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KAP-COVIDGLOBAL: A Multinational Survey of the Levels and Determinants of Public Knowledge, Attitudes, and Practices towards COVID-19 ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-043971

Article Type: Original research

Date Submitted by the 19-Aug-2020 Author:

Complete List of Authors: Masoud, Ahmed; Faculty of Medicine Zaazouee, Mohamed; Al-Azhar University - Assiut Branch Elsayed, Sara; Faculty of Medicine Ragab, Khaled; Minia University Faculty of Medicine Kamal, Esraa; Fayoum University Faculty of Medicine Alnasser, Yusra; Damascus University Faculty of Medicine Assar, Ahmed ; Faculty of Medicine Noreldin, Anas; Al-Azhar University Faculty of Medicine Istatiah, Loai; Fayoum University Faculty of Medicine Abd-Elgawad, Mohamed; Fayoum University Faculty of Medicine Abdelsattar, Ahmed; Fayoum University Faculty of Medicine Sofy, Ahmed; Fayoum University Faculty of Medicine Hegazy, Doaa; Harvard Medical School Femía, Vistor; Universidade do Vale do Sapucai http://bmjopen.bmj.com/ Mendonça, Adriana; Universidade do Vale do Sapucai Sayed, Fatma; Fayoum University Faculty of Medicine Elmoursi, Ahmed; University of Kentucky College of Medicine Alareidi, Alaa; Rutgers University Abd-Eltawab, Ahmed; Fayoum University Faculty of Medicine Abdelmonem, Mohamed; Fayoum University Faculty of Medicine Mohammed, Omar; Fayoum University Faculty of Medicine Derballa, EzzEldeen ; Fayoum University Faculty of Medicine

Elfass, Kareem; King Faisal University on October 4, 2021 by guest. Protected copyright. Abdel-Daim, Mohamed; Faculty of Veterinary Medicine; King Saud University College of Science Abushouk, Abdelrahman ; ,

Keywords: PUBLIC HEALTH, EPIDEMIOLOGY, VIROLOGY

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4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 37 38 http://bmjopen.bmj.com/ 39 40 41 42 43 44 45 46 on October 4, 2021 by guest. Protected copyright. 47 48 49 50 51 52 53 54 55 56 57 58 59 60

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 KAP-COVIDGLOBAL: A Multinational Survey of the Levels and Determinants of 5 Public Knowledge, Attitudes, and Practices towards COVID-19 6 7 Ahmed Taher Masoud1, Mohamed S. Zaazouee2, Sarah M. Elsayed3, Khaled M. Ragab4, Esraa M. Kamal1, 8 Yusra T. Alnasser5, Ahmed Assar6, Anas Z. Nourelden7, Loai J. Istatiah1, Mohamed M. Abd-Elgawad1, 9 Ahmed T. Abdelsattar1, Ahmed A. Sofy1, Doaa G. Hegazy8, MD, Victor Z. Femía9, Adriana R. Mendonça9, 10 1 10 11 1 1 11 Fatma M. Sayed , Ahmed Elmoursi , Alaa Alareidi , Ahmed K. Abd-Eltawab , Mohamed Abdelmonem , 12 Omar M. Mohammed1, EzzEldeen A. Derballa1, Kareem A. El-Fas12, PharmD, Mohamed Abdel-Daim13, ‡ 14 ‡ * 13 PhD , Abdelrahman I. Abushouk , MD for the KAP-COVIDGLOBAL Investigators 14 15 16 1 Faculty of Medicine, FayoumFor University, peer Fayoum, review only 17 2 18 Faculty of Medicine, Al-Azhar University, Assiut, Egypt

19 3 th 20 Faculty of Medicine, 6 of October University, Giza, Egypt 21 4 Faculty of Medicine, Minia University, Minia, Egypt 22 23 5 Faculty of Pharmacy, Damascus University, Damascus, Syria 24 25 6 Faculty of Medicine, Menoufia University, Menoufia, Egypt 26 27 7 Faculty of Medicine, Al-Azhar University of Cairo, Cairo, Egypt 28 8 29 Department of Ophthalmology, Harvard Medical School, Boston, MA 30 9 Universidade do Vale do Sapucaí, Pouso Alegre, Minas Gerais, Brazil 31 32 10 Division of Gastroenterology, Department of Internal Medicine, University of Kentucky, Lexington, KY 33 34 11 School of Environmental and Biological Sciences, Rutgers University, New Brunswick, NJ http://bmjopen.bmj.com/ 35 36 12 College of Clinical Pharmacy, King Faisal University, Hofuf, Saudi Arabia 37 13 38 Department of Zoology, College of Science, King Saud University, Riyadh, Saudi Arabia & Pharmacology 39 Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt 40 14 41 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 42 on October 4, 2021 by guest. Protected copyright. 43 * All collaborators are listed in Appendix file 1. 44 ‡ Both authors contributed equally and are considered conjoined senior authors. 45 46 47 Correspondence: Abdelrahman I. Abushouk, MD; 330 Brookline Ave, Boston, 02115, MA 48 49 Tel: +1 6173978718; Email: [email protected] & [email protected] 50 51 OR Mohamed Abdel-Daim; College of Science, King Saud University, Riyadh, 11362, Saudi Arabia 52 Tel: +2 01014295780; Email: [email protected] 53 54 Manuscript Word Count: 3357 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Abstract 5 6 Objective: The adherence to public health recommendations to control COVID-19 spread is influenced by 7 8 public knowledge, attitudes, and practices (KAP). We performed this cross-sectional study to assess the 9 10 levels and determinants of public KAP towards COVID-19 in a large, multinational sample. 11 12 Design: Cross-sectional study (survey). 13 14 15 Setting: The questionnaire was distributed to potential respondents via online platforms 16 For peer review only 17 Participants: 71,890 individuals from 22 countries. 18 19 Methods: We formulated a four-section questionnaire in English, followed by validation and translation 20 21 into seven languages. The questionnaire was distributed (May-June 2020) and each participant received 22 23 a score for each KAP section. 24 25 26 Results: Overall, the participants had fair knowledge (mean score: 19.24±3.59) and attitudes (3.72±2.31) 27 28 and good practices (12.12±1.83) regarding COVID-19. About 92% reported moderate-to-high compliance 29 30 with national lockdown. However, significant gaps were observed: only 68.2% knew that infected 31 32 individuals may be asymptomatic; 45.4% believed that antibiotics are effective treatments; and 55.4% 33 34 http://bmjopen.bmj.com/ 35 stated that a vaccine has been developed. However, 71.9% believed or were uncertain that COVID-19 is a 36 37 global conspiracy; 36.8% and 51% were afraid of contacting doctors and Chinese people, respectively. 38 39 Further, 66.4% reported the pandemic had moderate-to-high negative effects on their mental health. 40 41

Female gender, higher , and urban residents had significantly (p≤0.001) higher knowledge and on October 4, 2021 by guest. Protected copyright. 42 43 44 practices scores. Further, we observed significant correlations between all KAP scores. 45 46 Conclusions: Although the public have fair/good knowledge and practices regarding COVID-19, significant 47 48 gaps should be addressed. Future awareness efforts should target less advantaged groups and future 49 50 studies should develop new strategies to tackle COVID-19 negative mental health effects. 51 52 53 Keywords: COVID-19; Knowledge; Lockdown; Masks; Multinational; Survey 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Strengths and limitations 4 5 6  Besides our large sample size (of both individuals and countries), such comparative study can help 7 8 9 international organizations focus their efforts on countries with less developed public KAP against 10 11 COVID-19. 12 13  In addition, we analyzed the association between KAP and demographic factors, history of COVID- 14 15 19, as well as the correlation between different scores and scales of mental health effects and 16 For peer review only 17 18 compliance to lockdown. However, this study is not without limitations. 19 20  First, as a cross-sectional study, the temporal relevance of our findings may change with time or 21 22 implementation of large-scale prevention measures. 23 24  Second, the elderly population (most vulnerable to COVID-19) only represents 3.9% of our sample. 25 26 27 This is probably related to the online distribution of the questionnaire, which is likely to draw 28 29 younger populations. 30 31  Third, as a self-reported questionnaire, respondents may have opted towards socially desired 32 33

choices rather than their actual KAP. http://bmjopen.bmj.com/ 34 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Introduction 5 6 Starting in China in December 2019, SARS-Cov-2 (the causative agent of COVID-19) has spread to almost 7 1 th 8 every country worldwide. As of August 14 2020, over 21 million confirmed cases have been reported globally 9 10 with more than 750,000 deaths.2 The disease is transmitted by respiratory droplets. After an incubation period 11 12 of two to 14 days, patients may develop fever, cough, dyspnea, fatigue, and sore throat or are commonly 13 14 asymptomatic.3 4 The main cause of death is fatal pneumonia and respiratory distress. Adults with chronic 15 16 diseases and those overFor 65 years peer of age are review the most vulnerable. only5 Although various drugs and vaccine 17 18 candidates are under trial, the management remains mainly supportive. Therefore, prevention measures as 19 20 social distancing, wearing face masks, and public awareness campaigns are key players in controlling the 21 22 6 23 pandemic. 24 25 However, there is lack of data on the awareness and practices of different populations and their influence on 26 27 28 COVID-19 burden. Small cross-sectional studies have been conducted in some countries e.g. a survey in the US 29 30 revealed that a large portion of the public lacked critical knowledge about COVID-19 and were not changing 31 32 their daily routine and hygiene practices as per the recommendations of health authorities.7 Similar reports 33 34 were obtained from small studies in Saudi Arabia,8 India,9 Malaysia,10 Italy,11 and Turkey.12 However, when http://bmjopen.bmj.com/ 35 36 coupled with extensive governmental awareness efforts, the public awareness on COVID-19 can be significantly 37 38 improved as revealed by recent studies from Saudi Arabia 13 and ,14 which would reduce infection rates 39 40 and alleviate the medical and economic burdens of the disease. 41 42 on October 4, 2021 by guest. Protected copyright. 43 The success of prevention efforts is tied to public adherence and the latter has been linked to public knowledge, 44 45 attitudes, and practices (KAP).15 16 A large-scale, horizontal evaluation of KAP towards COVID-19 across 46 47 different countries is lacking. Plus, this evaluation was not performed in most developing/low income 48 49 50 countries. In the present multinational survey, we aimed to assess the levels of public KAP in different countries 51 52 towards COVID-19 and to determine the factors that could influence public practices in this regard. Our findings 53 54 may have implications for public awareness efforts worldwide. 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Materials and Methods 4 5 6 2.1. Study Design and Participants: We conducted a multi-national, cross-sectional study to assess public 7 8 KAP towards COVID-19 in 22 countries, using an online self-administered questionnaire during the period 9 10 of May 10th to June 25th, 2020. The study was conducted and reported in consistence with the STROBE 11 12 13 checklist (Appendix 2). Any citizen of the included countries above the age of 16 who agreed to fill the 14 15 questionnaire was eligible to participate. There were no demographic restrictions on participation. 16 For peer review only 17 18 2.2. Sampling: We used a convenience sampling method for data collection. The sample size was 19 20 calculated for each country using the equation: n = z2P(1-P)/d2.17 Under a 95% confidence interval, 50% 21 22 response distribution and 0.05 margin of error, a sample of 384 participants was considered as a minimum 23 24 sample to represent large populations. However, due to the limitations of convenience sampling and 25 26 27 online surveying, we empowered our sample by including a design effect (DE) factor in the equation. 28 29 According to previous studies, the minimal acceptable DE for convenience-sampled studies is 2.18 19 30 31 Therefore, an adjusted minimum sample of 768 (384 x 2) participants was considered for each country. 32 33 34 2.3. Questionnaire development: The questionnaire was developed using the frequently asked questions http://bmjopen.bmj.com/ 35 36 on the WHO and CDC websites in addition to the previously published national surveys of COVID-19/other 37 38 20-23 39 pandemics awareness. Experts from the departments of Community Medicine & Public Health and 40 41 Internal Medicine (division of infectious diseases) at Fayoum University (Fayoum, Egypt) formulated the 42 on October 4, 2021 by guest. Protected copyright. 43 questionnaire. The questionnaire was revised by the departments’ heads for face validity, relevance, 44 45 comprehensiveness, and clarity of each section, and some details were improved. 46 47 48 The final four-section questionnaire included: 49 50  Socio-demographic data: that collected participants’ age, gender, country, residency 51 52 53 (urban/rural), educational level, whether they or a family member/friend had been diagnosed (by 54 55 a medical doctor) with COVID-19. 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3  Knowledge about COVID-19: consisted of 28 questions about COVID-19 mode of transmission, 4 5 6 vulnerable groups for infection, symptoms, treatment, prevention measures, and mortality rate. 7 8 The answer to each question was Yes/No/I don't know choices, except for the question about the 9 10 mortality rate. Chronbach's alpha for the knowledge assessment section ranged from 0.55 to 0.76 11 12 for different language versions. 13 14 15  Attitudes towards COVID-19: consisted of eight questions assessing optimism about the current 16 For peer review only 17 situation; responsible public health attitudes; stigma against symptomatic individuals, healthcare 18 19 professionals, and Chinese people; and whether the participant believes in conspiracy theories 20 21 about the disease (Cronbach's alpha = 0.6 - 0.77). The available answers to each question were 22 23 24 Agree/Uncertain/Disagree. In addition, participants were asked to rate their fear of infection and 25 26 the negative impact the pandemic on their mental health on scales from one to 10. 27 28  Practices regarding COVID-19: included 14 questions describing different practices regarding 29 30 coughing and sneezing, hand washing, wearing masks, and contact with people. The available 31 32 33 answers to each question were Yes/Sometimes/No. In addition, the participants were asked to 34 http://bmjopen.bmj.com/ 35 rate their overall compliance with the lockdown or the measures applied by their country on a 36 37 scale from 1 to 10. The Cronbach's alpha values for the practices assessment questionnaire ranged 38 39 from 0.55 to 0.77 for different languages. The full version of the questionnaire can be found in 40 41

Tables 1-4. on October 4, 2021 by guest. Protected copyright. 42 43 44 The questionnaire was developed in English and was then translated into the native languages of the 45 46 47 included countries (Arabic, French, Indonesian, Nepali, Portuguese, Pakistani, and Sinhala). For each 48 49 language, two bilinguals initially performed forward translation, then another bilingual performed a 50 51 backward translation; the translated versions were compared and checked till a final draft was agreed on. 52 53 We checked the internal consistency of the questions in each section by calculation of Cronbach’s alpha 54 55 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 using the data of the first 150 responses from each language; these 150 responses were not included in 4 5 6 the final analysis. 7 8 2.4. Data collection and handling: We recruited collaborators between April 20th and May 1st, 2020. The 9 10 11 recruited collaborators were given an orientation session about the nature of the study and the data 12 13 collection strategy. We assigned a central investigator from each country to monitor the data collection 14 15 process to ensure the adequate contribution of all collaborators and to avoid over-representation of some 16 For peer review only 17 cities over others within each country. Each collaborator was granted access to view their responses only, 18 19 20 while the central investigator had access to all questionnaires of the country. 21

