key: cord-308400-8wihm63b
authors: Kanellopoulou, A.; Koskeridis, F.; Markozannes, G.; Bouras, E.; Soutziou, C.; Chaliasos, K.; Doumas, M. T.; Sigounas, D. E.; Tzovaras, V. T.; Panos, A.; Stergiou, Y.; Mellou, K.; Papamichail, D.; Aretouli, E.; Chatzidimitriou, D.; Chatzopoulou, F.; Bairaktari, E.; Tzoulaki, I.; Evangelou, E.; Rizos, E. C.; Ntzani, E.; Vakalis, K.; Tsilidis, K. K.
title: Awareness, knowledge and trust in the Greek authorities towards COVID-19 pandemic: results from the Epirus Health Study cohort
date: 2020-11-13
journal: nan
DOI: 10.1101/2020.11.10.20229146
sha: 
doc_id: 308400
cord_uid: 8wihm63b

Background: To assess the level of knowledge and trust in the policy decisions taken regarding the coronavirus disease (COVID-19) pandemic among Epirus Health Study (EHS) participants. Methods: The EHS is an ongoing and deeply-phenotyped prospective cohort study that has recruited 667 participants in northwest Greece until August 31st, 2020. Level of knowledge on coronavirus (SARS-CoV-2) transmission and COVID-19 severity was labeled as poor, moderate or good. Variables assessing knowledge and beliefs towards the pandemic were summarized overall and by gender, age group (25-39, 40-49, 50-59, 60+ years) and period of report (before the lifting of lockdown measures in Greece: March 30th to May 3rd, and two post-lockdown time periods: May 4th to June 31st, July 1st to August 31st). An exposure-wide association analysis was conducted to evaluate the associations between 153 explanatory variables and participants' knowledge. Correction for multiple comparisons was applied using a false discovery rate (FDR) threshold of 5%. Results: A total of 563 participants (49 years mean age; 60% women) had available information on the standard EHS questionnaire, the clinical and biochemical measurements, and the COVID-19-related questionnaire. Percentages of poor, moderate and good knowledge status regarding COVID-19 were 4.5%, 10.0% and 85.6%, respectively. The majority of participants showed absolute or moderate trust in the Greek health authorities for the management of the epidemic (90.1%), as well as in the Greek Government (84.7%) and the official national sources of information (87.4%). Trust in the authorities was weaker in younger participants and those who joined the study after the lifting of lockdown measures (p-value <= 0.001). None of the factors examined was associated with participants' level of knowledge after correction for multiple testing. Conclusions: High level of knowledge about the COVID-19 pandemic and trust in the Greek authorities was observed, possibly due to the plethora of good quality publicly available information and the timely management of the pandemic at its early stages in Greece. Information campaigns for the COVID-19 pandemic should be encouraged even after the lifting of lockdown measures to increase public awareness.

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The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint BACKGROUND 97

In December 2019, a cluster of patients suffering from atypical pneumonia was identified in the city of 98

Wuhan, China (1). The outbreak was caused by a novel coronavirus named Severe Acute Respiratory 99

Syndrome-Coronavirus-2 (SARS-CoV-2), which shares pathogenicity characteristics with Severe Acute 100

Respiratory Syndrome-Coronavirus (SARS-CoV) and Middle East Respiratory Syndrome-Coronavirus 101 (MERS-CoV), both responsible for epidemics caused in the 2010s (1,2). The rapid spread of the virus 102 around the globe led to a huge public health crisis and on March 11 th , 2020, the World Health Organization 103 (WHO) characterized coronavirus disease (COVID-19) as a pandemic (3). Up to August 24 th , 2020, more 104 than 20 million cases and 800,000 deaths due to the disease were recorded globally (4). 105

In Greece, the first cases of COVID-19 were confirmed in late February, 2020 and within a period of one 106 month, 1,212 people were diagnosed with the disease resulting in 46 deaths (5). The Greek Government 107 took immediate action to minimize the spread of the virus by applying a series of public health measures, 108

including the cancellation of local carnivals, closing of schools, universities, gyms, archaeological sites and 109 eventually shopping malls, cafeterias, restaurants, bars and beauty parlors. From March 23 rd to May 4 th , 110 2020, a mass lockdown was enforced, whereby citizens could leave their residences only under certain 111 circumstances and after special notification (5). 112

From the onset of the COVID-19 pandemic, a large amount of information has been produced with respect 113 to the biological features of the virus and the necessary measures of protection as well as the epidemiology 114 of COVID-19. Human-to-human SARS-CoV-2 transmission is achieved primarily through droplets coming 115 from infected person's coughing or sneezing that can land directly on the mouth, nose, or eyes of a nearby 116 person or on the surface of objects (6). Most common clinical symptoms of COVID-19 are loss of 117 taste/smell, fever, cough, myalgia, fatigue and dyspnea (7). The rates of asymptomatic carriers are unknown 118 with current estimations ranging from 40% to 45% and up to 62% of transmission may occur prior to the 119 onset of symptoms (8, 9) . Evidence on the SARS-CoV-2 transmission by asymptomatic cases exists but 120 relevant details still remain under discussion (10). 121

