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.