22 th 23 On May 10 , we started data collection using Google Forms, distributed on social media platforms 24 25 (Facebook, Twitter, WhatsApp, LinkedIn), online websites, blogs, contact with governmental, non- 26 27 governmental, and academic organizations in the included countries. Each participant was allowed to 28 29 answer the survey only once and no duplicates were included. After the data collection, we used Microsoft 30 31 Excel for data cleaning. The results of each country were translated automatically to English using the 32 33 34 “Replace All” function in Microsoft Excel and were combined in one Excel sheet for analysis. http://bmjopen.bmj.com/ 35 36 37 The correct responses to knowledge questions were given a score of 1, while incorrect/I don’t know 38 39 answers were given a score of zero (hence knowledge maximum score was of 28). The knowledge score 40 41 of each participant was classified into poor, fair, and good based on modified Bloom’s cut-off points. In 42 on October 4, 2021 by guest. Protected copyright. 43 terms of attitudes, the proper attitude was given a score of +1, the improper attitude was given a score 44 45 46 of -1, and uncertain was given a score of zero (hence a maximum positive attitudes score of 8). Regarding 47 48 practices questions, the correct practice was given a score of 1, (sometimes) was given a score of 0.5, and 49 50 incorrect practice was given a score of zero (hence a maximum practices score of 14). The participants’ 51 52 responses to scale questions (from one to 10) were classified as low (1-3), moderate (4-7), or high (8-10). 53 54 55 56 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 2.5. Statistical analysis: We used SPSS (version 24, IBM, Armonk, NY) for data analysis. Quantitative 4 5 6 outcomes (e.g. scores) were presented as mean ± standard deviations. Associations were analyzed using 7 8 the Independent sample t-test and one-way ANOVA with post-hoc Hochberg test, while the correlation 9 10 between different scores was assessed using Pearson Correlation tests. We used Tableau software 11 12 (Seattle, Washington) for geographical map presentation. 13 14 15 2.6. Ethical considerations: The study protocol was approved (R223) by the Institutional Review Board of 16 For peer review only 17 the Faculty of Medicine, Fayoum University (Fayoum, Egypt). Consent was obtained at the start of the 18 19 20 online questionnaire after explaining the goal and methods of the study. No personal data were collected. 21 22 23 2.7. Patient and Public Involvement: It was not appropriate or possible to involve patients or the public 24 25 in the design, or conduct, or reporting, or dissemination plans of our research. 26 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 3. Results 5 6 3.1. Demographic Characteristics and COVID-19 infection rates: The present sample comprised 71,890 7 8 respondents from 22 countries around the globe. The mean age of all participants was 27.64 ± 9.78 years 9 10 11 and 42601 (59.3%) were females. The majority lived in African and Asian countries, enrolled in/graduated 12 13 from college education, and were living in Urban settings. Among those surveyed, 1326 (1.84%) reported 14 15 having been diagnosed with COVID-19, while 9935 (13.82%) reported knowing a friend or a family 16 For peer review only 17 member who had been diagnosed with COVID-19 (Table 1). 18 19 20 3.2. Public knowledge regarding COVID-19: The mean knowledge score among all respondents was 21 22 19.24/28 ± 3.59 (fair). Of them, 14221 (19.8%), 45087 (62.7%), 12582 (17.5%) had poor, fair, and good 23 24 25 knowledge levels, respectively. The majority of respondents agreed that COVID-19 is a serious disease 26 27 (80.8%); correctly identified droplet transmission (90.6%) and contact with surfaces covered with infected 28 29 droplets (95.7%) as the mode of transmission; correctly identified elderly subjects (90%) and adults with 30 31 chronic disease (93.6%) as the vulnerable groups to COVID-19 infection; and the majority could identify 32 33 34 the correct prevention measures against COVID-19 infection. However, we detected some critical http://bmjopen.bmj.com/ 35 36 knowledge gaps e.g. only 68.2% knew that infected individuals may be asymptomatic; Regarding 37 38 treatment, 73.9% stated that there is an effective cure for COVID-19, 45.4% stated that antibiotics are 39 40 effective in treatment, and 55.4% stated that a vaccine has been developed, while only 59.1% identified 41 42 on October 4, 2021 by guest. Protected copyright. 43 the correct mortality rate for COVID-19 (Table 2). 44 45 Data analysis showed that demographic factors influenced knowledge scores, being significantly higher 46 47 48 (≤0.001) in females, urban residents, those with higher education, or who knew a family member or a 49 50 friend who had a confirmed diagnosis with COVID-19 disease. Interestingly, those who reported a 51 52 confirmed COVID-19 diagnosis before had a lower knowledge level. The one-way-ANOVA test showed 53 54 that the mean knowledge levels differed across the surveyed countries (p < 0.001), with the highest mean 55 56 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 scores from Brazil, Egypt, Jordan, , and Syria and the lowest mean scores from Indonesia, Nigeria, 4 5 6 Pakistan, and India (Appendix 3). 7 8 3.3. Public attitudes towards COVID-19: The mean attitudes score towards COVID-19 among the surveyed 9 10 11 respondents was 3.72/8 ± 2.31. Some positive attitudes were observed e.g. the majority of respondents 12 13 (>80%) stated that since the outbreak, they seek updated medical information and recommendations 14 15 about COVID-19. However, 71.9% believed or were uncertain that COVID-19 is a global conspiracy; >50% 16 For peer review only 17 were uncertain or not optimistic that the pandemic will finally end or that their government will be able 18 19 20 to control COVID-19 situation; 36.8% were uncertain or afraid of contacting doctors except for utmost 21 22 necessity and 51% were afraid or uncertain about contacting Chinese people and eating in Chinese 23 24 restaurants (Table 3). When the respondents were asked to rate their fear of getting COVID-19, 20021 25 26 (27.8%), 33752 (46.9%), 18117 (25.2%) reported low, moderate, and high levels of fear, respectively. 27 28 29 Further, 47712 (66.4%) reported that the pandemic had moderate-to-high negative effects on their 30 31 mental health. 32 33 34 Similar to knowledge levels, the overall attitude score was significantly higher in females (p=0.002) or http://bmjopen.bmj.com/ 35 36 those who knew a family member or a friend with a confirmed COVID-19 diagnosis (p=0.003). However, 37 38 those with previous COVID-19 diagnosis had less positive attitude scores (p<0.001), compared to those 39 40 without COVID-19 diagnosis history. Further, the overall attitudes score, fear of getting COVID-19, and the 41 42 on October 4, 2021 by guest. Protected copyright. 43 negative mental health impact varied by country (Appendix 3, Figure 1A, B). 44 45 46 3.4. Public practices regarding COVID-19: The mean practices score (12.12/14 ± 1.83) and answers to 47 48 individual questions showed good practices towards COVID-19. The majority of respondents indicated 49 50 that that usually follow proper practices regarding hand washing, coughing and sneezing, wearing face 51 52 masks, and social distancing. Few gaps were, however, noted. Although 82% indicated that they usually 53 54 55 wear face masks in crowded places, only 52% responded that they usually wear face masks outside in 56 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 general and 17% replied that they never wear face masks (Table 4). When the respondents were asked 4 5 6 about their overall compliance to their national lockdown/traffic ban, 5856 (8.1%), 19166 (26.7%), 46868 7 8 (65.2%) reported low, moderate, and high compliance levels, respectively. 9 10 11 Likewise, females, those with higher education, residing in Urban areas, or knowing an individual who had 12 13 a COVID-19 diagnosis had better practices scores (p ≤ 0.001). However, those who experienced COVID-19 14 15 diagnosis reported significantly lower practices scores than those who did not. The One-way ANOVA test 16 For peer review only 17 revealed that the overall practices score and compliance to national lockdown/traffic ban varied by 18 19 20 country (Appendix 3; Figure 1C). 21 22 23 3.5. Correlation between knowledge, attitudes, and practices towards COVID-19: We recorded 24 25 significant positive correlations (p <0.001) between knowledge, attitudes, and practices scores in our 26 27 sample, although the magnitude of these correlations in our sample was weak. For example, knowledge 28 29 scores were positively correlated to attitudes (r= 0.05) and practices (r= 0.12) scores, while attitudes 30 31 scores were positively correlated (r= 0.276) to practices scores. 32 33 http://bmjopen.bmj.com/ 34 Interestingly, knowledge was inversely associated with fear of getting COVID-19 (r=-0.04) and negative 35 36 37 mental health effects of the pandemic (r=-0.02) and was directly associated with compliance to lockdown 38 39 (r=0.11). Likewise, better attitudes were associated with lockdown compliance (r=0.08) and practices 40 41 scores were directly correlated to fear of getting COVID-19 (r= 0.167) (Appendix 3). 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 4. Discussion 5 6 The current cross-sectional study assessed the levels and determinants of KAP towards COVID-19 in 22 7 8 countries around the globe. Our results show that the public in those countries had fair knowledge and 9 10 11 good attitudes towards COVID-19. We, however, uncovered many gaps, in the public understanding and 12 13 behaviors towards COVID-19. For example, one third of our participants did not know that infected 14 15 individuals can be asymptomatic, which increases their risk of exposure to the disease. Further, about half 16 For peer review only 17 of the participants thought that antibiotics may be effective treatments and about 74% thought that a 18 19 curative treatment exists, which may give them a false sense of security. Another alarming finding that 20 21 22 almost half our participants held negative/uncertain attitudes regarding contacting Chinese people and 23 24 more than one third had similar attitudes towards doctors. 25 26 27 Our analysis showed that 82% of respondents usually wear face masks in crowded places, but only 52% 28 29 wear masks outdoors in general. This finding is relevant for public awareness programs. Several studies 30 31 and predictive models showed that wearing face masks can reduce COVID-19 spread.24 25 In compliance 32 33 34 with the building evidence, major public health authorities around the world unanimously recommend http://bmjopen.bmj.com/ 35 36 wearing face masks outdoors in general, not just in crowded places.26 27 However, the compliance rates to 37 38 these recommendations vary between and within countries. Our study highlights the importance of public 39 40 awareness about the value of masks in preventing infections and slowing the spread of COVID-19. 41 42 on October 4, 2021 by guest. Protected copyright. 43 In the current study, we found a significant positive correlation between knowledge and attitudes, which 44 45 coincides with several former studies on COVID-19.23 28 29 However, the magnitude of correlation in our 46 47 30 48 study was weak, similar to a former Indonesian study. This is probably because although knowledge is 49 50 essential in shaping attitudes, this is not absolute and several other factors may be involved. The same 51 52 can be said on the correlation between attitudes and practices. Interestingly, our analysis also showed 53 54 lower knowledge scores in those who reported having a confirmed diagnosis with COVID-19. This can be 55 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 explained in the light of our finding that knowledge scores were directly correlated to practices scores and 4 5 6 compliance with lockdown/traffic ban orders. This suggests that good knowledge translates into safe 7 8 practices, which can reduce one’s risk of COVID-19 infection. 9 10 11 We found an inverse correlation between knowledge level and fear of getting COVID-19. This implies that 12 13 improving the knowledge about COVID-19 can alleviate public anxiety and panic. During the SARS 14 15 epidemic (2002-2004), misinformation led to excessive public panic and resistance to comply with public 16 For peer review only 17 health guidelines.31 32 We could also infer that people’s knowledge would not be improved just by 18 19 20 communicating daily increases in COVID-19 cases. In the same vein, about two thirds of our participants 21 22 reported moderate-to-high negative mental health effects for the pandemic. These effects had significant 23 24 inverse correlations with knowledge and attitudes scores; however, the magnitude of the correlations 25 26 was weak. Several studies showed multiple risk factors for anxiety and mental health problems related to 27 28 29 COVID-19, including social media use, worry about economy and personal finances, working in COVID-19 30 31 hot spots, and being pregnant.33 34 Therefore, poor knowledge and attitudes may contribute -among a 32 33 multitude of factors- towards the growing incidence of mental health issues, being reported worldwide. 34 http://bmjopen.bmj.com/ 35 36 The association between KAP scores and demographic characteristics in the current study was 37 38 consistently significant. For example, females had better KAP scores towards COVID-19 than males. This 39 40 finding echoes previous studies by Al-Hanawi et al.8 and Azlan et al.10. In addition, those living in rural 41 42 on October 4, 2021 by guest. Protected copyright. 43 areas had lower knowledge and practice scores than their urban counterparts. This may be attributed to 44 45 relying on digital sources of information with easier access in urban settings or the higher levels of 46 47 education in urban areas, which were also associated with higher KAP scores in the present study. 48 49 50 Most of the included countries in the current analysis are developing/low-to-middle income countries. 51 52 These countries had varied KAP levels and also were significantly different when assessed on three rating 53 54 55 questions (fear of COVID-19, negative mental health effects, and compliance to lockdown). Other studies 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 have assessed KAP levels in countries that have been included in this analysis (e.g. US, UK, Egypt, Saudi 4 5 6 Arabia, Pakistan, and Indonesia) and countries outside our scope (e.g. Malaysia, Turkey, and Italy). 7 8 However, most of these studies had a small sample size and were limited in demographic coverage and 9 10 analysis of KAP determinants. To put our study in context, we performed a comprehensive review of 11 12 published public KAP studies in the literature about COVID-19 (Appendix 4). The combined sample size of 13 14 those studies is 55,662 individuals, which is less than our sample size. The majority of these studies 15 16 For peer review only 17 showed good public knowledge and practices across different countries, especially those conducted in the 18 19 later three months (probably due to the growing public awareness about COVID-19). 20 21 22 Practical and research recommendations: Although we did not explore sources of knowledge about 23 24 COVID-19 in this study, previous works highlighted television and social media as the primary sources of 25 26 knowledge. Using these platforms should be optimized to deliver evidence-based information to the most 27 28 29 vulnerable groups e.g. less educated and those living in rural areas. Political leaders and stake holders 30 31 should take action to eliminate fear and discrimination against healthcare professionals and Asian 32 33 community members.35 Research-wise, future studies should be more inclusive of the elderly and should 34 http://bmjopen.bmj.com/ 35 assess KAP association with other demographic factors as income. In addition, they should test the value 36 37 38 of innovative strategies in mitigating mental health effects of public health disasters like COVID-19. 39 40 Conclusion: The current multinational cross-sectional study showed fair public knowledge on COVID-19; 41 42 on October 4, 2021 by guest. Protected copyright. 43 however, it uncovered several gaps in the public understanding and practices about the diseases. 44 45 Moreover, it highlighted the negative mental health effects of COVID-19 pandemic. Some demographic 46 47 groups were less advantaged than others including the less educated and those living in rural areas. Future 48 49 awareness efforts should target those groups and develop innovative strategies to mitigate negative 50 51 52 mental health effects, as well as discriminatory behaviors against Asians and healthcare professionals. 53 54 55 56 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Acknowledgement: This work was supported by King Saud University, Deanship of Scientific Research, 4 5 6 College of Science Research Center (RSP 2019/ 121). 7 8 Funding Source: This work was supported by King Saud University, Deanship of Scientific Research, 9 10 11 College of Science Research Center (RSP 2019/ 121). 12 13 14 Conflicts of interest: All authors declare no relevant conflicts of interest. 15 16 Authors ContributionFor Statement: peer ATM, MSZ, reviewSME: Idea conception, only study design; KMR, EMK, YTA, AAs, 17 18 19 AZN, LJI, MME, ATA, AAS, DGH: Questionnaire formulation, validation and translation, VZF, ARM, FMS, AE: 20 21 Data curation, analysis, and interpretation; AAl, AKA, MA, OMM, EAD, KAE: Manuscript drafting; MA, AIA: 22 23 Study design, analysis planning and supervision. All authors contributed to data collection and all involved 24 25 investigators reviewed the manuscript and approved it for publication. 26 27 28 Data Statement: Data are available from the corresponding author upon reasonable request. 29 30 31 Figure Legends 32 33 34 Figure 1: Geographic representation of A) fear of getting COVID-19, B) negative mental health effects of http://bmjopen.bmj.com/ 35 36 COVID-19 pandemic, and C) compliance with governmental lockdown/traffic ban across the 22 countries. 37 38 39 The color gradient (from light to dark) in every map represents country scores (from low to high). 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 References 5 1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. New 6 7 England Journal of Medicine 2020 8 2. WHO. Coronavirus disease 2019 (COVID-19): situation report 2020 [Available from: 9 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep- 10 207-covid-19.pdf accessed 14 August 2020. 11 3. Guan W-j, Ni Z-y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. New England 12 journal of medicine 2020;382(18):1708-20. 13 4. CDC. Symptoms of coronavirus disease 2019 (COVID-19) 2020 [Available from: 14 https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html accessed 10 August 2020. 15 5. CDC. People Who Are at Higher Risk for Severe Illness - Coronavirus 2020 [Available from: 16 For peer review only 17 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher- 18 risk.html accessed 12 August 2020. 19 6. Wiersinga WJ, Rhodes A, Cheng AC, et al. Pathophysiology, Transmission, Diagnosis, and Treatment of 20 Coronavirus Disease 2019 (COVID-19): A Review. Jama 2020 doi: 10.1001/jama.2020.12839 21 [published Online First: 2020/07/11] 22 7. Wolf MS, Serper M, Opsasnick L, et al. Awareness, attitudes, and actions related to COVID-19 among 23 adults with chronic conditions at the onset of the US outbreak: a cross-sectional survey. Annals of 24 internal medicine 2020 25 26 8. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among 27 the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Frontiers in Public Health 28 2020;8 29 9. Parikh PA, Shah BV, Phatak AG, et al. COVID-19 pandemic: knowledge and perceptions of the public and 30 healthcare professionals. Cureus 2020;12(5) 31 10. Azlan AA, Hamzah MR, Sern TJ, et al. Public knowledge, attitudes and practices towards COVID-19: A 32 cross-sectional study in Malaysia. Plos one 2020;15(5):e0233668. 33

11. Cagetti MG, Cairoli JL, Senna A, et al. COVID-19 Outbreak in North Italy: An Overview on Dentistry. A http://bmjopen.bmj.com/ 34 35 Questionnaire Survey. International Journal of Environmental Research and Public Health 36 2020;17(11):3835. 37 12. Demirbilek Y, Pehlivantürk G, Özgüler ZÖ, et al. COVID-19 outbreak control, example of ministry of 38 health of Turkey. Turkish journal of medical sciences 2020;50(SI-1):489-94. 39 13. Almofada SK, Alherbisch RJ, Almuhraj NA, et al. Knowledge, Attitudes, and Practices Toward COVID- 40 19 in a Saudi Arabian Population: A Cross-Sectional Study. Cureus 2020;12(6) 41

