key: cord-0905004-af2p1r66 authors: Boutsikari, E. C.; Christakou, A.; Elpidoforou, M.; Kopsidas, I.; Nikolovienis, N.; Kardara, D.; Boutsikari, C. C.; Triantafyllou, C. title: Public's perceived importance of non-pharmacological interventions for COVID-19 control in Greece: preliminary evidence from a cross-sectional study date: 2020-07-17 journal: nan DOI: 10.1101/2020.07.15.20153098 sha: 50c0a1a26340b36383970e2fcd7b3f38a57f793a doc_id: 905004 cord_uid: af2p1r66 Background: In the early stages of coronavirus disease 2019 (COVID-19) pandemic, while effective pharmaceutical approaches are pending, COVID-19 management relies primarily on non-pharmaceutical interventions (NPIs), such as social distancing,which requirepublic's engagement and behavioral adjustment. This study aims to evaluate public's perceived importance of the NPIs imposed for COVID-19 control in personal and public health protection in Greece. Methods: This cross-sectional online study, enrolled 657 adult participants from the general Greek population in order to assess their beliefs and evaluate possible factors that influence their perceptions as regards NPI importance in personal and public health protection. Results: Overall, Greeks considered NPIs important for health protection. The participants who were less likely to consider NPIs important were men (OR versus females=1.64, 95% CI:1.15 to 2.36, p=0.007), people younger than 40 years old (OR between ages over 40 versus ages below 40=0.48, 95% CI:0.34 to 0.68, p<0.001), and people who did not chose the Hellenic National Public Health Organization (EODY) to get informed about COVID-19 (OR of EODY versus other sources of information = 0.65, 95% CI:0.46-0.92, p= 0.014). Conclusions: This study profiled Greek people who do and do not consider NPIs important, mainly as of their demographic features. Focused communicational strategies in certain population subgroups are recommended. In December 2019, the first case of coronavirus disease 2019 was reported in Wuhan China, signifying the beginning of a pandemic caused by SARS-CoV-2, a virus subsumed in a large family of zoonotic RNA single stranded viruses, known as corona viruses [1] . COVID-19 research is already a vibrant field as a search for the term "COVID-19" on PubMed on May 5th, 2020 yielded more than 9,200 publications that include the term "COVID-19" in their title or abstract, a random search of which suggest that most, if not all of them, are indeed relevant to COVID-19. Despite the profound quick global reflexes on public health research, the vast majority of studies relevant to COVID-19 are of general medical [1] and pharmacological interest[9, 10], while less research is being done on the role of public's perception in this global emergency. The aim of this study was to assess public's beliefs and evaluate possible factors that influence public's perceptions as regards NPI importance in personal and public health protection, in order to provide future recommendations that will enhance NPI effectiveness. The study was conducted in accordance with the recommendations of the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement [11] . This study was a cross-sectional online survey which started immediately after the national lockdown in Greece (March 23 rd ). We analyzed the preliminary data obtained from the participants between March 25 th and the first week of May 2020. Ethical approval was granted by the University of West Attica, Athens, Greece (ID:29341). Participants were asked to provide informed consent in order to gain access to the survey questions. All procedures were conducted in line with the Declaration of Helsinki [12] . Respondents were recruited through Facebook, where research assistants and research coordinators distributed the survey to public Facebook groups. The online survey was hosted on "Qualtrics" [13], a secure data collection platform. Inclusion criteria: 1. Participants are able and willing to provide informed consent 2. Participants are between 18 -85 years old . 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) The copyright holder for this preprint this version posted July 17, 2020. This study was an anonymous online survey and participants were informed, before providing consent, that inclusion of personal information was not allowed. Data are kept in the platform and only study investigators sustain access to them, while no paper-based files were utilized. The study was based on the existing literature about perceptions of infectious disease control measures [7] and it was undertaken through a self-developed structured completion form, adapted to assess public's perceptions as regards NPIs. The form consisted of 24 questions divided into 3 sections related to demographic factors, knowledge questions, beliefs about the importance of NPIs and self-reported adherence to home quarantine prior to national lockdown. Lastly, an open-ended field was provided for comments and feedback. Certain epidemiological terms related to COVID-19 control were assessed for their comprehensibility in awareness and belief section, by using information included in the main guidelines for COVID-19 control, as provided by the Hellenic National Organization of Public Health (EODY) [14] . These terms were "incubation period" and . 