DISCUSSION
According to our searches, so far, the survey is the first and only
nationwide KAP study conducted in Iran regarding COVID-19. Several KAP
studies have been carried out in Iran about the epidemic of viral
diseases such as Ebola, Crimean-Congo hemorrhagic fever, and H1N1
influenza, but all targeted specific groups such as students, residents,
and healthcare workers as study population (Askarian, Danaei, & Vakili,
2013; Holakouie-Naieni et al., 2015; Rahnavardi et al., 2008; Salimi et
al., 2016). Consequently, it was not possible to compare the level of
knowledge, attitude, and practice of Iranians towards different type of
viral disease epidemics. As we used some information from the recent KAP
study conducted in China to compile our questionnaire, it was possible
to compare some parts of the results between the two countries.
Since identifying demographic factors associated with KAP will be useful
for health policy-makers to recognize target populations for COVID-19
prevention and health education (Zhong et al., 2020), the effect of
different demographic groups on participants’ KAP was examined. In our
study, as in China, females had significantly more knowledge than males.
Similar results were obtained in KAP studies of SARS in Qatar and
Singapore (Bener & Al-Khal, 2004; Vijaya et al., 2004). Contrariwise,
results of the Indians KAP study regarding the H1N1 influenza epidemic
indicated males had higher knowledge than females (Kamate et al., 2010).
This discrepancy may be attributed to differences in the value of
countries’ indicator of adult female literacy rate. According to the
World Bank data, value of the indicator in Singapore(2018), China(2018),
Qatar(2017), Iran(2016) and India(2018) is 96, 95, 95, 81 and 66 %,
respectively(World Bank, 2019). In terms of age, younger respondents (18
to 25 years old) had poorer knowledge, attitude, and practice than other
age groups. Further, based on the post-hoc test, their practice score
was significantly lower than other age groups. Some studies have also
reported poorer knowledge in younger groups (Iliyasu et al., 2015;
Kamate et al., 2010; Zhong et al., 2020). According to data reported
from US CDC in March 16, 2020, showed that younger adults can be among
the at-risk groups of COVID-19, and some may need hospitalization, even
ICU (CDC weekly report)(CDC, 2020b). Therefore, they should be
considered as an important target group for further education. The mean
scores of marrieds’ knowledge, attitudes, and practice were higher than
singles. These findings agree with other studies (Iliyasu et al., 2015;
Kamate et al., 2010; Zhong et al., 2020).
Like many KAP studies (Iliyasu et al., 2015; Kamate et al., 2010; Xiang
et al., 2010; Zhong et al., 2020, the respondents’ knowledge was
directly related to their education level. However, there was no
significant difference between respondents’ attitude and practice with
different levels of education. In the KAP study of COVID-19 in China,
similarly, respondents with higher education had a slightly weaker
attitude, albeit the difference was not significant (Zhong et al.,
2020).
Similar to the Chines study, in which respondents received a mean score
of 90/100, in our study, the respondents’ level of knowledge was
assessed as very good with a mean score of 87.7/100. This shows that the
public education provided by the Ministry of Health through the national
official media at the beginning of the epidemic has greatly increased
the knowledge of Iranians and also reveals that the spread of
misinformation through informal media such as messengers has not had a
significant effect on public awareness. Furthermore, it can be
interpreted that the public has actively learned about COVID-19 due to
the serious situation of the epidemic and extensive news coverage (Zhong
et al., 2020).
One of the most challenging parts in the knowledge section of this
survey was the question about using face masks outside the home.
Contradictory news and misinformation about the virus being airborne in
the media may be one of the main reasons for this discrepancy. Health
authorities in different countries have also adopted different
decisions. In the latest documentary regarding the use of masks in the
context of COVID-19 which was released on April 6, 2020, WHO did not
consider the use of masks alone to be a complete preventative, and
declared that the use of masks not recommended for everyone (WHO,
2020a). The US CDC has also recommended that face masks should be worn
in public places, especially in places where it is not possible to
maintain social distance (CDC, 2020a). The disagreements in scientific
communities and even among health authorities around the world due to
the unknown nature of the virus and its characteristics can affect
public knowledge, attitudes, and practice and also confused them by the
propagation of misinformation without evidence. For example, a study in
Taiwan at the time of the outbreak showed that Internet searches for
COVID-19 and face masks were rapidly increased in the country
(Husnayain, Fuad, & Su, 2020). Despite the WHO’s advice and also the
recommendation of Iranian Health authorities, there are still some
resources and references have emphasized the use of masks for healthy
people in the community (Feng et al., 2020).
The results in the attitude section were slightly different. For
example, the results of the Chines study showed that 90.8% believed
that COVID-19 will finally be successfully controlled. In our study,
only 47.1% of respondents had a positive attitude toward the same
question. There are several possible reasons for the difference. First,
in the attitude section of our study, the 5 points Likert scale was used
to respond, so participants had more options than yes or no. For
example, in Chines study, the first question was a three-choice and the
second was a two-choice approach (Zhong et al., 2020). We also added two
more questions to the attitude section. Another notable rationale is
that, unlike China, this is the first widespread viral disease epidemic
in the country in recent decades that has affected everyone. Therefore,
the lack of experience in this field may cause a poor attitude among the
people. For instance, the level of healthcare providers’ attitude toward
MERS-CoV infection was reported to be very poor due to the novelty of
disease and lack of experience in dealing with it (Nour et al., 2015).
The other important reason for the relatively negative attitude of
Iranians compared to the Chinese toward the common question may be
attributed to the current economic and political situation of Iran
because of the imposition of the toughest sanctions(Takian, Raoofi, &
Kazempour-Ardebili, 2020), an important factor that can undermine
people’s confidence.
Due to proper public education and raising the level of knowledge, our
findings suggest that Iranians behaved well in the early stages of the
COVID-19 outbreak. Further, the outcomes of Pearson correlation test
indicated a positive correlation between sample knowledge, attitude and
practice. So sufficient public training will undoubtedly affect people’s
behavior. According to the Worldmeters data on 30 April 2020, from early
April, the daily Coronavirus active and new cases and also its death
have been declining (Worldmeters.info, 2020). Definitely, proper
practice of people in observing national preventive protocols is one of
the most important causes of the reduction of cases.