14. Reuben RC, Danladi MM, Saleh DA, et al. Knowledge, Attitudes and Practices Towards COVID-19: An on October 4, 2021 by guest. Protected copyright. 42 Epidemiological Survey in North-Central Nigeria. Journal of community health 2020:1-14. 43 44 15. Chirwa GC. “Who knows more, and why?” Explaining socioeconomic-related inequality in knowledge 45 about HIV in . Scientific African 2020;7:e00213. 46 16. Chirwa GC. Socio-economic Inequality in Comprehensive Knowledge about HIV in Malawi. Malawi 47 Medical Journal 2019;31(2):104-11. 48 17. Daniel W. Biostatistics: a foundation for analysis in the health sciences. New York: John Wiley & Sons 49 1999;7th ed. 50 18. Wejnert C, Heckathorn DD. Web-based network sampling: efficiency and efficacy of respondent-driven 51 sampling for online research. Sociological Methods & Research 2008;37(1):105-34. 52 19. Wejnert C, Pham H, Krishna N, et al. Estimating design effect and calculating sample size for 53 54 respondent-driven sampling studies of injection drug users in the United States. AIDS and 55 Behavior 2012;16(4):797-806. 56 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 20. Albano L, Matuozzo A, Marinelli P, et al. Knowledge, attitudes and behaviour of hospital health-care 4 workers regarding influenza A/H1N1: a cross sectional survey. BMC infectious diseases 5 6 2014;14(1):208. 7 21. Hasan F, Khan MO, Ali M. Swine flu: Knowledge, attitude, and practices survey of medical and dental 8 students of Karachi. Cureus 2018;10(1) 9 22. Wong LP, Sam I-C. Knowledge and attitudes in regard to pandemic influenza A (H1N1) in a multiethnic 10 community of Malaysia. International Journal of Behavioral Medicine 2011;18(2):112-21. 11 23. Zhong B-L, Luo W, Li H-M, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese 12 residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional 13 survey. International journal of biological sciences 2020;16(10):1745. 14 24. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid-19 crisis. Bmj 15 16 2020;369 For peer review only 17 25. Eikenberry SE, Mancuso M, Iboi E, et al. To mask or not to mask: Modeling the potential for face mask 18 use by the general public to curtail the COVID-19 pandemic. Infectious Disease Modelling 2020 19 26. Brooks JT, Butler JC, Redfield RR. Universal masking to prevent SARS-CoV-2 transmission—the time is 20 now. Jama 2020 21 27. WHO. Coronavirus disease (COVID-19) advice for the public: When and how to use masks 2020 22 [Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice- 23 for-public/when-and-how-to-use-masks accessed 10 August 2020. 24 25 28. Salman M, Mustafa ZU, Asif N, et al. Knowledge, attitude and preventive practices related to COVID- 26 19: a cross-sectional study in two Pakistani university populations. Drugs & Therapy Perspectives 27 2020:1. 28 29. Kumar J, Katto MS, Siddiqui AA, et al. Knowledge, Attitude, and Practices of Healthcare Workers 29 Regarding the Use of Face Mask to Limit the Spread of the New Coronavirus Disease (COVID-19). 30 Cureus 2020;12(4) 31 30. Sari DK, Amelia R, Dharmajaya R, et al. Positive Correlation Between General Public Knowledge and 32 Attitudes Regarding COVID-19 Outbreak 1 Month After First Cases Reported in Indonesia. Journal 33

of community health 2020:1-8. http://bmjopen.bmj.com/ 34 35 31. Person B, Sy F, Holton K, et al. Fear and stigma: the epidemic within the SARS outbreak. Emerging 36 infectious diseases 2004;10(2):358. 37 32. Tao N. An analysis on reasons of SARS-induced psychological panic among students. Journal of Anhui 38 Institute of Education 2003;21:78-9. 39 33. Li X, Lu P, Hu L, et al. Factors Associated with Mental Health Results among Workers with Income 40 Losses Exposed to COVID-19 in China. Int J Environ Res Public Health 2020;17(15) doi: 41

10.3390/ijerph17155627 [published Online First: 2020/08/08] on October 4, 2021 by guest. Protected copyright. 42 34. Holingue C, Badillo-Goicoechea E, Riehm KE, et al. Mental Distress during the COVID-19 Pandemic 43 44 among US Adults without a Pre-existing Mental Health Condition: Findings from American Trend 45 Panel Survey. Preventive medicine 2020:106231. doi: 10.1016/j.ypmed.2020.106231 [published 46 Online First: 2020/08/08] 47 35. Devakumar D, Shannon G, Bhopal SS, et al. Racism and discrimination in COVID-19 responses. The 48 Lancet 2020;395(10231):1194. 49 50 51 52 53 54 55 56 57 58 17 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 1: Demographic characteristics and COVID-19 confirmed infection rates among survey respondents. 4 5 Demographics Count (%) 6 (N = 71,890) 7 Age Mean ± SD (yr.) 27.64 ± 9.78 8 9 ≤ 30 years 53048 (73.8) 10 31 – 50 years 16073 (22.3) 11 > 50 years 2769 (3.9) 12 Gender 13 Male 28449 (39.6) 14 Female 42601 (59.3) 15 Country 16 Egypt For peer review6830 only (9.49) 17 4300 (6.00) 18 Algeria 4900 (6.81) 19 Morocco 1755 (2.44) 20 Sudan 4381 (6.09) 21 Nigeria 3449 (4.80) 22 1847 (2.56) 23 South Africa 1979 (2.75) 24 Syria 6576 (9.14) 25 Lebanon 3380 (4.70) 26 Palestine 5993 (8.33) 27 Iraq 2092 (2.92) 28 Jordan 5882 (8.20) 29 Saudi Arabia 1616 (2.24) 30 Pakistan 1723 (2.40) 31 Indonesia 4444 (6.18) 32 Nepal 2657 (3.70) 33 Sri-Lanka 1793 (2.50) http://bmjopen.bmj.com/ 34 India 1464 (2.04) 35 Brazil 839 (1.16) 36 Ireland 1026 (1.43) 37 UK 2160 (3.00) 38 USA 804 (1.12) 39 Education 40 High School 7577 (10.54) 41

Undergraduate 44436 (61.80) on October 4, 2021 by guest. Protected copyright. 42 Graduated 16269 (22.65) 43 Prefer not to say 3608 (5.01) 44 Residency 45 Urban 57653 (80.2) 46 Rural 14237 (19.8) 47 48 Have you had a confirmed infection with COVID-19? * 49 Yes 1326 (1.84) 50 No 70559 (98.16) 51 Do you know a friend or a family member who had a 52 confirmed COVID-19 infection? * 53 Yes 9935 (13.82) 54 No 61952 (86.18) 55 The presented data are count (valid %) unless otherwise specified. 56 * Confirmed infection was explained to participants as having diagnosis by a licensed healthcare professional. 57 58 18 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 2: Answers to knowledge questions about COVID-19 among survey respondents. 4 5 6 Yes No/I don’t 7 8 know 9 10 COVID-19 is a serious disease. 58121 (80.8) 13769 (19.2) 11 Regarding the mode of transmission of the virus 12 13 Eating wild animals (e.g. bats) 37829 (52.6) 34061 (47.4) 14 15 Droplet transmission 65126 (90.6) 6764 (9.4) 16 Contact with infectedFor surfaces peer then putting review your hand on youronly 68819 (95.7) 3071 (4.3) 17 18 face, mouth, or nose 19 20 The most vulnerable group to infection is 21 Children (0-18) years 32973 (45.9) 38917 (54.1) 22 23 Adults (18 -50) years 29448 (41.0) 42442 (59.0) 24 25 Elderly (more than 50) years 64736 (90.0) 7154 (10.0) 26 Adults with chronic diseases 67282 (93.6) 4608 (6.4) 27 28 The Clinical symptoms of COVID-19 include 29 30 Fever 68565 (95.4) 3325 (4.6) 31 Fatigue 57076 (79.4) 14814 (20.6) 32 33 Dry Cough 66882 (93.0) 5008 (7.0) 34 http://bmjopen.bmj.com/ 35 Myalgia 50672 (70.5) 21218 (29.5) 36 Stuffy Nose 21127 (29.4) 50763 (70.6) 37 38 Runny Nose 23449 (32.6) 48441 (67.4) 39 40 Sneezing 14094 (19.6) 57796 (80.4) 41

Shortness of breath 68589 (95.4) 3301 (4.6) on October 4, 2021 by guest. Protected copyright. 42 43 Diarrhea 35293 (49.1) 36597 (50.9) 44 45 Asymptomatic 49057 (68.2) 22833 (31.8) 46 47 Regarding treatment of COVID-19 48 There is effective cure for it 53148 (73.9) 18742 (26.1) 49 50 The treatment is symptomatic only 51140 (71.1) 20750 (28.9) 51 52 Antibiotics are effective in treatment 32628 (45.4) 39262 (54.6) 53 There are various drugs under trial 58231 (81.0) 13659 (19.0) 54 55 A vaccine has been developed 39798 (55.4) 32092 (44.6) 56 57 58 19 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Regarding prevention of COVID-19 which of the following is effective? 5 6 Wearing medical masks 67365 (93.7) 4524 (6.3) 7 Avoiding crowded places 70509 (98.1) 1380 (1.9) 8 9 Isolation of infected individuals 70551 (98.1) 1338 (1.9) 10 11 Healthy diet and avoiding high-fat containing diet 18159 (25.3) 53730 (74.7) 12 To what extent does COVID-19 cause death? Less than Wrong 13 14 15%: 42522 answers: 15 16 For peer review only(59.1) 29368 (40.9) 17 Data are presented as count (%). 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 20 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 3: Answers to attitudes questions about COVID-19 among survey respondents. 4 5 6 Positive Uncertain Negative 7 8 Attitude Attitude 9 10 Do you believe that COVID-19 is a global 20191 (28.1) 32559 (45.3) 19140 (26.6) 11 conspiracy? 12 13 Do you believe that COVID-19 pandemic will 34053 (47.4) 30851 (42.9) 6986 (9.7) 14 15 finally end? 16 Do you believe thatFor your country peer will be able review 32526 (45.2) only28603 (39.8) 10760 (15.0) 17 18 to control COVID-19 situation soon? 19 20 Since the outbreak, I seek more medical 59215 (82.4) 9090 (12.6) 3585 (5.0) 21 information about COVID-19 to keep updates. 22 23 Since the outbreak, I follow the 66609 (92.7) 4350 (6.1) 931 (1.3) 24 25 recommendations to deal with the pandemic. 26 Since the outbreak, I am afraid to contact 55788 (77.6) 10236 (14.2) 5866 (8.2) 27 28 anyone with ordinary flu symptoms. 29 30 Since the outbreak, I am afraid of contacting 45475 (63.2) 13292 (18.5) 13123 (18.3) 31 any doctors except for the utmost necessity 32 33 Since the outbreak, Are you afraid of eating in 35243 (49.0) 15356 (21.4) 21291 (29.6) 34 http://bmjopen.bmj.com/ 35 Chinese restaurant or contact chinse people? 36 Data are presented as count (%). 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 21 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 4: Answers to practices questions about COVID-19 among survey respondents. 4 5 6 Proper Sometimes Wrong 7 8 Practice Practice 9 10 When coughing or sneezing, Do you 11 Cover your mouth and nose with a tissue? 62946 (87.6) 6749 (9.4) 2195 (3.1) 12 13 Throw away the used tissue into the bin? 66291 (92.2) 2731 (3.8) 2868 (4.0) 14 15 Turn your face away from the surrounding 67664 (94.1) 2303 (3.2) 1923 (2.7) 16 people? For peer review only 17 18 As for your hands, you wash them 19 20 Before touching your eye and nose 52267 (72.7) 14516 (20.2) 5107 (7.1) 21 After covering the nose while sneezing 56198 (78.2) 9994 (13.9) 5698 (7.9) 22 23 After coming from outside 67791 (94.3) 2815 (3.9) 1284 (1.8) 24 25 Using soap and water 68337 (95.1) 2299 (3.2) 1254 (1.7) 26 Using concentrated alcohol 39729 (55.3) 16862 (23.5) 15299 (21.3) 27 28 Regarding wearing a face mask, you 29 30 Wear a face mask in crowded places 58939 (82.0) 5082 (7.1) 7869 (10.9) 31 Wear a face mask outside in general (not crowded) 37364 (52.0) 12371 (17.2) 22155 (30.8) 32 33 Never use a face mask 46829 (65.1) 12813 (17.8) 12247 (17.0) 34 http://bmjopen.bmj.com/ 35 Regarding the preventive measures from infection, you 36 Avoid contact with an infected person 69776 (97.1) 1037 (1.4) 1077 (1.5) 37 38 Avoid touching and shaking hands 61981 (86.2) 7044 (9.8) 2865 (4.0) 39 40 Avoid going to crowded places 63201 (87.9) 6684 (9.3) 2005 (2.8) 41 Data are presented as count (%). 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 22 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Figure 1: Geographic representation of A) fear of getting COVID-19, B) negative mental health effects of http://bmjopen.bmj.com/ 34 COVID-19 pandemic, and C) compliance with governmental lockdown/traffic ban across the 22 countries. 35 The color gradient (from light to dark) in every map represents country scores (from low to high). 36 37 159x131mm (144 x 144 DPI) 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Appendix file 1 5 6 National leaders : Egypt: Mariam Salah Moris (Faculty of Medicine, , Assiut, Egypt.); Syria: 7 8 Ayman Essa Nabhan (Al-Andalus University for Medical Sciences, Qadmus, Syria); Palestine: Mohammed 9 Jehad Al-kfarna (Faculty of Pharmacy, Al-Azhar University, Gaza, Palestine); Jordan: Hala Aladwan (Faculty 10 11 of Pharmacy, The University Of Jordan, Amman, Jordan); Algeria: Amira Yasmine Benmelouka (Faculty of 12 13 Medicine, University of Algiers, Algeria); Sudan: Manar Mohammed Hosny (Faculty of Medicine, Fayoum 14 15 University, Fayoum, Egypt); Libya: Sara Rajab Araara (Faculty of Medicine, Tripoli University, Tripoli, Libya) 16 For peer review only 17 Algeria Collaborators: Nedjima Mouhoubi, Nour Salem (University of Constantine 3); Boutheyna Drid, 18 19 Hamel Asma (Faculty of Medecine, University of Tlemcen); Sara Menzer, Krazdi Asma (Faculty of 20 Medecine, University of Batna 2); Affaf Sahih (Faculty of Medecine, University of Oran); Manal Benatia, 21 22 Wiame Benhabiles (Faculty of Medicine, University of Algiers); Rahmani Meriem, Mohamed Elkhalil 23 24 Bouaich, Benslimane Sahar, Khennoussi Amel, Ahelam Zerga, Yassamine ouerdane (Faculty of Medicine, 25 University of Saad Dahlab) 26 27 28 Egypt Collaborators: Maryam Abd-Elmalak Shafik (Faculty of Medicine, Ain Shams University); Ahmed 29 Bostamy Elsnhory, Aya Mosad Elhelesy, Esraa Ghanem, Mostafa Mahmoud Meshref (Faculty of Medicine, 30 31 Al-Azhar University, Cairo); MennatulRahman Mohamed Daa-ElEnsaf (Faculty of Medicine, Al-Azhar 32 33 University, Assiut); Mohamed Marey Yahya, Salama Ahmed Ali (Faculty of Medicine, Al-Azhar University, http://bmjopen.bmj.com/ 34 Damietta); Alaa Ahmed Elshanbary, Mariam Ahmed Maray (Faculty of Medicine, ); 35 36 Mohamed Mahmoud Abdelkarem (Faculty of Medicine, Assiut University); Osama Mohamed Rokaby 37 38 (Faculty of Medicine, ); Manar Ahmed Kamal (Faculty of Medicine, ); 39 Ahmed Saeed Ahmed (Faculty of Medicine, Fayoum University); Merna Ahmed Riad, Radwa Mohamed 40 41 Awadalla, Ahmed Sultan (Faculty of Medicine, Kasr Alainy ); Noha Ahmed Ammar (Faculty 42 on October 4, 2021 by guest. Protected copyright. 43 of Medicine, Menoufia University); Mohamed Essam (Faculty of Medicine, ); Sara 44 Gamal Fayad (Faculty of Medicine, ); Israa Mohamed Elshahawy (Faculty of Pharmacy, 45 46 ); Ahmed Fares Ghannam (Faculty of Medicine, Fayoum University) 47 48 Jordan Collaborators: Hiba Ramadan, Mais Hutham Sabri (Al-Balqa Applied University); Hayat Ghaseb 49 50 Abu-Alkhoun, Malak Eyad Abu-Qaddoura (Yarmouk University); Batool Emad Al-Masri, Israa Ayed Al-Odat, 51 52 Mahmoud Omar Alshneikat (Faculty of Medicine, Jordan University); Mustafa Ismat Aburumman, Hani 53 Adnan Bashir, Tasneem suhail Abu-Alkhair (Hashemite University); Obada Ahmad Al-Jayyousi, Faris Jamal 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Abu-Za'nouneh, Mohammad Hasan Ismail, Mo'men Helmi Suleiman (Jordan University of Science and 4 5 Technology) 6 7 8 9 Libya Collaborators: Reem Khaled Wishah (Faculty of Public Health, Benghazi University); Asma Abubakr 10 Saleh (Faculty of Medicine, Alzawia University); Ahmed Ateia Alzedam, Hamdan Hilan (Faculty of 11 12 Medicine, Misurata University); Alarabi Alsalem Ali Alarabi (Faculty of Medicine, Sebha University); Amal 13 14 Sharif Eljali, Ahmad Bouhuwaish (Faculty of Medicine, Tobruk University); Sahar Azaz (Faculty of 15 Medicine, University of Sabratha); Abdulkarim Aldoukali Babaa, Mabruka Mohamed Algallal, Nawal 16 For peer review only 17 Aldokali Muhammed, Mohaned Mohammed Zlitni, Mohammed Salem Mansour, Islam Ammar, 18 19 Mohammed Salem Mansour (Faculty of Medicine, Tripoli University). 20 21 22 Palestine Collaborators: Roaa Waleed Abu-Ereban (Faculty of Dentistry, Al Azhar University); Ayat Abed- 23 24 Albaset Mahamid (Faculty of Dentistry, Arab American University); Sojoud Saleem Alabed, Omar A. 25 Safarini, Ammar Ahmad Thabaleh (Faculty of Medicine and Health Sciences, An-Najah National 26 27 University); Mahmoud Aref Aldrini, Nataly Mazen Salhab, Qusai N Zreqat (Faculty of Medicine, Al-Quds 28 29 University); Sahar kamel Balasi (Faculty of Medicine, Palestine Polytechnic University); Hala Jamal Redwan 30 (Faculty of Pharmacy, Al Azhar University); Ithar Moufak Barghouthi (Faculty of Pharmacy, Nursing and 31 32 Health Professions, Ramallah); Bushra Majd Barghouthe (Faculty of Science, Birzeit University) 33 34 http://bmjopen.bmj.com/ 35 Sudan Collaborators: Tayseer Hatim Mohammed, Mona Muhe-Eldeen Eshag, Elaf Mohamed Elhassan 36 37 (Faculty of Medicine, Bahri University); Hiba Mahgoub Eltayeb, Arwa F. Hassan (Faculty of Medicine, 38 39 Gezira University); Anfal Mahmoud Alkhalifa, Walaa Elnaiem , Suad Elsadig Yousif, Lina Sameer Ibrahim 40 (Faculty of Medicine, Khartoum University); Sjda Ameen Merghany (Faculty of Medicine, AHFAD 41 42 University for women); Mazen Bashir Ahmed (Faculty of Medicine and Surgery, Shendi University); Tareq on October 4, 2021 by guest. Protected copyright. 43 44 Fouad Neme (Faculty of Medicine, Al-Neelain University) 45

