While in Malaysia, we could see that one wave after another hit the country with the latest re-surging of cases since early April 2021 (4). This has been postulated that could be a sign of pandemic fatigue in the population, which can be de ned as demotivation to follow the recommended protective behaviours, emerging gradually over time and affecting many emotions, experiences, and perception (5).
Furthermore, the uncertainties, fake news, and misunderstanding on the COVID-19 itself would cause a lot of confusion among the public. This can directly affect how people react and behave towards COVID-19, in which any incongruence may lead to the deterioration of the preventive and control behaviours.
Consequently, this indicates the need to assess the knowledge, attitude, and practice (KAP) towards COVID-19 and the anticipated challenges for such assessment in the post-COVID-19 era.
KAP survey is referred to a study that is conducted to collect the information on the knowledge (based on what the people known), attitudes (based on what the people thought and perceived) and practices (based on what the people followed or done) either on a general or speci c topic. It is usually done through a structured interview or self-directed by the respondents using a standardised questionnaire that may include quantitative and qualitative data (6). The KAP survey is very useful as the data generated from the survey can identify the knowledge gaps, cultural beliefs, and behavioural pattern, which can further identify the needs and barriers in implementing speci c health interventions. Also, the data will deepen the understanding, attitude, practice and the factors associated with the studied topic and behaviour. Of course, the data also can act as baseline data to be compared following the implementation of a particular intervention. These will help the policymaker and stakeholders to be able to set a program and decision depending on the priorities (6). In the case of COVID-19, the effect of the implementation of movement control order, health education campaigns as well as vaccination program can also be measured using the KAP survey, which also can be done from time to time (7)(8)(9) COVID-19 infection is known to be caused by a novel virus. Till now, the essential public health intervention such as hand hygiene, social and physical distancing and wearing mask with or without eye protection remains as the best weapons to combat the disease regardless of the vaccine's arrival (10).
The effectiveness of these measures is very much dependent on the cooperation and compliance of the population (11). On top of that, following the vaccination program on COVID-19, which has started, the KAP survey can also be one of the approaches to assess the impact from time to time and especially in terms of the factors that may be associated with the acceptability of the vaccines (6,12). To support the importance of the KAP survey and the questionnaire used, we need to ensure that the data gained from the KAP questionnaire should be reliable and valid for the usage of the intended population so that it can help to collect a better quality of data with high comparability and credibility of the data (13). It should be appropriately developed, validated, and psychometrically sound (14). Although using an existing questionnaire will save time and resources but, the questionnaire that measures the construct of interest may not be readily available or not available in the language that researchers want to (14). Perhaps, people tend to take it for granted and decided to use a questionnaire that has only shown good reliability without testing its validity. This has led to the need for this review in assessing the KAP survey tools available for COVID-19 in the literature and the validity and reliability of the tools.
To our knowledge, there are no published systematic reviews that focus on the assessment tool of the knowledge, attitude, and practice of COVID-19, similar to our study. Previous systematic reviews may cover the patterns of knowledge, attitudes, and practices on the COVID-19 in Ethiopia (15,16) and the factors associated (17). This review aims to identify, describe and evaluate the KAP assessment tool on COVID-19 available in the literature. A comprehensive review of all questionnaires on the KAP studies on COVID-19 will be collated and con rm the valid and reliable assessment tool for future KAP research in this eld.

Registration
This study protocol has been registered under the INPLASY registry with the registration number INPLASY202150039. The review will be done following the reporting standards suggested in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Eligibility Criteria
The research question was performed by identifying the type of evidence needed to answer the question.
The strategy uses domain, determinant, and outcome (DDO) format in the study. DDO format will be used to obtain relevant answers and to identify the question, and concentrate the mind.
The domain will be the "COVID-19". The determinant is an "assessment" OR "questionnaire" OR "survey".
The outcomes will be "knowledge" OR "attitude" OR "practice".
The searching procedure will be conducted using bibliographic databases and other evidence sources to address the review question. The procedure of a comprehensive literature search will be looking at the eligibility articles, searching strategy for identi cation of studies, study selection, and data extraction.
The studies that do not meet the speci c inclusion criteria for this study will be eliminated. The inclusion criteria in this study are research articles and case reports, human studies, English language, and articles published from December 2019 to January 2021. The exclusion criteria are review articles, in vivo or in vitro studies, other languages, non-free full-text articles. This systematic review will consider the only cross-sectional study of good quality.