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) The copyright holder for this preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint "contact with SARS-CoV-2", with the last being defined as one's contact with a symptomatic confirmed COVID-19 case or an asymptomatic SARS-CoV-2 carrier, which is not followed by the individual's symptomatic manifestation. Furthermore, as person in "high risk" for COVID-19 infection, was considered any respondent clinically compatible to COVID-19 or anyone who had travelled within March or had contacted another person clinically compatible to COVID-19, whereas "low risk" respondents were those who had not travelled, or met people with COVID-19 symptomatology or having manifested COVID-19 symptomatology themselves. Biases associated with the verbal frame of surveys were avoided at the best applicable degree. Simple and comprehensible language was used, the valid answers in the questions with "right/wrong" design were the incorrect ones in order to minimize the halo effect [15] , while optimal recall periods where adjusted in the domains of interest [16] . In 2020, the Greek population was estimated in 10,430,130 people [17] , with more than 80% of them sustaining Facebook accounts [18] , thus Facebook users were considered a numerically representative source population. Sample size calculation based on the overall Greek population, with a confidence level of 95% and a 5% margin of error, determined that 385 respondents were required for the completion of the study, according to the Cochran's formula [19] . All questions apart from demographic factors were a posteriori scored in order be furtherly assessed. Section about knowledge and awareness of the NPIs included 10 . 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) The copyright holder for this preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint multiple choice questions, with each one granted 1 point when answered correctly and 0 when answered incorrectly, thus the overall section score ranged from 0 to 10. In belief section 11 NPIs were given to be rated as of their importance for public and personal health, through horizontal 11-point numeric unipolar gliding scales ranging from 0 to 10, where 0 was "not important at all" and 10 "extremely important", with the overall score of this section found between 0 and 110. Lastly, 4 questions relevant to self-reported adherence to home-quarantine were given, where every answer relevant to adherence was granted 1 point, and every opposite answer was granted 0 points, with the overall score of the section ranging from 0 to 4. All details about the scoring methodology are demonstrated on Table 1 . [ Table 1 ] The numeric variables utilized to assess perceived importance of NPIs were the scores of knowledge and self-reported behavior as regards home quarantine. Demographic factors apart from sex and risk status, which naturally sustain two categories, were categorized into two subgroups. Since public's perceptions were found different between post-secondary education and other education levels, as well as between areas with the most confirmed COVID-19 cases and the other areas of a country [7], post-secondary education was assessed separately from other education levels, likewise Athens from other areas of Greece. There is evidence that ages above 40 are related to higher possibility of infection [20] and higher case -fatality rate in Europe [21],thus age was categorized based on that cutoff point. As of cohabitation, people living with at least one infant or elder person were considered a different subgroup from those who did not. Formal government announcements were studied separately from every other source of information, in accordance to research approach of the existing literature [22] . . 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint The analysis included only fully completed forms, with or without missing values. Missing values were addressed by the default approach of the statistical package which is the "listwise deletion" method [23] . Descriptive statistics and total responses were calculated for all variables and Spearman's correlation coefficient was utilized for collinearity control among numeric variables. The outcome analyzed, namely the dependent variable, was the score regarding perceived importance of NPIs and it was dichotomized according to the "median split" method [24] .Univariate analyses were performed to identify the exposure variables which demonstrate the greatest association with the outcome. A multivariate logistic regression model was used to evaluate relationships between the outcome and the exposure variables, while odds ratios (OR) and their 95% confidence intervals (95%) were used to quantify these associations. Logistic regression was performed with the "forward stepwise" method, where the ratio of observations to the independent variables was kept above 5 [19] . Based on our study design, data were assumed to be independent and a p-value<0.05 was considered as statistically significant for all comparisons. The analysis was performed by the statistical package STATA ©, version 16.0. The survey was initially completed by 669 individuals. Of those, 12 were excluded because they stated permanent residence outside of Greece. Demographic characteristics of the remaining 657 participants are described in Table2. [ Table 2 ] . 