46 47 Syria Collaborators: Salam Muhammad Sharif, Houssein Deeb, Katrina Taha Al-Bank (Albaath University); 48 49 Farah AL Bakkar, Bana Zuhair Alafandi, Mohamad AlHashemi, Hasan Hassan Raslan (Faculty of Medicine, 50 Aleppo University); Raghad Dannan, Sabah Refaieh, Sami Jomaa, Laith Alsabek (Damascus University); 51 52 Tarek Al Soufi, Yara Issa, Danny Salem Knaizeh (Faculty of Medicine, Tishreen University); Mohammad 53 54 Yaser Haidar (Faculty of Medicine, University of Kalamoon) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Brazil Collaborators: Victor Carlos Nuvunga (Instituto Superior de Ciências e Educação a Distância) 4 5 6 Ghana Collaborators: Priscilla Sarfo Adu, Attah Al-Hassan Dawuni, Eliham Salifu, Isaac Mawunyega Kwaku, 7 8 Faisal Tikuma Abdallah, Rachel Laadi Sulia (Kwame Nkrumah University of Science and Technology) 9 10 India Collaborators: Avantika Pandey (Darshan Dental College and Hospital); Neetish Patel, Motilal Nehru 11 12 (National Institute of Technology, Allahabad); Shweta Patel (Galgotias University); Kamni raj Bavoria, 13 14 (University of Jammu); Avantika Pandey (Rajasthan University of Health and Science); Neetish Rani Patel 15 (National Institute of Technology Allahabad); Sreenath Sreekantan (District Health Services, Kollam) 16 For peer review only 17 18 Iraq Collaborators: Mohammed J Al-Awady (College of Biotechnology - Al Qasim Green University); Renas 19 20 Husain Isa (College of Agricultural Sciences, University of Duhok); Mohanad Jawad Kadhim 21 22 (College of Biotechnology, Al-Qasim Green University); Raad A. Alharmoosh (Medical Laboratory 23 Techniques, Altoosi University College) 24 25 26 Saudi Arabia Collaborators: Maram Al-Enzi (Kuwait University, Kuwait); Fatemah Alalawi (Emergency 27 28 Medicine, Dammam Medical Complex, Dammam, Saudi Arabia) 29 30 Ireland Collaborators: Osman Kamal Osman Elmahi (National University of Ireland); Muhammad 31 32 Mahmoud (Trinity College Dublin)

33 34 http://bmjopen.bmj.com/ 35 USA Collaborators: Dhouha Daassi (Massachusetts General Hospital, Harvard Medical School, MA); 36 Mohamed M. Khodeiry (Bascom Palmer Eye Institute, FL); Hasan Mirza (Beth Israel Deaconess Medical 37 38 Center, Harvard Medical School, MA); Pratha Rajesh Taiwade (Smolensk State Medical University, Russia)

39 40 41 Indonesia Collaborators: Sanju gautam (University of Southern Denmark, Denmark); Febtrias Mandeabuti on October 4, 2021 by guest. Protected copyright. 42 Prasetio (Dondo Primary and Public Healthcare Center, Central Sulawesi); Dewi Anggraini (Faculty of 43 44 Mathematical and Natural Sciences, Lambung Mangkurat University); Dini Setyowati (Faculty of Dental 45 46 Medicine, Universitas Airlangga); Ninuk Hariyani (Faculty of Dental Medicine, Universitas Airlangga); Risa 47 Haryati Tambunan (Maratua Public Health Center, Berau Regency); Bernike Yuriska Metabuti Prasetio 48 49 (Maranatha Christian University); Theresia Pakaedith Lodang Hurint (Puskesmas Paga, Sikka, East Nusa 50 51 Tenggara); Dewi Ayu Ratna Sari (Puskesmas Cancar, Manggarai); Bernike Yuriska Metabuti Prasetio 52 (Maranatha Christian University); Mulia Daniel Sihotang (University of North Sumatera); Oktavia 53 54 Manuama (MEAL Officer, Indonesia) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Nepal Collaborators: Kuber Bajgain (Institute of Medicine, Tribhuvan University); Suresh Panthee 4 5 (Sustainable Study and Research Institute, Kathmandu); Buddha Bahadur Basnet (Academy of Science and 6 7 Technology, Patan); Bimala Panthee (School of Nursing and Midwifery, Patan Academy of Health 8 Sciences); Nanda Kumar Tharu (Department of Statistics, Tribhuvan University); Rakesh Kumar Lama 9 10 (Management, Tribhuvan University); Ramesh Kumar Yadav (Faculty of Medical and Allied Sciences, 11 12 Purbanchal University); Sandeep Khattri (Kathmandu University); Amrita Acharya (Kathmandu University, 13 Dhulikhel, Nepal); Nashib Pandey (Kantipur Dental College Teaching Hospital & Research Center) 14 15 16 For peer review only 17 Lebanon Collaborators: Hanane Amer Chamma (Institute of Human Genetics, Montpellier, France); Hadi 18 Mohammad Fateh Shammaa, Tarek Abdulkarim Baroud, Marc Samir Machaalani, Bachir Toufik Zrayka, 19 20 Amir Rabih Al Ayoubi, Lemir Majed Lemir Ahmad El Ayoubi, Ilham Hassan Said-Salman, Jad Samer Al Masri 21 22 (Lebanese University); Anthony Dany Daher, Fouad Mario Assaf, Diala Samer Al Masri (Balamand 23 University); Miguel Michel Farraj (Antonine University); Manal Ali El Ahmar (University of Saint Joseph); 24 25 Louna Karam (Lebanese American University) 26

27 28 Sri Lanka Collaborators: Apareka Gamage Dinusha Madhubhashini Perera (Faculty of Graduate Studies, 29 30 University of Kelaniya); Uchini Shermilie Bandaranayake (Sabaragamuwa University of Sri Lanka); Miyuru 31 Chandradasa (Faculty of Medicine, University of Kelaniya); Jayaweera Arachchige Asela Sampath 32 33 Jayaweera (Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka); Ayesha Lakmali 34 http://bmjopen.bmj.com/ 35 Weerasingha (Faculty of Agriculture, Eastern University); Ayesha Lakmali Weerasingha (Eastern University 36 Sri Lanka); Veranga Kavithri Wickramasinghe (University of Colombo); Jayakodi Arachchige Isuru Sohan 37 38 (District Project Coordinator, Good Neighbors International) 39 40 41

Nigeria Collaborators: Oloyede Oyedibu Oyebayo (Faculty of Science, ); Adewuyi A. on October 4, 2021 by guest. Protected copyright. 42 43 Tunde (Faculty of Environmental, Nigeria Defence Academy); Anwar Jamal Abdulnasir (King Saud 44 45 University, Saudi Arabia); Jamal Raihan Abdulnasir, Salisu Danjuma Gezawa, Shuaibu Omeiza Salawudeen 46 (); Kazeem Bidemi Okesina (); Nuraddeen Wada (Al-Qalam 47 48 University Katsina); Yakubu Egigogo Raji (Ibrahim Badamasi Babangida University) 49 50 51 South Africa Collaborators: Anthonia Omotola Ishabiyi, Patrick Hosea Olayiwola, Muhammed 52 Olatunbosun Ogunlola (University of KwaZulu-Natal); Abdultaofeek Abayomi (Faculty of Natural Sciences, 53 54 Mangosuthu University of Technology) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Morocco Collaborators: Bouya ilyass (Faculty of Medicine Paris 13, Paris, France); Othmane Lamoihi 4 5 (Faculte de Medecine et de Pharmacie de Marrakech); Achraf Hafdi, Hiba Lazrek (Faculty of Medicine, 6 7 Caddi Ayad University); Lahmouz Nouhaila (Faculty of Medicine and Pharmacy of Rabat) 8 9 10 Pakistan Collaborators: Irfan Ullah (Kabir Medical College, Gandhara University); Asma Nawaz (Faculty of 11 12 Sciences, Virtual University of Pakistan); Khayam ul haq, (NCS University system); Abdul Rafay (Ameer-ud- 13 din Medical College/Lahore General Hospital); Kainat Khan (Burns ward, Civil hospital, Hyderabad); Latif 14 15 ullah khattak (Nutrition and public health, Alelaj hospital wah cantt Pakistan); Noreen Aslam (Islamia 16 For peer review only 17 University Bshawalpur) 18 19 20 UK Collaborators: Ei Cho Lin (Dorset County Hospital, Dorchester); Taghreed Saud Almansouri (Faculty of 21 22 Medicine, University of Sheffield); Maheswaran Warren Archunan (Norfolk and Norwich University 23 Hospital); Hasan Hazim Alsararatee (Northampton General Hospital); Asif Mahmood (The Queen Elizabeth 24 25 Hospital King’s Lynn); Doaa Hamed Sobeih (London School of Hygiene and Tropical Medicine, University 26 27 of London) 28

29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 41

1 2 3 Appendix (2) STROBE Statement: Checklist of items that should be included in reports of observational studies 4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 (Cross sectional study) (1). 6 7 Item Page 8 No Recommendation No 9 10 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the 1 11 abstract 12 (b) Provide in the abstract an informative and balanced summary of what was 2 13 14 done and what was found 15 Introduction 16 Background/rationale 2 Explain the scientific background and rationale for the investigation being 3 17 18 Forreported peer review only 19 Objectives 3 State specific objectives, including any prespecified hypotheses 3 20 Methods 21 22 Study design 4 Present key elements of study design early in the paper 4 23 Setting 5 Describe the setting, locations, and relevant dates, including periods of 4 24 recruitment, exposure, follow-up, and data collection 25 26 Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods 4 27 of selection of participants 28 Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and 4-6 29 effect modifiers. Give diagnostic criteria, if applicable 30 31 Data sources/ 8* For each variable of interest, give sources of data and details of methods of 4-6 32 measurement assessment (measurement). Describe comparability of assessment methods if 33 there is more than one group 34 Bias 9 Describe any efforts to address potential sources of bias. 4-6 35 36 Study size 10 Explain how the study size was arrived at. 4 37 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, 7 http://bmjopen.bmj.com/ 38 describe which groupings were chosen and why 39 40 Statistical methods 12 (a) Describe all statistical methods, including those used to control for 7 41 confounding 42 (b) Describe any methods used to examine subgroups and interactions 7 43 (c) Explain how missing data were addressed NA 44 45 (d) Cross-sectional study—If applicable, describe analytical methods taking NA 46 account of sampling strategy on October 4, 2021 by guest. Protected copyright. 47 (e) Describe any sensitivity analyses NA 48 49 50 Results 51 Participants 13* Report numbers of individuals at each stage of study—eg numbers potentially 5 52 53 eligible, examined for eligibility, confirmed eligible, included in the study, 54 completing follow-up, and analysed 55 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and 5 56 information on exposures and potential confounders 57 58 (b) Indicate number of participants with missing data for each variable of interest NA 59 Main results 15 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates 5-6 60 and their precision (e.g., 95% confidence interval). Make clear which confounders

1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 41 BMJ Open

1 2 were adjusted for and why they were included 3 (b) Report category boundaries when continuous variables were categorized NA 4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 (c) If relevant, consider translating estimates of relative risk into absolute risk for NA 6 a meaningful time period 7 Other analyses 16 Report other analyses done—eg analyses of subgroups and interactions, and 5-6 8 9 sensitivity analyses 10 Discussion 11 Key results 17 Summarise key results with reference to study objectives 11 12 13 Limitations 18 Discuss limitations of the study, taking into account sources of potential bias or 13 14 imprecision. Discuss both direction and magnitude of any potential bias 15 Interpretation 19 Give a cautious overall interpretation of results considering objectives, 11-13 16 limitations, multiplicity of analyses, results from similar studies, and other 17 18 Forrelevant peer evidence review only 19 Generalisability 20 Discuss the generalisability (external validity) of the study results 13 20 21 Other information 22 Funding 21 Give the source of funding and the role of the funders for the present study and, 13 23 if applicable, for the original study on which the present article is based 24 * NA: Not applicable. 25 26 * Give information separately for cases and controls in case-control studies and, if applicable, for exposed and 27 unexposed groups in cohort and cross-sectional studies. 28 . 29 Reference: 30 31 32 1. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the 33 Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational 34 studies. Preventive medicine. 2007;45(4):247-51. 35 36 37 38 http://bmjopen.bmj.com/ 39 40 41 42 43 44 45 46 on October 4, 2021 by guest. Protected copyright. 47 48 49 50 51 52 53 54 55 56 57 58 59 60

2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Appendix 3: Supplementary Tables 5

6 7 Supplementary Table 1: Association of scores with demographic characteristics. 8 9 Knowledge Scores Attitude Scores Practices scores 10 Score P value Score P value Score P value 11 Age 12 13 ≤ 30 years 19.25 ± 3.53 3.66 ± 2.32 12.05 ± 1.84 14 31 to 50 years 19.23 ± 3.71 0.001 3.90 ± 2.28 <0.001 12.31 ± 1.75 0.006 15 > 50 years 18.99 ± 3.95 3.80 ± 2.34 12.14 ± 1.98 16 Gender For peer review only 17 Male 18.94 ± 3.78 <0.001 3.59 ± 2.36 0.002 11.96 ± 2.0 <0.001 18 Female 19.40 ± 3.44 3.84 ± 2.26 12.22 ± 1.72 19 Education 20 High School 17.58 ± 3.72 3.84 ± 2.46 12.11 ± 2.01 21 22 Undergraduate 19.43 ± 3.48 <0.001 3.72 ± 2.28 <0.001 12.10 ± 1.80 <0.001 23 Graduated 19.52 ± 3.58 3.67 ± 2.30 12.21 ± 1.76 24 Prefer not to say 19.16 ± 3.74 3.70 ± 2.40 11.84 ± 2.10 25 Residency 26 Urban 19.32 ± 3.55 0.001 3.71 ± 2.31 0.07 12.16 ± 1.80 <0.001 27 Rural 18.90 ± 3.73 3.76 ± 2.35 11.92 ± 1.98 28 Previous confirmed COVID-19 diagnosis 29 Yes 17.10 ± 4.35 <0.001 3.42 ± 2.61 <0.001 11.64 ± 2.70 <0.001 30 31 No 19.28 ± 3.56 3.73 ± 2.31 12.12 ± 1.81 32 Knowing someone with confirmed 33 COVID-19 diagnosis 34 Yes 19.84 ± 3.50 <0.001 3.39 ± 2.36 0.003 12.47 ± 1.83 0.001 http://bmjopen.bmj.com/ 35 No 19.15 ± 3.60 3.77 ± 2.30 12.11 ± 1.83 36 Data are presented as mean ± standard deviation. Analysis was conducted using independent t-test or ANOVA test 37 with post-hoc Hochberg test. 38 39 40 41

on October 4, 2021 by guest. Protected copyright. 42

43 44 45 46 47 48 49 50 51

52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 3: Knowledge cut-off scores per country 4 5 6 Poor Fair Good N 7 8 Algeria 656 (13.38) 3207 (65.45) 1037 (21.16) 4900 9 10 Egypt 716 (10.48) 4391 (64.28) 1723 (25.22) 6830 11 Ghana 507 (27.45) 1175 (63.62) 165 (8.93) 1847 12 13 Indonesia 1362 (30.65) 2883 (64.87) 199 (4.47) 4444 14 15 Iraq 340 (16.25) 1370 (65.48) 382 (18.26) 2092 16 For peer review only 17 Jordan 731 (12.41) 3737 (63.54) 1414 (24.04) 5881 18 Lebanon 441 (13.05) 2263 (66.95) 676 (20.00) 3380 19 20 Libya 1115 (25.93) 2511 (58.40) 674 (15.67) 4300 21 22 Morocco 400 (22.79) 1048 (59.72) 307 (17.49) 1755 23 24 Nepal 769 (28.94) 1666 (62.70) 222 (8.35) 2657 25 26 Nigeria 1330 (38.54) 1959 (56.82) 160 (4.64) 3448 27 Pakistan 627 (36.40) 963 (55.90) 133 (7.72) 1723 28 29 Palestine 1010 (16.85) 3950 (65.91) 1033 (17.24) 5993 30 31 Saudi Arabia 249 (15.41) 1064 (65.84) 303 (18.75) 1616 32 33 South Africa 576 (29.11) 1201 (60.69) 202 (10.21) 1979 http://bmjopen.bmj.com/ 34 Sudan 481 (10.98) 3033 (69.23) 867 (19.80) 4381 35 36 Syria 908 (13.81) 4059 (61.72) 1609 (24.47) 6576 37 38 UK 474 (21.94) 1167 (54.03) 519 (24.03) 2160 39 40 India 498 (34.02) 888 (60.66) 78 (5.32) 1464 41