The need to control transmission necessitates the assessment of awareness, knowledge and adapted 122 practices towards the new pandemic among the general population. Therefore, the primary objective of this 123 study was to investigate the levels of knowledge and beliefs on the COVID-19 pandemic and the magnitude 124 of trust upon Greek authorities and how these measures differed according to age, gender and time period 125 among the participants of an ongoing Greek cohort study, the Epirus Health Study (EHS). We also explored 126 possible factors associated with the population's knowledge regarding SARS-CoV-2 transmission and 127 seriousness of COVID-19 in a high-dimensional, agnostic manner to provide guidance for future public 128 health policies tailored to certain population subgroups. 129

The EHS (https://ehs.med.uoi.gr/) was initiated in June 2019 and is an ongoing population-based 133 prospective cohort study, which aims to provide meaningful insight on the complex etiology of 134 multifactorial chronic diseases and contribute to the improvement of the overall health state of the Greek 135 population. The EHS cohort consists of permanent residents of the northwest region of Epirus in Greece, 136 aged 25 to 70 years. Recruitment methods include advertisements to the local press and social media, 137 promotions via study's website, participation in events organized by local health agencies and invitations 138

to Epirus residents and especially to the staff of companies of the private and public sector. Up to August 139 31 st , 2020, a total of 667 subjects agreed to participate. 140

The study was approved by the Research Ethics Committee of the University of Ioannina and is conducted 141 in accordance with the Declaration of Helsinki. All participants provide written informed consent prior to 142 participation in the study. 143 144 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

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Socio-demographic characteristics, general health status and lifestyle data 146 All participants were interviewed by two trained interviewers with the use of a standard questionnaire at 147 recruitment. Information was collected regarding i) socio-demographic characteristics, such as age, gender, 148 place of birth, marital status, educational level, employment status and income, ii) general health status, 149 including symptoms of anxiety and depression, iii) personal and family medical history, and iv) lifestyle 150 factors, including physical activity and sedentariness, smoking habits, alcohol consumption, cellphone use, 151 sleep patterns, birth history, reproductive factors in women, cancer screening, medication and dietary 152 supplement use, and dietary behaviours with a special focus on adherence to Mediterranean diet. 153

Symptoms of anxiety and depression were assessed with the two leading questions from the General 154

Anxiety Disorder-7 (GAD-7) (11) and the Patient Health Questionnaire-9 (PHQ-9) (12), respectively. 155

Adherence to Mediterranean diet was estimated by calculating the 14-point Mediterranean Diet Adherence 156 Screener (MEDAS), which defines adherence as low (0-6 points) or high (7-14 points) (13). The 157

participants' sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) (14), which ranges 158 from 0 to 21 and the higher the score, the poorer the sleep quality. Participants were classified as non-159 smokers, former smokers and current smokers according to their self-reported smoking habits. Finally, 160 duration of recreational physical activity was assessed in days per week and minutes per day and then 161 converted to metabolic equivalents of energy expenditure (MET). Each type of activity was assigned to a 162 specific MET score, that is, 3.0 for walking, 6.0 and 9.0 for moderate-intensity and vigorous-intensity 163 physical activity, respectively (15). The activity-specific MET value was then multiplied by the duration of 164 activity in number of hours per week. 165

All participants attended a series of extensive clinical examinations at the baseline visit by two trained 167 medical professionals. Weight and standing height were measured after removal of heavy clothing and 168 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint shoes. Waist and hip circumference were measured at standing position after taking a deep breath at the 169 thinnest spot of the waist and the widest spot of the hip, respectively. All anthropometric variables were 170 measured using SECA equipment. Bioelectrical impedance analysis was performed using the Tanita MC-171 780MA machine. Pulse oxymetry was performed using the H-100B EDAN. Systolic and diastolic blood 172 pressures were measured using the MicroLife A6 PC-AFIB PC monitor. Arterial stiffness was measured 173 using the Mobil-O-Graph PWA New Generation 24h ABPM Classic monitor (16). In addition, cognitive HDL and TG, respectively, and 3.30%, 6.62%, 4.41%, 6.34% and 4.72% for the between-lab variability. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint towards the available information regarding the pandemic and trust in the Greek Government and health 194 authorities for mitigating COVID-19. The COVID-19 sub-questionnaire was administered with face-to-195 face interviews, except for participants who joined the study before May 18 th , 2020, for whom telephone-196 based interviews were conducted. If the corresponding answers were "No" and "Many people survive, many people die", "Some people 208 survive, most people die" or "Almost everyone dies", respectively, then the knowledge status was 209 characterized as moderate. Finally, good knowledge was established if participants answered correctly to 210 all aforementioned questions (Additional File 1). 211 212