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint Overall, the participants demonstrated high knowledge score (mean=7, Standard Deviation (SD) =1.53). Four hundred thirty-seven participants (67.96%) were aware of the term "contact with the new coronavirus", as well as of all the main symptoms of COVID-19 (n=507, 78.97%). The term "incubation" though was understood only by 107 (16.56%) participants. Details about knowledge questions are provided in Table 3 . [ Table 3 ] The mean score of the NPIs as of their importance in personal and public health protection was 98.84. The highest score in personal health protection was given to hand hygiene measure which demonstrated a mean score of 9.82 and the lowest score to mask and glove usage (mean = 6.73). In public health protection the same NPIs prevailed, with the highest importance score being given to hand hygiene and the lowest score to mask and glove usage, with mean scores 9.83 and 6.44, respectively. Self-reported adherence to home quarantine, was found above average, with a mean value equal to 2.59 (SD=0.88). Prior to the national lockdown, the majority of the participants (n=370, 58.92%) were capable of staying all day in the house from 0 to 4 days per week, while the remaining 258 (41.08%) of them could stay in the house from 5 to 7 days. The main barrier in one's ability to apply home-quarantine proved to be work duties (n=317, 49.53%), and the main facilitator was the respondents' sense of duty in adhering to NPIs (n=547, 86.41%). Detailed description about perceived importance of NPIs and selfreported adherence to social distancing are demonstrated in Table 4. . 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 preprint this version posted July 17, 2020. This research aimed to assess public's beliefs and evaluate possible factors that influence public's perceptions concerning importance of NPIs in health protection. A unique aspect of this study is that it estimates Greek population's perceptions in the field of COVID-19, . 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 preprint this version posted July 17, 2020. Greek community rated NPIs as important, a fact that possibly played a major role in Greece's success in prompt COVID-19 control and early flattening of the epidemic curve [29] .Although scoring high on knowledge questions and despite the respondents' high education level, "incubation" appeared to be incomprehensible, since it was misinterpreted by the majority of the participants (77.86%) as the symptom period, a fact that consists an apparent knowledge gap. Future research should investigate the . 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint "knowledge gap hypothesis" in COVID-19, a phenomenon observed in other infectious diseases too [22] , in which information is unequally distributed thorough a social system, where highly educated individuals are more properly informed than individuals of lower socioeconomic status. Provided that the sample of this study was mainly of high educational background, and yet unable to understand "incubation", only assumptions can be made about knowledge gaps among people of different educational status. Limitations of this study lie primarily on biases existing by the study design [15, 16] such as sampling bias, according to which the lack of internet access or social media 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint should not only be carefully designed in order to achieve proper and equable information of the population, but targeted on the population subgroups that underestimate the importance of NPIs. The investigation of these issues will contribute in more effective and efficient management of prospective COVID-19 epidemic outbreaks and in enhancement of public health protection strategies. . 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint Contributors ΕΒ conceived and funded the study. ME and IK contributed in the design of the form. CT and AC reviewed the form. All authors contributed in manuscript composition and revision before submission. The final draft was reviewed by CT. This study is self-funded by the first author (ECB); no supplementary funding was provided for this study. Dataset available upon request . 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 preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint The authors declare that they have no conflicts of interest. This article does not contain any studies with animals performed by any of the authors. This article contains a cross-sectional online study with anonymous participation of humans. All procedures were performed in accordance with the ethical standards of the Institutional Research Committee which granted the ethical approval, the 1964 Declaration of Helsinki and its later amendments. Informed consent was obtained from all individual participants included in the study, prior to participation. Not required. . 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 preprint this version posted July 17, 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. The copyright holder for this preprint this version posted July 17, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted July 17, 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. The copyright holder for this preprint this version posted July 17, 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. The copyright holder for this preprint this version posted July 17, 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. The copyright holder for this preprint this version posted July 17, 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. The copyright holder for this preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 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) The copyright holder for this preprint this version posted July 17, 2020. . https://doi.org/10.1101/2020.07.15.20153098 doi: medRxiv preprint Coronavirus Infections in Children Including COVID-19: An Overview of the Epidemiology, Clinical Features, Diagnosis, Treatment and Prevention Options in Children Early dynamics of transmission and control of COVID-19: a mathematical modelling study Ερωτήσεις και απαντήσεις για τον νέο κορωνοϊό SARS-Cov-2 για τις εκπαιδευτικές μονάδες A Catalog of Biases in Questionnaires Choice of recall period for patient-reported outcome (PRO) measures: criteria for consideration Greece Population (2020) -Worldometer. (n.d.). Retrieved Social Media Stats Greece. (n.d.). StatCounter Global Stats. 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