Sri-Lanka 475 (26.50) 1136 (63.36) 182 (10.15) 1793 on October 4, 2021 by guest. Protected copyright. 42 43 Ireland 265 (25.83) 539 (52.53) 222 (21.64) 1026 44 45 Brazil 55 (6.55) 511 (60.90) 273 (32.54) 839 46 47 USA 236 (29.35) 366 (45.52) 202 (25.12) 804 48 Total 14221 (19.78) 45087 (62.72) 12582 (17.50) 71890 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 41 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 3: Mean knowledge, attitudes, and practices scores and rate questions for each 4 country 5 6 7 N Knowledge Attitudes Practices Fear of Compliance Negative 8 getting with mental 9 10 COVID-19 lockdown effects 11 Algeria 4900 19.94 ± 3.22 3.78 ± 2.13 12.21 ± 1.66 5.39 ± 2.78 8.28 ± 2.21 5.14 ± 3.01 12 13 Egypt 6830 20.35 ± 3.10 3.68 ± 2.25 11.79 ± 1.85 6.14 ± 2.81 7.70 ± 2.32 6.02 ± 2.97 14 15 Ghana 1847 18.28 ± 3.24 3.36 ± 2.30 12.64 ± 1.48 5.62 ± 3.00 7.77 ± 2.25 3.88 ± 2.76 16 For peer review only 17 Indonesia 4444 17.74 ± 3.24 3.49 ± 2.33 12.90 ± 1.42 6.57 ± 2.18 8.14 ± 1.74 5.77 ± 2.56 18 Iraq 2092 19.52 ± 3.42 4.51 ± 2.00 12.35 ± 1.57 5.26 ± 2.94 7.88 ± 2.28 4.80 ± 3.06 19 20 Jordan 5581 20.13 ± 3.32 4.53 ± 2.10 12.58 ± 1.58 4.89 ± 2.85 8.57 ± 2.03 5.69 ± 3.14 21 22 Lebanon 3380 19.91 ± 3.19 3.17 ± 2.31 12.29 ± 1.66 5.12 ± 2.71 7.55 ± 2.20 5.23 ± 2.93 23 24 Libya 4300 18.69 ± 4.01 4.04 ± 2.36 11.58 ± 2.23 4.50 ± 2.92 6.89 ± 2.82 5.09 ± 3.25 25 26 Morocco 1755 19.05 ± 3.61 2.33 ± 2.41 12.59 ± 1.49 5.55 ± 2.58 8.65 ± 1.92 5.53 ± 2.87 27 28 Nepal 2657 18.07 ± 3.51 3.76 ± 2.31 12.60 ± 1.50 6.17 ± 2.53 7.54 ± 2.42 4.93 ± 2.76 29 Nigeria 3448 17.12 ± 3.80 3.82 ± 2.25 11.94 ± 2.21 6.18 ± 3.01 7.29 ± 2.50 5.26 ± 3.02 30 31 Pakistan 1723 17.49 ± 3.94 3.82 ± 2.43 12.39 ± 1.81 5.77 ± 2.64 6.06 ± 2.73 5.59 ± 2.87 32 33 Palestine 5993 19.42 ± 3.31 3.95 ± 2.28 11.50 ± 2.03 4.43 ± 2.75 7.22 ± 2.67 5.56 ± 3.16 34 http://bmjopen.bmj.com/ 35 Saudi Arabia 1616 19.63 ± 3.33 4.76 ± 1.93 12.54 ± 1.31 5.26 ± 2.75 8.68 ± 2.01 4.40 ± 2.94 36 37 South Africa 1979 18.20 ± 3.62 3.55 ± 2.28 12.60 ± 1.56 5.93 ± 3.09 7.84 ± 2.36 5.16 ± 2.94 38 39 Sudan 4381 20.05 ± 3.04 3.70 ± 2.16 12.01 ± 1.90 5.36 ± 3.05 8.13 ± 2.30 4.88 ± 3.19 40 Syria 6576 20.02 ± 3.45 3.66 ± 2.34 11.55 ± 1.86 4.27 ± 2.56 7.10 ± 2.50 5.06 ± 3.06 41 on October 4, 2021 by guest. Protected copyright. 42 UK 2160 19.29 ± 4.33 2.92 ± 2.49 11.69 ± 2.09 5.70 ± 2.48 7.64 ± 2.52 5.09 ± 2.79 43 44 India 1464 17.45 ± 3.55 4.18 ± 2.15 12.66 ± 1.50 6.38 ± 2.57 7.10 ± 2.76 5.60 ± 2.87 45 46 SriLanka 1793 18.40 ± 3.16 3.31 ± 2.24 12.34 ± 1.50 4.52 ± 2.41 8.28 ± 2.45 4.29 ± 2.80 47 48 Ireland 1026 19.00 ± 4.06 2.94 ± 2.40 11.98 ± 1.66 5.85 ± 2.62 7.98 ± 2.12 4.76 ± 2.85 49 50 Brazil 839 21.09 ± 3.04 2.17 ± 2.17 11.74 ± 1.46 6.72 ± 2.57 6.72 ± 2.95 5.68 ± 2.96 51 52 USA 804 19.00 ± 4.28 2.66 ± 2.40 12.31 ± 1.42 5.51 ± 2.30 7.79 ± 2.23 5.11 ± 2.66 53 Total 71890 19.24 ± 3.59 3.72 ± 2.31 12.12 ± 1.83 5.37 ± 2.83 7.70 ± 2.43 5.27 ± 3.02 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 41 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 4: Correlations between knowledge, attitudes, and practices 4 scores. 5 6 Knowledge Attitude Practice Score 7 8 Score Score

9 ** ** 10 Knowledge Pearson Correlation 1 0.058 .124 11 Score Sig. (2-tailed) <0.001 <0.001 12 13 Attitude Score Pearson Correlation 0.058** 1 0.276** 14 15 Sig. (2-tailed) <0.001 <0.001 16 For peer review only 17 Practice Score Pearson Correlation 0.124** 0.276** 1 18 19 Sig. (2-tailed) <0.001 <0.001 20 21 Fear of getting Pearson Correlation -0.044 0.126 0.167 22 COVID-19 Sig. (2-tailed) 23 0.000 0.000 0.000 24 Compliance Pearson Correlation 25 0.111 0.081 0.225 26 with lockdown Sig. (2-tailed) 0.000 0.000 0.000 27 28 Negative Pearson Correlation -0.019 -0.013 0.002 29 mental effects 30 Sig. (2-tailed) 0.000 0.001 0.598 31 of lockdown 32 **. Correlation is significant at the 0.01 level (2-tailed). 33 http://bmjopen.bmj.com/ 34 Analysis was performed using Kendall's tau_b test. 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 4 Appendix file 4: Other KAP studies on COVID-19 5 6 Study ID Country Survey Sample Summary of Results 7 Month Size 8 9Azlan Malaysia March, 4850 “The overall correct rate of the knowledge questionnaire was 80.5%. Most participants held positive attitudes toward the 102020 1 April successful control of COVID-19 (83.1%), the ability of Malaysia to conquer the disease (95.9%) and the way the Malaysian 11 government was handling the crisis (89.9%). Most participants were also taking precautions such as avoiding crowds (83.4%) 12 andFor practicing peer proper hand hygiene review (87.8%) in the week beforeonly the movement control order started. However, wearing face 13 masks was less common (51.2%)”. 14 15Hanafiah Malaysia April 1075 “A total of 1075 individuals responded to the survey with average completion time of 5 minutes and 90% completion rate (96- 2 162020 99% for Demographic items, 92% for Knowledge & Perception items, and 89% for Communication items)”. 17Clements USA March 1034 “For every point increase in knowledge, the odds of participation in purchasing more goods (odds ratio [OR] 0.88, 95% CI 0.81- 182020 3 0.95), attending large gatherings (OR 0.87, 95% CI 0.81-0.93), and using medical masks (OR 0.56, 95% CI 0.50-0.62) decreased 19 by 12%, 13%, and 44%, respectively. Gen X and millennial participants had 56% and 76%http://bmjopen.bmj.com/ higher odds, respectively, of increased 20 purchasing behavior compared to baby boomers. The results suggest that there is a politicization of response 21 recommendations. Democrats had 30% lower odds of attending large gatherings (OR 0.70, 95% CI 0.50-0.97) and 48% lower 22 odds of using medical masks (OR 0.52, 95% CI 0.34-0.78) compared to Republicans”. 23 4 24Roy 2020 India March 662 “The anxiety levels identified in the study were high. More than 80 % of the people were preoccupied with the thoughts of 25 COVID-19 and 72 % reported the need to use gloves, and sanitizers. In this study, sleep difficulties, paranoia about acquiring 26 COVID-19 infection and distress related social media were reported in 12.5 %, 37.8 %, and 36.4 % participants respectively. 27 The perceived mental healthcare need was seen in more than 80 % of participants”. on October 4, 2021 by guest. Protected copyright. 28Reuben Nigeria June 589 “Respondents had good knowledge (99.5%) of COVID-19, gained mainly through the internet/social media (55.7%) and 292020 5 Television (27.5%). The majority of the respondents (79.5%) had positive attitudes toward the adherence of government IPC 30 measures with 92.7, 96.4 and 82.3% practicing social distancing/self-isolation, improved personal hygiene and using face mask 31 32 respectively. However, 52.1% of the respondents perceived that the government is not doing enough to curtail COVID-19 in 33 Nigeria. Pearson’s correlation showed significant relationship between knowledge of COVID-19 and attitude towards 34 preventive measures (r = 0.177, p = 0.004, r = 0.137, p = 0.001). Although 61.8% of the respondents have no confidence in the 35 present intervention by Chinese doctors, only 29.0% would accept COVID-19 vaccines when available” 36Zhong China February 6910 “Among the survey completers (n=6910), 65.7% were women, 63.5% held a bachelor degree or above, and 56.2% engaged in 372020 6 mental labor. The overall correct rate of the knowledge questionnaire was 90%. The majority of the respondents (97.1%) had 38 confidence that China can win the battle against COVID-19. Nearly all of the participants (98.0%) wore masks when going out 39 in recent days. In multiple logistic regression analyses, the COVID-19 knowledge score (OR: 0.75-0.90, P<0.001) was 40 significantly associated with a lower likelihood of negative attitudes and preventive practices towards COVID-2019”. 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3Abdelhafiz Egypt March 559 “The mean knowledge score was 16.39 out of 23, gained mainly though social media (66.9%), and the internet (58.3%). 4 2020 7 Knowledge was significantly lower among older, less educated, lower income participants, and rural residents. Most 5 6 participants (86.9%) were concerned about the risk of infection. While 37.6% thought that their salary will be continued if 7 they become isolated, 68.5% believed that it should be continued during this period. About 73.0% were looking forward to 8 get the vaccine when available” 9Serwaa Ghana March 350 “Regarding COVID-19, 62.7% had “good” knowledge about the outbreak, 68.3% had a high risk of contracting the COVID-19 102020 8 infection and 81.4% had a moderate preparedness skill to prevent and control the disease. Internet (77.1%) was the major 11 sources of information. Knowledge of COVID-19 was significantly associated with education (p<0.001), age (p=0.018), 12 employmentFor (p=0.011)peer and health review-related occupation (P=0.001) only but only religion was associated with risk perception”. 13 Lin 2020 9 China April 2446 “The mean and SD for the total knowledge score was 20.3 (SD ± 2.9) out of a possible score of 23. The social disruption and 14 15 household economic impact were notable, particularly in provinces with higher cumulative confirmed cases. The majority of 16 responses indicated a low perceived susceptibility of being infected (86.7% [95%CI 85.4–88.1]), with a fair proportion of 17 respondents perceiving a higher severity (62.9% [95% CI 61.0–64.8]). The mean total impact score was 9.9 (SD ± 3.8) out of a 18 possible score of 15. The mean score for STAI-S was 48.7 (SD ± 10.8), whereas the mean STAI-T score was 45.7 (SD ± 8.5). By 19 demographics, women reported significantly higher odds for higher levels of both STAIhttp://bmjopen.bmj.com/ -S (OR = 1.67) and STAI-T (OR = 1.30) 20 compared to men. People of a younger age were also more likely to experience higher STAI-S and STAI-T. Higher perceived 21 susceptibility and severity and impact were strong predictors of higher levels of STAI-S and STAI-T”. 22 Gharpure USA May 502 “1. (39 %) of respondents reported engaging in not recommended high-risk practices as washing food products with bleach, 23 10 242020 applying household cleaning or disinfectant products to bare skin, and intentionally inhaling or ingesting these products 25 2. Respondents who engaged in high-risk practices reported more adverse health effects as a result of using disinfectants 26 than those who did not report engaging in these practices”. 27Al-Hanawi Saudi March 3388 “The mean knowledge score was 17.96 (SD= 2.24) Which is a high knowledge level. on October 4, 2021 by guest. Protected copyright. The score attitude was 28.23 (SD = 2.76 282020 11 Arabia range = 6 - 30) which is optimistic attitude. The practice score was 4.34 (SD = 0.87, range: 0–5), indicating good practices. Men 29 have less knowledge, less optimistic attitudes, and less good practice toward COVID-19, than women. Older adults are likely 30 to have better knowledge and practices, than younger people”. 31 Faasse Australia March 3086 “1. Two thirds of respondents were at least moderately worried about a widespread COVID-19 outbreak in Australia 32 2020 12 33 2. Health-behavior engagement over the previous month was lower in some demographic groups, including males and 34 younger individuals (18-29 age group) 35 36 3. These was a substantial mismatch between respondents’ expected symptoms of infection and emerging evidence that a 37 meaningful proportion of people who contract the novel coronavirus will experience asymptomatic infection 38 39 4. Only 0.3% believed that they personally would not experience any symptoms if they were infected 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 5. Uncertainty and misconceptions about COVID-19 were common, including one third of respondents who reported being 4 unsure whether people are likely have natural or existing immunity 5 6 6. There was also uncertainty around whether specific home remedies (e.g., vitamins, saline rinses) would offer protection, 7 whether the virus could spread via the airborne route, and whether the virus was human made and deliberately released”. 8 9Naser Jordan, March, 1208 “1. Moderate overall COVID-19 knowledge with a mean score of 7.93 (SD = 1.72) out of 12, 66.1%. 102020 13 Saudi April 2. Participants had better knowledge about disease prevention and control with 83.0%, 11 Arabia, 3. The lowest sub-scale scores were for questions about disease transmission routes (43.3%). 12 Kuwait 4.For High education peer level was an importantreview predictor of greater only COVID-19 knowledge scores (p<0.01)” 13 14Saqlain Pakistan April, 689 “1. More than half had good knowledge; 80% had good practices regarding COVID-19 and majority seek knowledge from 14 152020 May social media. 16 2. Knowledge was significantly higher (OR>1.00, p<0.05) among educated and higher income participants. 17 3. Positive practices were significantly (OR>1.00, p<0.05) related to the older age (≥50 years), higher education, higher income 18 and good knowledge regarding COVID-19” http://bmjopen.bmj.com/ 19Olapegba Nigeria March, 1357 “1. Approximately half of the respondents opined that COVID-19 was “a biological weapon designed by Chinese government. 20 2020 15 April 2. About 94% of the respondents identified “contact with airborne droplets via breathing, sneezing, or coughing” as the most 21 22 common mode of transmission 23 3. most respondents associated COVID-19 with coughing (81.13%), shortness of breath (73.47%) and fever (62.79%). 24 4. “Regular hand washing and social distancing” was selected by most respondents (94.25%) as a way of preventing infection 25 5. 11.86% reported “consuming gins, garlic, ginger, herbal mixtures and African foods/soups” as preventive measures against 26 COVID-19. 27 6. Majority of the respondents (91.73%) thought COVID-19 is deadly; and most respondents on October 4, 2021 by guest. Protected copyright. (84.3%) got ≥ 4 answers correctly. 28 7. It was also observed that the traditional media (TV/Radio) are the most common source of health information about COVID- 29 19 (93.5%)”. 30 February 31Lau 2020 Philippin 2224 “1. 94.0% heard of COVID-19. 16 32 es , March 2. Traditional media sources such as television (85.5%) and radio (56.1%) were reported as the main sources of information 33 about the virus. 34 3. Coughing and sneezing were identified as a transmission route by 89.5% of respondents, while indirect hand contact was 35 the least common by 72.6% of respondents. 36 4. Hand washing was identified by 82.2% of respondents as a preventive measure against the virus, but social distancing by 37 32.4% and avoiding crowds by 40.6%. 38 5. A greater number of preventive measures were taken by those with more knowledge of potential transmission routes.” 39 March 40Mannan Banglade 435 “1. All of the participants agreed that they heard about COVID-19 (97.8%). 17 412020 sh 2. Most of population used social media to obtain regarding the COVID-19 information. 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 3. A significant proportion of had poor knowledge of its transmission and symptoms onset and showed a positive perception 4 of COVID-19 prevention and control. 5 6 4. Factors such as profession and age are correlated with inadequate knowledge of COVID-19” 7Meier Netherla March 9796 “Participants indicated support for governmental measures related to avoiding social gatherings, selective closure of public 82020 18 nds, places, and hand hygiene and respiratory measures (range for all measures: 95.0%-99.7%). Respondents from the Netherlands 9 Germany were less likely to consider a complete social lockdown effective (59.2%), compared to respondents in Germany (76.6%) or 10 , Italy Italy (87.2%). Italian residents did not only apply enforced social distancing measures more frequently (range: 90.2%-99.3%, 11 German and Dutch residents: 67.5%-97.0%), but also self-initiated hygienic and social distancing behaviors (range: 36.3%- 12 96.6%,For German peer and Dutch residents: review 28.3%-95.7%). Respondents only largely reported being sufficiently informed about the 13 COVID-19 outbreak and about behaviors to avoid infection (range across countries: 90.2%-91.1%). Information channels most 14 15 commonly reported included television (range: 53.0%-82.0%), newspapers (range: 31.0%-63.0%), official health websites 16 (range: 39.0%-54.1%), and social media (range: 40.0%-55.8%). We observed no major changes in answers over time”. 17Abir 2020 Banglade March & 1005 “The mean knowledge (8.4 vs. 8.1, P=0.022) and risk perception (11.2 vs. 10.6, P < 0.001) scores differ significantly between 1819 sh May early and late lockdown. Compared to the early lockdown period, the scores for perceived risk of contracting COVID-19 19 decreased significantly while public knowledge about COVID-19 was lower but not statisticallyhttp://bmjopen.bmj.com/ significant”. 20Li 2020 20 China February 4607 “The participants indicated that they had medium level of knowledge about the COVID-19 (3.56 out of 5). Moreover, 21 participants perceived the COVID-19 to be highly severe (4.09 out of 5) and modestly controllable (3.25 out of 5). Regarding 22 their emotional and behavioral reactions, the results showed that the COVID-19 did not change much of the frequency of 23 24 participants’ positive and negative feelings and a range of behavior, with the mean score ranging from 2.61 to 3.77. In fact, 25 participants indicated that the frequencies of sleep problem, aggression, and substance use after the outbreak were slightly 26 lower compared to the ones before the outbreak of the COVID-19. As for social participation, participants appeared to not 27 very actively participate in the social events regarding the COVID-19 (1.75 out of 4). However, on October 4, 2021 by guest. Protected copyright. participants reported that they 28 displayed intensive precautionary behavior to prevent the COVID-19 (3.33 out of 4)”. 29Kwok January- 1715 “Analysis from 1715 complete responses indicated high perceived susceptibility (89%) and high perceived severity (97%). Most 302020 21 February respondents were worried about COVID-19 (97%), and had their daily routines disrupted (slightly/greatly: 98%). The anxiety 31 level, measured by the Hospital Anxiety and Depression Scale, was borderline abnormal (9.01). Nearly all respondents were 32 33 alert to the disease progression (99.5%). The most trusted information sources were doctors (84%), followed by broadcast 34 (57%) and newspaper (54%), but they were not common information sources (doctor: 5%; broadcast: 34%; newspaper: 40%). 35 Only 16% respondents found official websites reliable. Enhanced personal hygiene practices and travel avoidance to China 36 were frequently adopted (>77%) and considered effective (>90%). The adoption of social-distancing measures was lower 37 (39%-88%), and their drivers for greater adoption include: being female (adjusted odds ratio [aOR]:1.27), living in the New 38 Territories (aOR:1.32-1.55), perceived as having good understanding of COVID-19 (aOR:1.84) and being more anxious 39 (aOR:1.07)”. 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3Geldsetze United March 5974 “US and UK participants’ median estimate for the probability of a fatal disease course among those infected with severe acute 4 r 2020 22 States respiratory syndrome coronavirus 2 (SARS-CoV-2) was 5.0% (IQR 2.0%-15.0%) and 3.0% (IQR 2.0%-10.0%), respectively. 5 6 and Participants generally had good knowledge of the main mode of disease transmission and common symptoms of COVID-19. 7 United However, a substantial proportion of participants had misconceptions about how to prevent an infection and the 8 Kingdom recommended care-seeking behavior. For instance, 37.8% (95% CI 36.1%-39.6%) of US participants and 29.7% (95% CI 28.1%- 9 31.4%) of UK participants thought that wearing a common surgical mask was “highly effective” in protecting them from 10 acquiring COVID-19, and 25.6% (95% CI 24.1%-27.2%) of US participants and 29.6% (95% CI 28.0%-31.3%) of UK participants 11 thought it was prudent to refrain from eating at Chinese restaurants. Around half (53.8%, 95% CI 52.1%-55.6%) of US 12 participantsFor andpeer 39.1% (95% CI 37.4%review-40.9%) of UK participants only thought that children were at an especially high risk of death 13 when infected with SARS-CoV-2”. 14 N/A 15Islam Banglade 190 “The respondents (n=189) who took part in the survey seems to be aware of the facts of COVID-19. 73.4% responded that 23 162020 sh they have good knowledge on COVID-19, whereas 3.2% of respondent have low level of knowledge. 23% have an average 17 knowledge. The respondents were mainly professionals and students over 18. That is why, most of them were aware of 18 the facts of COVID-19 through different media. Among the respondents, nearly 99% are maintaining social distancing 19 corresponding the government’s request”. http://bmjopen.bmj.com/ 20Qian 2020 China February 1011 “The prevalence rates of moderate or severe anxiety (score ≥10 on GAD-7) were 32.7% (n=167) among Wuhan participants 2124 and 20.4% (n=102) among Shanghai participants. 78.6% (n=401) of Wuhan participants and 63.9% (n=320) of Shanghai 22 participants had carried out all six precautionary behaviors. For both measures, Wuhan participants were more responsive to 23 24 the outbreak (p<0.001). Controlling for personal characteristics, logistic regression results suggested that risks of moderate 25 or severe anxiety were positively associated with perceived susceptibility (odds ratio 1.6, 95% confidence interval 1.3-1.8) and 26 severity of the disease (1.6, 1.4-1.9) and confusion about information reliability (1.6, 1.5-1.9). Having confidence in taking 27 measures to protect oneself against the disease was associated with a lower risk (0.6, on October 4, 2021 by guest. Protected copyright. 0.5-0.7). The strongest predictor of 28 behavioral change was perceived severity, followed by confusion about information reliability”. 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 4 References 5 1. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study 6 7 in Malaysia. Plos one. 2020;15(5):e0233668. 8 2. Mohd Hanafiah K, Wan CD. Public knowledge, perception and communication behavior surrounding COVID-19 in Malaysia. 2020. 9 10 3. Clements JM. Knowledge and Behaviors Toward COVID-19 Among US Residents During the Early Days of the Pandemic: Cross-Sectional 11 Online Questionnaire. JMIR Public Health and Surveillance. 2020;6(2):e19161. 12 For peer review only 13 4. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in 14 Indian population during COVID-19 pandemic. Asian Journal of Psychiatry. 2020:102083. 15 16 5. Reuben RC, Danladi MM, Saleh DA, Ejembi PE. Knowledge, Attitudes and Practices Towards COVID-19: An Epidemiological Survey in North- 17 Central Nigeria. Journal of community health. 2020:1-14. 18 19 6. Zhong B-L, Luo W, Li H-M, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residentshttp://bmjopen.bmj.com/ during the rapid rise 20 period of the COVID-19 outbreak: a quick online cross-sectional survey. International journal of biological sciences. 2020;16(10):1745. 21 22 7. Abdelhafiz AS, Mohammed Z, Ibrahim ME, et al. Knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease 23 (COVID-19). Journal of Community Health. 2020:1-10. 24 25 8. Serwaa D, Lamptey E, Appiah AB, Senkyire EK, Ameyaw JK. Knowledge, risk perception and preparedness towards coronavirus disease- 26 2019 (COVID-19) outbreak among Ghanaians: a quick online cross-sectional survey. The Pan African medical journal. 2020;35(44). 27 on October 4, 2021 by guest. Protected copyright. 28 9. Lin Y, Hu Z, Alias H, Wong LP. Knowledge, Attitudes, Impact, and Anxiety Regarding COVID-19 Infection Among the Public in China. Frontiers 29 in Public Health. 2020;8:236. 30 10. Gharpure R, Hunter CM, Schnall AH, et al. Knowledge and practices regarding safe household cleaning and disinfection for COVID-19 31 32 prevention—United States, May 2020. Morbidity and Mortality Weekly Report. 2020;69(23):705. 33 11. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi 34 35 Arabia: A Cross-Sectional Study. Frontiers in Public Health. 2020;8. 36 12. Faasse K, Newby JM. Public perceptions of COVID-19 in Australia: perceived risk, knowledge, health-protective behaviours, and vaccine 37 intentions. medRxiv. 2020. 38 39 13. Naser AY, Dahmash EZ, Alwafi H, et al. Knowledge and practices towards COVID-19 during its outbreak: a multinational cross-sectional 40 study. medRxiv. 2020. 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 14. Saqlain M, Ahmed A, Gulzar A, et al. Public Knowledge and Practices regarding COVID-19: A cross-sectional survey from Pakistan. medRxiv. 4 2020. 5 6 15. Olapegba PO, Ayandele O, Kolawole SO, et al. A Preliminary Assessment of Novel Coronavirus (COVID-19) Knowledge and Perceptions in 7 Nigeria. 2020. 8 9 16. Lau LL, Hung N, Go DJ, et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: A cross- 10 sectional study. Journal of global health. 2020;10(1). 11 12 17. Mannan DKA, Mannan KA.For Knowledge peer and perception towardsreview Novel Coronavirus only (COVID 19) in Bangladesh. International Research 13 Journal of Business and Social Science. 2020;6(2). 14 15 18. Meier K, Glatz T, Guijt MC, et al. Public perspectives on social distancing and other protective measures in Europe: a cross-sectional survey 16 study during the COVID-19 pandemic. medRxiv. 2020. 17 18 19. Abir T, Kalimullah NA, Osuagwu UL, et al. Factors Associated with the Perception of Risk and Knowledge of Contracting the SARS-Cov-2 19 among Adults in Bangladesh: Analysis of Online Surveys. International journal of environmental researchhttp://bmjopen.bmj.com/ and public health. 20 2020;17(14):5252. 21 22 20. Li J-B, Yang A, Dou K, Wang L-X, Zhang M-C, Lin X-Q. Chinese public’s knowledge, perceived severity, and perceived controllability of the 23 COVID-19 and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: A national 24 survey. 2020. 25 26 21. Kwok KO, Li KK, Chan HH, et al. Community responses during the early phase of the COVID-19 epidemic in Hong Kong: risk perception, 27 information exposure and preventive measures. MedRxiv. 2020. on October 4, 2021 by guest. Protected copyright. 28 29 22. Geldsetzer P. Use of rapid online surveys to assess People's perceptions during infectious disease outbreaks: a cross-sectional survey on 30 COVID-19. Journal of medical Internet research. 2020;22(4):e18790. 31 32 23. Islam MD, Siddika A. COVID-19 and Bangladesh: A study of the public perception on the measures taken by the government. 2020. 33 24. Qian M, Wu Q, Wu P, et al. Psychological responses, behavioral changes and public perceptions during the early phase of the COVID-19 34 35 outbreak in China: a population based cross-sectional survey. medRxiv. 2020. 36 37 38 39 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