Participants' baseline characteristics were summarized using means and standard deviations (SD) for 214 continuous variables, and percentages for categorical variables. All questions included in the COVID-19 215 sub-questionnaire were summarized overall and by gender, age group (25-39, 40-49, 50-59, ≥60 years) and 216 date of interview (March 30 th to May 3 rd , 2020, and two post-lockdown time periods: May 4 th to June 31 st , 217 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint 2020 and July 1 st to August 31 st , 2020). Pearson's chi-square and Fisher's exact tests were employed to 218 detect differences between subgroups. 219

An agnostic exposure-wide association analysis was conducted using ordinal logistic regression models to 220 quantify the associations between the level of participants' knowledge towards the COVID-19 pandemic 

Of the 667 subjects enrolled in the EHS cohort up to August 31 st , 2020, we excluded 105 (15.7%) 234 participants who joined the study before March, 2020 and could not be reached via telephone to answer the 235 COVID-19 sub-questionnaire. The distribution of baseline descriptive characteristics is shown in Table 1 , 236 and they were very similar between the EHS total and analytical sample [ Table 1 near here]. A total of 563 237 participants, 337 women and 226 men, constituted the analytical study sample, of them 170 women and 238 114 men completed the study before May 4 th , 2020 when lockdown measures were partially lifted. The 239 mean age of participants enrolled before or after May 4 th , 2020 was 48.6 (SD=11.1) and 48.7 (SD=11.0) 240 years, respectively. The majority (66.4%) of participants had university education, 31% were current 241 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint smokers, 43% drank alcohol at least once per week, reported low levels of recreational physical activity 242 and had a mean BMI of 26.6 kg/m 2 (SD=4.7), and mean body fat percentage of 28.4% (SD=7.8) ( Table 1) . 243 244

In Table 2 , COVID-19-related questions are presented in the total analytical sample and by gender, age 246 group and period of interview [ Table 2 near here]. The vast majority of study participants (98.4%) were 247 aware of the pandemic, although a significant difference was observed by gender as male participants 248 showed slightly smaller awareness (96.9% vs 99.4%, p-value=0.034). Only 14 (2.5%) participants reported 249 having a SARS-CoV-2 molecular test with none of them reporting a positive result. A total of 23 (4.5%) 250 participants reported that they believed they had contracted the virus, although not tested, and 42 (7.5%) 251 participants reported suffering from COVID-19-relevant symptoms during previous months, such as fever, 252 cough, dyspnea and loss of taste/smell. The percentage of participants reporting belief of self-infection and 253 symptoms of SARS-CoV-2 infection were higher for participants that joined the study during July and 254

August, 2020 (15% and 21.7%, respectively) compared to previous months (p-value<0.001). Only two 255 participants reported having a family member tested positive for SARS-CoV-2. Approximately 33% of 256 participants considered themselves as absolutely capable of protecting themselves against SARS-CoV-2 257 with higher proportions observed in earlier times of interview (by time period: 43.6% vs. 23.4% vs. 19.2%, 258 p-value<0.001), whereas 4.3% and 27.6% reported absolute and moderate certainty that they will not get 259 infected, respectively, and the percentage of moderate certainty decreased with time (by time period: 33.3% 260 vs. 27.4% vs. 14.2%, p-value<0.001) ( Table 2) . 261 262

More than 95% of participants reported that SARS-CoV-2 could be transmitted by droplets in the air, by 264 contacting infected people or by touching contaminated surfaces ( Table 2) . Approximately 14%, 28% and 265 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint 4% of participants reported that SARS-CoV-2 could be transmitted through blood transfusion, sexual 266 intercourse or mosquito bite, respectively, and a larger proportion of participants younger than 50 years 267 compared to older participants reported that SARS-CoV-2 can be transmitted through sexual intercourse 268 (p-value<0.001). Almost all participants (98%) reported that SARS-CoV-2 could be transmitted by 269 asymptomatic cases. Concerning COVID-19 severity, most participants (94.5%) reported that most people 270 who contracted SARS-CoV-2 survive and some die ( 

Only 12 (7.8%) explanatory variables were found significantly associated with the level of participants' 281 knowledge towards the COVID-19 pandemic at the 0.05 level (see Figure 1 and Additional File 2) [ Figure  282 1 near here]. Odds of having a lower knowledge status were associated with higher extracellular water-to-283 total body water ratio, increased incapability to fall asleep within 30 minutes during last month, frequent 284 talking on cellphone away from the ear during last three months, lower self-reported health status, higher 285 heart rate, frequent pain at night during last month, having family members diagnosed with acute depression 286 or osteoporosis/hip fracture and limited interest for personal or professional activities during last two weeks. 287