Search Strategy for Identi cation of Studies
The search strategy aims to obtain published articles only. The process of searching strategy for identi cation of studies will include all published studies. It involved a three-stage protocol (Figure 1). The rst stage will be followed by an analysis of the text words contained in the titles and abstracts and of the index terms used to describe each article. In the second stage, a Boolean search will be conducted using the identi ed keywords of the selected databases. In the third stage, the reference lists of key articles will be searched for additional studies.

Published articles
The published articles referring to any article have been published in peer-reviewed indexed journals. The rst step is to locate the published articles for this research using computer-based information search.
The established databases to be searched in this review will be WHO COVID-19, Science Direct, Scopus, PubMed, MEDLINE, and EMBASE.
Boolean search will be performed on each database using the search term: "COVID-19" AND ("assessment" OR "questionnaire" OR "survey") AND ("knowledge" OR "attitude" OR "practice"). The published literature will be carefully searched for this study. An initial limited search of WHO COVID-19, Science Direct, Scopus, PubMed, MEDLINE, and EMBASE databases will be undertaken.

Screening Title and Abstract
Study screening and selection of potentially eligible studies will be conducted by at least two independent researchers. Titles and abstracts of studies retrieved using the abovementioned search strategy will be downloaded into the reference manager tool, Endnote software. When all researchers agreed on a suitable title and abstract, the full-text of the article will be retrieved. Duplicated articles will be deleted.

Obtaining Full-text Published Articles Studies
All published articles will be searched. Full-text articles will be obtained and downloaded from the established resources (WHO COVID-19, Science Direct, Scopus, PubMed, MEDLINE, and EMBASE) with a search term. Articles searched in this study were only obtained in a free article. The articles without full text will be excluded from the study.

Selecting Suitable of Full-text Published Articles
The process of selecting suitable full-text published articles will be done and selected by the three reviewers who expert in methodology and topic under review. An agreement of inclusion and exclusion criteria will be made before starting the review process. It will be reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ow diagram (18). Then, valid articles will be assessed for their quality before retrieving information. Any disagreements between the reviewers will be resolved through discussion and consideration to the fourth reviewer.

Critical Appraisal
Three independent researchers will perform the critical appraisal to assess study quality and minimise bias. Most methods encompass issues such as appropriateness of study design to the research objective. The articles which do not ful l the and poor-quality studies will be excluded or discussed in detail. The methodological quality of the studies will be assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) for a cross-sectional study. Any disagreements between the reviewers will be resolved through discussion and consideration to the fourth reviewer.

Data extraction
Two independent researchers will perform data extraction to establish inter-rater reliability and avoid data entry errors. Study context factors of published articles will include the information describing the study and its subjects. Reported ndings of the remaining studies will be extracted onto a data extraction form.
Lists of included studies will be then created. Data extraction will be independently cross-checked.

Data Management
All relevant articles will be manually coded in the spreadsheets and described in evidence tables. The electronic spreadsheets will be utilised to import the data into excel form for data analysis.

Outcome measures
The outcome measures reported in studies meeting the inclusion criteria will be grouped under the following headings: country, questionnaire items, study population, language, number of items in each domain (knowledge, attitude, and practice), and the validity and reliability of each domain.

Descriptive analysis
A narrative synthesis of the outcomes of the selected studies will be presented in the nal review. This will include the following: the country where the study conducted, questionnaires items, study population, language used in the questionnaire, number of items in each domain (knowledge, attitude, and practice), and the validity and reliability of each domain.

Statistical Analysis
We are interested in the assessment of the knowledge, attitude, and practice on COVID-19 infection. Data will be analysed using descriptive statistics. The numerical outcomes will be analysed using mean and standard deviation. The categorical outcomes will be analysed using frequency and percentage. The statistical analysis will be performed using Statistical Package of Social Science Version 27.

Discussion
This systematic review of KAP measurement tools will provide a detailed summary of the existing tools used to assess the KAP levels towards COVID-19 in different settings and populations. Besides, the review also will evaluate the reliability and validity of the assessment tools used in measuring the knowledge, attitude, and practice in various settings and countries. We anticipate that this review will be helpful and bene cial to the stakeholders and researchers seeking a valid and reliable assessment tool on KAP of COVID-19 and improving the methods of data collection in the future. This comprehensive review also provides evidence on the importance of the reliability and validity of the assessment tools in ensuring quality data from future research.