KAP-COVIDGLOBAL: A Multinational Survey of the Levels and Determinants of Public Knowledge, Attitudes, and Practices towards COVID-19 ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2020-043971.R1

Article Type: Original research

Date Submitted by the 18-Jan-2021 Author:

Complete List of Authors: Masoud, Ahmed; Fayoum University Faculty of Medicine Zaazouee, Mohamed; Al-Azhar University - Assiut Branch Elsayed, Sarah; October 6 University Faculty of Medicine Ragab, Khaled; Minia University Faculty of Medicine Kamal, Esraa; Fayoum University Faculty of Medicine Alnasser, Yusra; Damascus University Faculty of Medicine Assar, Ahmed ; Menoufia University Faculty of Medicine Nourelden, Anas; Al-Azhar University Istatiah, Loai; Fayoum University Faculty of Medicine Abd-Elgawad, Mohamed; Fayoum University Faculty of Medicine Abdelsattar, Ahmed; Fayoum University Faculty of Medicine Sofy, Ahmed; Fayoum University Faculty of Medicine Hegazy, Doaa; Harvard Medical School Femía, Victor; Universidade do Vale do Sapucaí http://bmjopen.bmj.com/ Mendonça, Adriana; Universidade do Vale do Sapucai Sayed, Fatma; Fayoum University Faculty of Medicine Elmoursi, Ahmed; University of Kentucky College of Medicine Alareidi, Alaa; Rutgers University Abd-Eltawab, Ahmed; Fayoum University Faculty of Medicine Abdelmonem, Mohamed; Fayoum University Faculty of Medicine Mohammed, Omar; Fayoum University Faculty of Medicine Derballa, EzzEldeen ; Fayoum University Faculty of Medicine

El-Fas, Kareem; King Faisal University on October 4, 2021 by guest. Protected copyright. Abdel-Daim, Mohamed; Suez Canal University Faculty of Veterinary Medicine; King Saud University College of Science Abushouk, Abdelrahman ; Ain Shams University,

Primary Subject Public health Heading:

Secondary Subject Heading: Epidemiology, Global health, Research methods

Keywords: PUBLIC HEALTH, EPIDEMIOLOGY, VIROLOGY

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4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the terms applicable for US Federal Government officers or employees acting as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author Forunless you peer are acting as review an employee on behalf only of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34 35 36 37 38 http://bmjopen.bmj.com/ 39 40 41 42 43 44 45 46 on October 4, 2021 by guest. Protected copyright. 47 48 49 50 51 52 53 54 55 56 57 58 59 60

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 KAP-COVIDGLOBAL: A Multinational Survey of the Levels and Determinants of 5 Public Knowledge, Attitudes, and Practices towards COVID-19 6 7 Ahmed Taher Masoud1, Mohamed S. Zaazouee2, Sarah M. Elsayed3, Khaled M. Ragab4, Esraa M. Kamal1, 8 Yusra T. Alnasser5, Ahmed Assar6, Anas Z. Nourelden7, Loai J. Istatiah1, Mohamed M. Abd-Elgawad1, 9 Ahmed T. Abdelsattar1, Ahmed A. Sofy1, Doaa G. Hegazy8, MD, Victor Z. Femía9, Adriana R. Mendonça9, 10 1 10 11 1 1 11 Fatma M. Sayed , Ahmed Elmoursi , Alaa Alareidi , Ahmed K. Abd-Eltawab , Mohamed Abdelmonem , 12 Omar M. Mohammed1, EzzEldeen A. Derballa1, Kareem A. El-Fas12, PharmD, Mohamed Abdel-Daim13, ‡ 14 ‡ * 13 PhD , Abdelrahman I. Abushouk , MD for the KAP-COVIDGLOBAL Investigators 14 15 16 1 Faculty of Medicine, FayoumFor University, peer Fayoum, review Egypt only 17 2 18 Faculty of Medicine, Al-Azhar University, Assiut, Egypt

19 3 th 20 Faculty of Medicine, 6 of October University, Giza, Egypt 21 4 Faculty of Medicine, Minia University, Minia, Egypt 22 23 5 Faculty of Pharmacy, Damascus University, Damascus, Syria 24 25 6 Faculty of Medicine, Menoufia University, Menoufia, Egypt 26 27 7 Faculty of Medicine, Al-Azhar University of Cairo, Cairo, Egypt 28 8 29 Department of Ophthalmology, Harvard Medical School, Boston, MA 30 9 Universidade do Vale do Sapucaí, Pouso Alegre, Minas Gerais, Brazil 31 32 10 Division of Gastroenterology, Department of Internal Medicine, University of Kentucky, Lexington, KY 33 34 11 School of Environmental and Biological Sciences, Rutgers University, New Brunswick, NJ http://bmjopen.bmj.com/ 35 36 12 College of Clinical Pharmacy, King Faisal University, Hofuf, Saudi Arabia 37 13 38 Department of Zoology, College of Science, King Saud University, Riyadh, Saudi Arabia & Pharmacology 39 Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt 40 14 41 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA on October 4, 2021 by guest. Protected copyright. 42 43 ‡ Both authors contributed equally and are considered conjoined senior authors. 44 45 Correspondence: Abdelrahman I. Abushouk, MD; 330 Brookline Ave, Boston, 02115, MA 46 47 Tel: +1 6173978718; Email: [email protected] 48 49 OR Mohamed Abdel-Daim; College of Science, King Saud University, Riyadh, 11362, Saudi Arabia 50 51 Tel: +2 01014295780; Email: [email protected] 52 Manuscript Word Count: 3357 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Abstract 5 6 Objective: The adherence to public health recommendations to control COVID-19 spread is influenced by 7 8 public knowledge, attitudes, and practices (KAP). We performed this cross-sectional study to assess the 9 10 levels and determinants of public KAP towards COVID-19 in a large, multinational sample. 11 12 Design: Cross-sectional study (survey). 13 14 15 Setting: The questionnaire was distributed to potential respondents via online platforms 16 For peer review only 17 Participants: 71,890 individuals from 22 countries. 18 19 Methods: We formulated a four-section questionnaire in English, followed by validation and translation 20 21 into seven languages. The questionnaire was distributed (May-June 2020) and each participant received 22 23 a score for each KAP section. 24 25 26 Results: Overall, the participants had fair knowledge (mean score: 19.24±3.59) and attitudes (3.72±2.31) 27 28 and good practices (12.12±1.83) regarding COVID-19. About 92% reported moderate-to-high compliance 29 30 with national lockdown. However, significant gaps were observed: only 68.2% knew that infected 31 32 individuals may be asymptomatic; 45.4% believed that antibiotics are effective treatments; and 55.4% 33 34 http://bmjopen.bmj.com/ 35 stated that a vaccine has been developed. 71.9% believed or were uncertain that COVID-19 is a global 36 37 conspiracy; 36.8% and 51% were afraid of contacting doctors and Chinese people, respectively. Further, 38 39 66.4% reported the pandemic had moderate-to-high negative effects on their mental health. Female 40 41

gender, higher education, and urban residents had significantly (p≤0.001) higher knowledge and practices on October 4, 2021 by guest. Protected copyright. 42 43 44 scores. Further, we observed significant correlations between all KAP scores. 45 46 Conclusions: Although the public have fair/good knowledge and practices regarding COVID-19, significant 47 48 gaps should be addressed. Future awareness efforts should target less advantaged groups and future 49 50 studies should develop new strategies to tackle COVID-19 negative mental health effects. 51 52 53 Keywords: COVID-19; Knowledge; Lockdown; Masks; Multinational; Survey 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Strengths and limitations 4 5 6  Besides our large sample size (of both individuals and countries), such comparative study can help 7 8 9 international organizations focus their efforts on countries and population groups with less 10 11 developed public KAP against COVID-19. 12 13  In addition, we analyzed the association between KAP and demographic factors, history of COVID- 14 15 19, as well as the correlation between different scores and scales of mental health effects and 16 For peer review only 17 18 compliance to lockdown. However, this study is not without limitations. 19 20  First, as a cross-sectional study, the temporal relevance of our findings may change with time or 21 22 implementation of large-scale prevention measures. 23 24  Second, the elderly population (most vulnerable to COVID-19) only represents 3.9% of our sample. 25 26 27 This is probably related to the online distribution of the questionnaire, which is likely to draw 28 29 younger populations. The requirement of access to electronic devices and the internet may have 30 31 limited the reach based on wealth and literacy. 32 33