Higher pulse volume, increased trust in national health authorities to limit spread of the virus and increased 288 paid hours of work per week were associated with higher level of knowledge. However, none of these 289 associations were significant after correcting for multiple comparisons (Figure 1 and Additional File 2) . 290 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

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Publicly available information regarding COVID-19 pandemic was characterized as good (20.8%) and very 293 good (42.2%) by more than half of the study sample ( Table 2) , but the responses differed by time period 294 with more participants reporting better quality of information when interviewed before compared to after 295

May 4 th , 2020 (by time period: 70.6% vs. 58.3% vs. 50.9%, p-value<0.001). The percentage of study 296 participants who reported absolute and moderate trust in the Greek Government for mitigating the spread 297 of the virus was 44% and 40.7%, respectively; these percentages increased with higher age of participants 298 The participants demonstrated high levels of knowledge regarding SARS-CoV-2 transmission and COVID-310 19 severity without statistically significant differences by age, gender and time of interview. High levels of 311 trust in the Greek authorities for providing information and mitigating the spread of SARS-CoV-2 were 312 also observed, which were stronger in older participants and those that joined the study closer to the start 313 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. certain sleep disorder symptoms, higher heart rate and limited interest for participating in social and 337 professional activities were inversely associated with higher knowledge status that could be explained by 338 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint poorer ability to process relevant medical information. After adjustment for multiple testing, none of these 339 factors remained significant (smallest FDR-adjusted p-value= 0.19). The relatively small sample size and 340 the lack of large variability across participants' level of knowledge may partially explain our null results. Greek Government and health authorities decreased from approximately 92% and 94% in March/April, 354 2020 to 61% and 73% in July/August, 2020, respectively. Visual inspection of the trends did not provide 355 any insights on a potential correlation between the weaning trust and the patterns of the number of 356 This study is one of the first population-based studies conducted in Greece that not only attempted to shed 361 light on participants' perceptions surrounding the COVID-19 pandemic and trust upon authorities but also 362 evaluated trends by age, gender and time of assessment that can provide guidance for future public health 363 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint policies tailored to certain population subgroups. Another strength of the study includes that the COVID-364 19-related data were collected as part of an ongoing prospective and heavily phenotyped epidemiological 365 study, which provided the ability to systematically examine a number of potential factors and correlates in 366 relation to participants' level of knowledge for the pandemic. Several limitations should also be considered 367 in interpreting our findings. The sample size was relatively small, but several of our findings have been 368 previously observed in larger studies. The study sample constituted only by residents of the region of Epirus 369 and had a higher participation of women and individuals with university education; thus, findings might 370 not be generalizable to the general public. As a validated questionnaire to assess knowledge on the COVID-371 19 pandemic is not yet available, we constructed an aggregated variable to assess knowledge of SARS- is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Data are available upon reasonable request to the corresponding author. 420

The authors declare that they have no competing interests. 422 

Franssen PM, Imholz BP. Evaluation of the mobil-O-Graph new generation ABPM device using 488 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. 1 (0.2) 0 (0) 1 (0.3) 1 (0.8) 0 (0) 0 (0) 0 (0) 0 (0) 1 (0.6) 0 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

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Abbreviations: COVID-19, Coronavirus disease 2019; NA, Not applicable; SARS-CoV-2, Severe Acute Respiratory Syndrome-Coronavirus-2 *P-value from Pearson's chi-square test . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 13, 2020. ; https://doi.org/10.1101/2020.11.10.20229146 doi: medRxiv preprint Legends Figure 1 : Volcano plot showing results from the exposure-wide association study regarding the association between 153 clinical parameters, medical characteristics, demographic and lifestyle factors and knowledge regarding the SARS-CoV-2 transmission routes and COVID-19 severity in the Epirus Health Study cohort. The Yaxis shows the p-values in −log10 scale from the ordinal logistic regression models for each factor. The X-axis shows the estimated odds ratios for each factor. All models were adjusted for continuous age and gender. The black points indicate the continuous/ordinal exposures and the grey points indicate the categorical exposures. The dashed horizontal line represents the nominal level of statistical significance (0.05) and the solid horizontal line represents the FDRcorrected level of statistical significance (0.0003268). Abbreviation: COVID-19; Coronavirus disease 2019, ECW/TBW; Extracellular water-to-total body water ratio. OR; Odds ratio . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

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percentage (%) of Epirus Health Study (EHS) participants according to the level of knowledge for the COVID-19 pandemic ove up and date of report