 Third, as a self-reported questionnaire, respondents may have opted towards socially desired http://bmjopen.bmj.com/ 34 35 36 choices rather than their actual KAP. Fourth, due to variations in the population size of the 37 38 included countries, our fixed minimum sample size may have been less representative of more 39 40 populous nations as India, Brazil, and the United States. 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 3 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Introduction 5 6 Starting in China in December 2019, SARS-Cov-2 (the causative agent of COVID-19) has spread to almost 7 1 th 8 every country worldwide. As of August 14 2020, over 21 million confirmed cases have been reported globally 9 10 with more than 750,000 deaths.2 The disease is transmitted by respiratory droplets. After an incubation period 11 12 of two to 14 days, patients may develop fever, cough, dyspnea, fatigue, and sore throat or are commonly 13 14 asymptomatic.3 4 The main cause of death is fatal pneumonia and respiratory distress. Adults with chronic 15 16 diseases and those overFor 65 years peer of age are review the most vulnerable. only5 Although various drugs and vaccine 17 18 candidates are under trial, the management remains mainly supportive. Therefore, prevention measures as 19 20 social distancing, face masks, and public awareness campaigns are key players in controlling the pandemic.6 21 22 23 However, there is lack of data on the awareness and practices of different populations and their influence on 24 25 COVID-19 burden. Multiple cross-sectional studies have been conducted in many countries, e.g. an early 26 27 7 8 28 questionnaire was developed by Zhong et al in China, and it was later applied in other countries as Italy, 29 30 India,9 Malaysia,10 Pakistan,11 and Colombia.12 Another survey in the United States revealed that a large 31 32 portion of the public lacked critical knowledge about COVID-19 and were not changing their daily routine and 33 http://bmjopen.bmj.com/ 34 hygiene practices as per the recommendations of health authorities.13 However, when coupled with extensive 35 36 governmental awareness efforts, the public awareness on COVID-19 can be significantly improved as revealed 37 38 by recent studies from Saudi Arabia 14 and Nigeria,15 which would reduce infection rates and alleviate the 39 40 41 medical and economic burdens of the disease. 42 on October 4, 2021 by guest. Protected copyright. 43 The success of prevention efforts is tied to public adherence and the latter has been linked to public knowledge, 44

45 16 17 46 attitudes, and practices (KAP). A large-scale, horizontal evaluation of KAP towards COVID-19 across 47 48 different countries is lacking. Plus, this evaluation was not performed in most developing/low income 49 50 countries. In the present multinational survey, we aimed to assess the levels of public KAP in different countries 51 52 towards COVID-19 and to determine the factors that could influence public practices in this regard. Our findings 53 54 may have implications for public awareness efforts worldwide. 55 56 57 58 4 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Materials and Methods 4 5 6 2.1. Study Design and Participants: We conducted a multi-national, cross-sectional study to assess public 7 8 KAP towards COVID-19 in 22 countries, using an online self-administered questionnaire during the period 9 10 of May 10th to June 25th, 2020. The study was conducted and reported in consistence with the STROBE 11 12 13 checklist (Appendix 1). Any citizen of the included countries above the age of 18 who agreed to fill the 14 15 questionnaire was eligible to participate. There were no demographic restrictions on participation. 16 For peer review only 17 18 2.2. Sampling: We used a convenience sampling method for data collection. The sample size was 19 20 calculated for each country using the equation: n = z2P(1-P)/d2.18 Under a 95% confidence interval, 50% 21 22 response distribution and 0.05 margin of error, a sample of 384 participants was considered as a minimum 23 24 sample to represent large populations. However, due to the limitations of convenience sampling and 25 26 27 online surveying, we empowered our sample by including a design effect (DE) factor in the equation. 28 29 According to previous studies, the minimal acceptable DE for convenience-sampled studies is 2.19 20 30 31 Therefore, an adjusted minimum sample of 768 (384 x 2) participants was considered for each country. 32 33 34 2.3. Questionnaire development: The questionnaire was developed using the frequently asked questions http://bmjopen.bmj.com/ 35 36 on the WHO and CDC websites in addition to the previously published national surveys of COVID-19/other 37 38 7 21-23 39 pandemics awareness. Experts from the departments of Community Medicine & Public Health and 40 41 Internal Medicine (division of infectious diseases) at Fayoum University (Fayoum, Egypt) formulated the 42 on October 4, 2021 by guest. Protected copyright. 43 questionnaire. The questionnaire was revised by the departments’ heads for face validity, relevance, 44 45 comprehensiveness, and clarity of each section, and some details were improved. 46 47 48 The final four-section questionnaire included: 49 50  Socio-demographic data: that collected participants’ age, gender, country, residency 51 52 53 (urban/rural), educational level, whether they or a family member/friend had been diagnosed (by 54 55 a medical doctor) with COVID-19. 56 57 58 5 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3  Knowledge about COVID-19: consisted of 28 questions about COVID-19 mode of transmission, 4 5 6 vulnerable groups for infection, symptoms, treatment, prevention measures, and mortality rate. 7 8 The answer to each question was Yes/No/I don't know choices, except for the question about the 9 10 mortality rate. Chronbach's alpha values for the knowledge assessment section were 0.76, 0.55, 11 12 0.70, 0.60, 0.75, 0.70, 0.60, and 0.64 for English, Arabic, French, Indonesian, Neplai, Pakistani, 13 14 15 Sinhala and Portoguese languages, respectively. 16 For peer review only 17  Attitudes towards COVID-19: consisted of eight questions assessing optimism about the current 18 19 situation; responsible public health attitudes; stigma against symptomatic individuals, healthcare 20 21 professionals, and Chinese people; and whether the participant believes in conspiracy theories 22 23 24 about the disease. The possible answers to each question were Agree/Uncertain/Disagree. 25 26 Chronbach's alpha values for the attitudes assessment section were 0.60, 0.60, 0.77, 0.60, 0.66, 27 28 0.64, 0.72, and 0.60 for English, Arabic, French, Indonesian, Neplai, Pakistani, Sinhala and 29 30 Portoguese languages, respectively. 31 32  33 In addition, participants were asked to rate their fear of infection and the negative impact the 34 http://bmjopen.bmj.com/ 35 pandemic on their mental health on scales from one to 10. 36 37  Practices regarding COVID-19: included 14 questions describing different practices regarding 38 39 coughing and sneezing, hand washing, wearing masks, and contact with people. The available 40 41 42 answers to each question were Yes/Sometimes/No. In addition, the participants were asked to on October 4, 2021 by guest. Protected copyright. 43 44 rate their overall compliance with the lockdown or the measures applied by their country on a 45 46 scale from 1 to 10. The Cronbach's alpha values for the practices assessment questionnaire were 47 48 0.77, 0.67, 0.66, 0.66, 0.67, 0.55, 0.68, and 0.55 for English, Arabic, French, Indonesian, Neplai, 49 50 Pakistani, Sinhala and Portoguese languages, respectively. The full version of the questionnaire 51 52 53 can be found in Tables 1-4. 54 55 56 57 58 6 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 9 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 The questionnaire was developed in English and was then translated into the native languages of the 4 5 6 included countries (Arabic, French, Indonesian, Nepali, Portuguese, Pakistani, and Sinhala). For each 7 8 language, two bilinguals initially performed forward translation, then another bilingual performed a 9 10 backward translation; the translated versions were compared and checked till a final draft was agreed on. 11 12 We checked the internal consistency of the questions in each section by calculation of Cronbach’s alpha 13 14 using the data of the first 150 responses from each language; these 150 responses were not included in 15 16 For peer review only 17 the final analysis. 18 19 th st 20 2.4. Data collection and handling: We recruited collaborators between April 20 and May 1 , 2020 in a 21 22 snowball fashion. The recruited collaborators were given an orientation session about the nature of the 23 24 study and the data collection strategy. We assigned a central investigator from each country to monitor 25 26 the data collection process to ensure the adequate contribution of all collaborators (≥100 participants) 27 28 29 and to avoid over-representation of some cities over others within each country. Each collaborator was 30 31 granted access to view their responses only, while the central investigator had access to all responses of 32 33 the country. All collaborators are listed in Appendix 2. 34 http://bmjopen.bmj.com/ 35 36 On May 10th, we started data collection using Google Forms, distributed on social media platforms 37 38 (repeated posting on Facebook, Twitter, WhatsApp, and LinkedIn), online websites, blogs, and contact 39 40 with non-governmental organizations and academic institutions in the included countries. Each 41 42 on October 4, 2021 by guest. Protected copyright. 43 participant was allowed to answer the survey only once and no duplicates were included. After the data 44 45 collection, we used Microsoft Excel for data cleaning. The results of each country were translated 46 47 automatically to English and were combined in one datasheet for analysis. 48 49 50 The correct responses to knowledge questions were given a score of 1, while incorrect/I don’t know 51 52 answers were given a score of zero (hence knowledge maximum score was of 28). The knowledge score 53 54 55 of each participant was classified based on the modified Bloom’s cut-off points into poor (<60%: <16.8), 56 57 58 7 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 fair (60-79%: 16.8 to 22.1), and good (≥80%: 22.2 to 28). In terms of attitudes, the proper attitude was 4 5 6 given a score of +1, the improper attitude was given a score of -1, and uncertain was given a score of zero 7 8 (hence a maximum positive attitudes score of 8). Regarding practices questions, the correct practice was 9 10 given a score of 1, (sometimes) was given a score of 0.5, and incorrect practice was given a score of zero 11 12 (hence a maximum practices score of 14). The participants’ responses to scale questions (from one to 10) 13 14 were classified as low (1-3), moderate (4-7), or high (8-10). 15 16 For peer review only 17 2.5. Statistical analysis: We used SPSS (version 24, IBM, Armonk, NY) for data analysis. Quantitative 18 19 20 outcomes (e.g. scores) were presented as mean ± standard deviations. Associations were analyzed using 21 22 the Independent sample t-test and one-way ANOVA with post-hoc Hochberg test, while the correlation 23 24 between different scores was assessed using Pearson Correlation tests. We used Tableau software 25 26 (Seattle, Washington) for geographical map presentation. 27 28 29 2.6. Ethical considerations: The study protocol was approved (R223) by the Institutional Review Board of 30 31 the Faculty of Medicine, Fayoum University (Fayoum, Egypt). Consent was obtained at the start of the 32 33 34 online questionnaire after explaining the goal and methods of the study. No personal data were collected. http://bmjopen.bmj.com/ 35 36 37 2.7. Patient and Public Involvement: It was not appropriate or possible to involve patients or the public 38 39 in the design, or conduct, or reporting, or dissemination plans of our research. 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 8 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 3. Results 5 6 3.1. Demographic Characteristics and COVID-19 infection rates: The present sample comprised 71,890 7 8 respondents from 22 countries around the globe. The mean age of all participants was 27.64 ± 9.78 years 9 10 11 and 42601 (59.3%) were females. The majority lived in African and Asian countries, enrolled in/graduated 12 13 from college education, and were living in urban settings. Among those surveyed, 1326 (1.84%) reported 14 15 having been diagnosed with COVID-19, while 9935 (13.82%) reported knowing a friend or a family 16 For peer review only 17 member who had been diagnosed with COVID-19 (Table 1). 18 19 20 3.2. Public knowledge regarding COVID-19: The mean knowledge score among all respondents was 21 22 19.24/28 ± 3.59 (fair). Of them, 14221 (19.8%), 45087 (62.7%), 12582 (17.5%) had poor, fair, and good 23 24 25 knowledge levels, respectively. The majority of respondents agreed that COVID-19 is a serious disease 26 27 (80.8%); correctly identified droplet transmission (90.6%) and contact with surfaces covered with infected 28 29 droplets (95.7%) as the mode of transmission; correctly identified elderly subjects (90%) and adults with 30 31 chronic disease (93.6%) as the vulnerable groups to COVID-19 infection; and the majority could identify 32 33 34 the correct prevention measures against COVID-19 infection. However, we detected some critical http://bmjopen.bmj.com/ 35 36 knowledge gaps e.g. only 68.2% knew that infected individuals may be asymptomatic; Regarding 37 38 treatment, 73.9% stated that there is an effective cure for COVID-19, 45.4% stated that antibiotics are 39 40 effective in treatment, and 55.4% stated that a vaccine has been developed, while only 59.1% identified 41 42 on October 4, 2021 by guest. Protected copyright. 43 the correct mortality rate for COVID-19 (Table 2). 44 45 Data analysis showed that demographic factors influenced knowledge scores, being significantly higher 46 47 48 (≤0.001) in females, urban residents, those with higher education, or who knew a family member or a 49 50 friend who had a confirmed diagnosis with COVID-19 disease. Interestingly, those who reported a 51 52 confirmed COVID-19 diagnosis before had a lower knowledge level. The one-way-ANOVA test showed 53 54 that the mean knowledge levels differed across the surveyed countries (p < 0.001), with the highest mean 55 56 57 58 9 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 scores from Brazil, Egypt, Jordan, Sudan, and Syria and the lowest mean scores from Indonesia, Nigeria, 4 5 6 Pakistan, and India (Appendix 3). 7 8 3.3. Public attitudes towards COVID-19: The mean attitudes score towards COVID-19 among the surveyed 9 10 11 respondents was 3.72/8 ± 2.31. Some positive attitudes were observed e.g. the majority of respondents 12 13 (>80%) stated that since the outbreak, they seek updated medical information and recommendations 14 15 about COVID-19. However, 71.9% believed or were uncertain that COVID-19 is a global conspiracy; >50% 16 For peer review only 17 were uncertain or not optimistic that the pandemic will finally end or that their government will be able 18 19 20 to control COVID-19 situation; 36.8% were uncertain or afraid of contacting doctors except for utmost 21 22 necessity and 51% were afraid or uncertain about contacting Chinese people and eating in Chinese 23 24 restaurants (Table 3). When the respondents were asked to rate their fear of getting COVID-19, 20021 25 26 (27.8%), 33752 (46.9%), 18117 (25.2%) reported low, moderate, and high levels of fear, respectively. 27 28 29 Further, 47712 (66.4%) reported that the pandemic had moderate-to-high negative effects on their 30 31 mental health. 32 33 34 Similar to knowledge levels, the overall attitude score was significantly higher in females (p=0.002) or http://bmjopen.bmj.com/ 35 36 those who knew a family member or a friend with a confirmed COVID-19 diagnosis (p=0.003). However, 37 38 those with previous COVID-19 diagnosis had less positive attitude scores (p<0.001), compared to those 39 40 without COVID-19 diagnosis history. Further, the overall attitudes score, fear of getting COVID-19, and the 41 42 on October 4, 2021 by guest. Protected copyright. 43 negative mental health impact varied by country (Appendix 3, Figure 1A, B). 44 45 46 3.4. Public practices regarding COVID-19: The mean practices score (12.12/14 ± 1.83) and answers to 47 48 individual questions showed good practices towards COVID-19. The majority of respondents indicated 49 50 that that usually follow proper practices regarding hand washing, coughing and sneezing, wearing face 51 52 masks, and social distancing. Few gaps were, however, noted. Although 82% indicated that they usually 53 54 55 wear face masks in crowded places, only 52% responded that they usually wear face masks outside in 56 57 58 10 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 general and 17% replied that they never wear face masks (Table 4). When the respondents were asked 4 5 6 about their overall compliance to their national lockdown/traffic ban, 5856 (8.1%), 19166 (26.7%), 46868 7 8 (65.2%) reported low, moderate, and high compliance levels, respectively. 9 10 11 Likewise, females, those with higher education, residing in Urban areas, or knowing an individual who had 12 13 a COVID-19 diagnosis had better practices scores (p ≤ 0.001). However, those who experienced COVID-19 14 15 diagnosis reported significantly lower practices scores than those who did not. The One-way ANOVA test 16 For peer review only 17 revealed that the overall practices score and compliance to national lockdown/traffic ban varied by 18 19 20 country (Appendix 3; Figure 1C). 21 22 23 3.5. Correlation between knowledge, attitudes, and practices towards COVID-19: We recorded 24 25 significant positive correlations (p <0.001) between knowledge, attitudes, and practices scores in our 26 27 sample, although the magnitude of these correlations in our sample was weak. For example, knowledge 28 29 scores were positively correlated to attitudes (r= 0.05) and practices (r= 0.12) scores, while attitudes 30 31 scores were positively correlated (r= 0.276) to practices scores. 32 33 http://bmjopen.bmj.com/ 34 Interestingly, knowledge was inversely associated with fear of getting COVID-19 (r=-0.04) and negative 35 36 37 mental health effects of the pandemic (r=-0.02) and was directly associated with compliance to lockdown 38 39 (r=0.11). Likewise, better attitudes were associated with lockdown compliance (r=0.08) and practices 40 41 scores were directly correlated to fear of getting COVID-19 (r= 0.167) (Appendix 3). 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 11 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 4. Discussion 5 6 The current cross-sectional study assessed the levels and determinants of KAP towards COVID-19 in 22 7 8 countries around the globe. Our results show that the public in those countries had fair knowledge and 9 10 11 good attitudes towards COVID-19. We, however, uncovered many gaps, in the public understanding and 12 13 behaviors towards COVID-19. For example, one third of our participants did not know that infected 14 15 individuals can be asymptomatic, which increases their risk of exposure to the disease. Further, about half 16 For peer review only 17 of the participants thought that antibiotics may be effective treatments and about 74% thought that a 18 19 curative treatment exists, which may give them a false sense of security. Another alarming finding that 20 21 22 almost half our participants held negative/uncertain attitudes regarding contacting Chinese people and 23 24 more than one third had similar attitudes towards doctors. 25 26 27 Our analysis showed that 82% of respondents usually wear face masks in crowded places, but only 52% 28 29 wear masks outdoors in general. This finding is relevant for public awareness programs. Several studies 30 31 and predictive models showed that wearing face masks can reduce COVID-19 spread.24 25 In compliance 32 33 34 with the building evidence, major public health authorities around the world unanimously recommend http://bmjopen.bmj.com/ 35 36 wearing face masks outdoors in general, not just in crowded places.26 27 However, the compliance rates to 37 38 these recommendations vary between and within countries. Our study highlights the importance of public 39 40 awareness about the value of masks in preventing infections and slowing the spread of COVID-19. 41 42 on October 4, 2021 by guest. Protected copyright. 43 In the current study, we found a significant positive correlation between knowledge and attitudes, which 44 45 coincides with several former studies on COVID-19.7 28 29 However, the magnitude of correlation in our 46 47 30 48 study was weak, similar to a former Indonesian study. This is probably because although knowledge is 49 50 essential in shaping attitudes, this is not absolute and several other factors may be involved. A stronger 51 52 correlation was found between attitudes and practices, indicating that promoting knowledge alone is 53 54 insufficient and effective interventions to improve practices should target promoting both adequate 55 56 57 58 12 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 knowledge and positive attitudes. Interestingly, our analysis also showed lower knowledge scores in those 4 5 6 who reported having a confirmed diagnosis with COVID-19. This can be explained in the light of our finding 7 8 that knowledge scores were directly correlated to practices scores and compliance with lockdown/traffic 9 10 ban orders. This suggests that good knowledge translates into safe practices, which can reduce one’s risk 11 12 of COVID-19 infection. 13 14 15 We found an inverse correlation between knowledge level and fear of getting COVID-19. This implies that 16 For peer review only 17 improving the knowledge about COVID-19 can alleviate public anxiety and panic. During the SARS 18 19 20 epidemic (2002-2004), misinformation led to excessive public panic and resistance to comply with public 21 22 health guidelines.31 32 We could also infer that people’s knowledge would not be improved just by 23 24 communicating daily increases in COVID-19 cases. In the same vein, about two thirds of our participants 25 26 reported moderate-to-high negative mental health effects for the pandemic. These effects had significant 27 28 29 inverse correlations with knowledge and attitudes scores; however, the magnitude of the correlations 30 31 was weak. Several studies showed multiple risk factors for anxiety and mental health problems related to 32 33 COVID-19, including social media use, worry about economy and personal finances, working in COVID-19 34 http://bmjopen.bmj.com/ 35 hot spots, and being pregnant.33 34 Therefore, poor knowledge and attitudes may contribute -among a 36 37 38 multitude of factors- towards the growing incidence of mental health issues, being reported worldwide. 39 40 The association between KAP scores and demographic characteristics in the current study was 41 42 on October 4, 2021 by guest. Protected copyright. 43 consistently significant. For example, females had better KAP scores towards COVID-19 than males. This 44 45 finding echoes previous studies by Al-Hanawi et al.35 and Azlan et al.10. In addition, those living in rural 46 47 areas had lower knowledge and practice scores than their urban counterparts. This may be attributed to 48 49 relying on digital sources of information with easier access in urban settings or the higher levels of 50 51 52 education in urban areas, which were also associated with higher KAP scores in the present study. 53 54 55 56 57 58 13 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Most of the included countries in the current analysis are developing/low-to-middle income countries. 4 5 6 These countries had varied KAP levels and also were significantly different when assessed on three rating 7 8 questions (fear of COVID-19, negative mental health effects, and compliance to lockdown). Other studies 9 10 have assessed KAP levels in countries that have been included in this analysis (e.g. US, UK, Egypt, Saudi 11 12 Arabia, Pakistan, and Indonesia) and countries outside our scope (e.g. Malaysia, Turkey, and Italy). To put 13 14 our study in context, we performed a comprehensive review of published public KAP studies in the 15 16 For peer review only 17 literature about COVID-19 (Appendix 4). The majority of these studies showed good public knowledge and 18 19 practices across different countries, especially those conducted in the later three months (probably due 20 21 to the growing public awareness about COVID-19). 22 23 24 Practical and research recommendations: Although we did not explore sources of knowledge about 25 26 COVID-19 in this study, previous works highlighted television and social media as the primary sources of 27 28 29 knowledge. Using these platforms should be optimized to deliver evidence-based information to the most 30 31 vulnerable groups e.g. less educated and those living in rural areas. Political leaders and stake holders 32 33 should take action to eliminate fear and discrimination against healthcare professionals and Asian 34 http://bmjopen.bmj.com/ 35 community members.36 Research-wise, future studies should evaluate other populations, not surveyed in 36 37 38 the present study; considering the relatively low Cronbach’s alpha values (< 0.6) in few language 39 40 translations in our study, these studies should perform validation through pilot testing and revision. In 41 42 addition, they should test the value of innovative strategies in mitigating mental health effects of public on October 4, 2021 by guest. Protected copyright. 43 44 health disasters like COVID-19. 45 46 47 Conclusion: The current multinational cross-sectional study showed fair public knowledge on COVID-19; 48 49 however, it uncovered several gaps in the public understanding and practices about the diseases. 50 51 52 Moreover, it highlighted the negative mental health effects of COVID-19 pandemic. Some demographic 53 54 groups were less advantaged than others including the less educated and those living in rural areas. Future 55 56 57 58 14 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 awareness efforts should target those groups and develop innovative strategies to mitigate negative 4 5 6 mental health effects, as well as discriminatory behaviors against Asians and healthcare professionals. 7 8 Acknowledgement: This work was supported by King Saud University, Deanship of Scientific Research, 9 10 11 College of Science Research Center (RSP 2019/ 121). 12 13 14 Funding Source: This work was supported by King Saud University, Deanship of Scientific Research, 15 16 College of Science ResearchFor Center peer (RSP 2019/ review 121). only 17 18 19 Conflicts of interest: All authors declare no relevant conflicts of interest. 20 21 22 Authors Contribution Statement: ATM, MSZ, and SME: Idea conception, study design; KMR, EMK, YTA, 23 24 25 and AAs, AZN, LJI, MME, ATA, AAS, and DGH: Questionnaire formulation, validation and translation, VZF, 26 27 ARM, FMS, and AE: Data curation, analysis, and interpretation; AAl, AKA, MA, OMM, EAD, and KAE: 28 29 Manuscript drafting; MA and AIA: Study design, analysis planning and supervision. All authors contributed 30 31 to data collection and all involved investigators reviewed the manuscript and approved it for publication. 32 33 34 Data Statement: Data are available from the corresponding author upon reasonable request. http://bmjopen.bmj.com/ 35 36 37 Figure Legends 38 39 40 Figure 1: Geographic representation of A) fear of getting COVID-19, B) negative mental health effects of 41 on October 4, 2021 by guest. Protected copyright. 42 COVID-19 pandemic, and C) compliance with governmental lockdown/traffic ban across the 22 countries. 43 44 The color gradient (from light to dark) in every map represents country scores (from low to high). 45 46 47 48 49 50 51 52 53 54 55 56 57 58 15 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 References 5 1. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. New 6 7 England Journal of Medicine 2020 8 2. WHO. Coronavirus disease 2019 (COVID-19): situation report 2020 [Available from: 9 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep- 10 207-covid-19.pdf accessed 14 August 2020. 11 3. Guan W-j, Ni Z-y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. New England 12 journal of medicine 2020;382(18):1708-20. 13 4. CDC. Symptoms of coronavirus disease 2019 (COVID-19) 2020 [Available from: 14 https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html accessed 10 August 2020. 15 5. CDC. People Who Are at Higher Risk for Severe Illness - Coronavirus 2020 [Available from: 16 For peer review only 17 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher- 18 risk.html accessed 12 August 2020. 19 6. Wiersinga WJ, Rhodes A, Cheng AC, et al. Pathophysiology, Transmission, Diagnosis, and Treatment of 20 Coronavirus Disease 2019 (COVID-19): A Review. Jama 2020 doi: 10.1001/jama.2020.12839 21 [published Online First: 2020/07/11] 22 7. Zhong B-L, Luo W, Li H-M, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese 23 residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional 24 survey. International journal of biological sciences 2020;16(10):1745. 25 26 8. Galle F, Sabella EA, Da Molin G, et al. Understanding Knowledge and Behaviors Related to CoViD–19 27 Epidemic in Italian Undergraduate Students: The EPICO Study. International Journal of 28 Environmental Research and Public Health 2020;17(10):3481. 29 9. Dkhar SA, Quansar R, Saleem SM, Khan SMS. Knowledge, attitude, and practices related to COVID-19 30 pandemic among social media users in J&K, India. Indian Journal of Public Health 2020;64(6):205- 31 10. 32 10. Azlan AA, Hamzah MR, Sern TJ, et al. 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cross-sectional study in Malaysia. Plos one 2020;15(5):e0233668. http://bmjopen.bmj.com/ 34 35 11. Mubeen SM, Kamal S, Kamal S, Balkhi F. Knowledge and awareness regarding spread and prevention 36 of COVID-19 among the young adults of Karachi. The journal of Pakistan medical association 37 2020;70(5):S169-S174. 38 12. Bates BR, Botero AV, Grijalva MJ. Knowledge, attitudes, and practices towards COVID-19 among 39 Colombians during the outbreak: an online cross-sectional survey. Journal of Communication in 40 Healthcare 2020;13(4):262-70. 41

13. Wolf MS, Serper M, Opsasnick L, et al. Awareness, attitudes, and actions related to COVID-19 among on October 4, 2021 by guest. Protected copyright. 42 adults with chronic conditions at the onset of the US outbreak: a cross-sectional survey. Annals of 43 44 internal medicine 2020 45 14. Almofada SK, Alherbisch RJ, Almuhraj NA, et al. Knowledge, Attitudes, and Practices Toward COVID- 46 19 in a Saudi Arabian Population: A Cross-Sectional Study. Cureus 2020;12(6) 47 15. Reuben RC, Danladi MM, Saleh DA, et al. Knowledge, Attitudes and Practices Towards COVID-19: An 48 Epidemiological Survey in North-Central Nigeria. Journal of community health 2020:1-14. 49 16. Chirwa GC. “Who knows more, and why?” Explaining socioeconomic-related inequality in knowledge 50 about HIV in Malawi. Scientific African 2020;7:e00213. 51 17. Chirwa GC. Socio-economic Inequality in Comprehensive Knowledge about HIV in Malawi. Malawi 52 Medical Journal 2019;31(2):104-11. 53 54 18. Daniel W. Biostatistics: a foundation for analysis in the health sciences. New York: John Wiley & Sons 55 1999;7th ed. 56 57 58 16 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 19. Wejnert C, Heckathorn DD. Web-based network sampling: efficiency and efficacy of respondent-driven 4 sampling for online research. Sociological Methods & Research 2008;37(1):105-34. 5 6 20. Wejnert C, Pham H, Krishna N, et al. Estimating design effect and calculating sample size for 7 respondent-driven sampling studies of injection drug users in the United States. AIDS and 8 Behavior 2012;16(4):797-806. 9 21. Albano L, Matuozzo A, Marinelli P, et al. Knowledge, attitudes and behaviour of hospital health-care 10 workers regarding influenza A/H1N1: a cross sectional survey. BMC infectious diseases 11 2014;14(1):208. 12 22. Hasan F, Khan MO, Ali M. Swine flu: Knowledge, attitude, and practices survey of medical and dental 13 students of Karachi. Cureus 2018;10(1) 14 23. Wong LP, Sam I-C. Knowledge and attitudes in regard to pandemic influenza A (H1N1) in a multiethnic 15 16 community ofFor Malaysia. peer International reviewJournal of Behavioral only Medicine 2011;18(2):112-21. 17 24. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid-19 crisis. Bmj 18 2020;369 19 25. Eikenberry SE, Mancuso M, Iboi E, et al. To mask or not to mask: Modeling the potential for face mask 20 use by the general public to curtail the COVID-19 pandemic. Infectious Disease Modelling 2020 21 26. Brooks JT, Butler JC, Redfield RR. Universal masking to prevent SARS-CoV-2 transmission—the time is 22 now. Jama 2020 23 27. WHO. Coronavirus disease (COVID-19) advice for the public: When and how to use masks 2020 24 25 [Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice- 26 for-public/when-and-how-to-use-masks accessed 10 August 2020. 27 28. Salman M, Mustafa ZU, Asif N, et al. Knowledge, attitude and preventive practices related to COVID- 28 19: a cross-sectional study in two Pakistani university populations. Drugs & Therapy Perspectives 29 2020:1. 30 29. Kumar J, Katto MS, Siddiqui AA, et al. Knowledge, Attitude, and Practices of Healthcare Workers 31 Regarding the Use of Face Mask to Limit the Spread of the New Coronavirus Disease (COVID-19). 32 Cureus 2020;12(4) 33

30. Sari DK, Amelia R, Dharmajaya R, et al. Positive Correlation Between General Public Knowledge and http://bmjopen.bmj.com/ 34 35 Attitudes Regarding COVID-19 Outbreak 1 Month After First Cases Reported in Indonesia. Journal 36 of community health 2020:1-8. 37 31. Person B, Sy F, Holton K, et al. Fear and stigma: the epidemic within the SARS outbreak. Emerging 38 infectious diseases 2004;10(2):358. 39 32. Tao N. An analysis on reasons of SARS-induced psychological panic among students. Journal of Anhui 40 Institute of Education 2003;21:78-9. 41

33. Li X, Lu P, Hu L, et al. Factors Associated with Mental Health Results among Workers with Income on October 4, 2021 by guest. Protected copyright. 42 Losses Exposed to COVID-19 in China. Int J Environ Res Public Health 2020;17(15) doi: 43 44 10.3390/ijerph17155627 [published Online First: 2020/08/08] 45 34. Holingue C, Badillo-Goicoechea E, Riehm KE, et al. Mental Distress during the COVID-19 Pandemic 46 among US Adults without a Pre-existing Mental Health Condition: Findings from American Trend 47 Panel Survey. Preventive medicine 2020:106231. doi: 10.1016/j.ypmed.2020.106231 [published 48 Online First: 2020/08/08] 49 35. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 50 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Frontiers in Public 51 Health 2020;8 52 53 36. Devakumar D, Shannon G, Bhopal SS, et al. Racism and discrimination in COVID-19 responses. The 54 Lancet 2020;395(10231):1194. 55 56 57 58 17 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 1: Demographic characteristics and COVID-19 confirmed infection rates among survey respondents. 4 5 Demographics Count (%) 6 (N = 71,890) 7 Age Mean ± SD (yr.) 27.64 ± 9.78 8 9 ≤ 30 years 53048 (73.8) 10 31 – 50 years 16073 (22.3) 11 > 50 years 2769 (3.9) 12 Gender 13 Male 28449 (40) 14 Female 42601 (60) 15 Country 16 Algeria For peer review4900 only (6.81) 17 Brazil 839 (1.16) 18 Egypt 6830 (9.49) 19 Ghana 1847 (2.56) 20 India 1464 (2.04) 21 Indonesia 4444 (6.18) 22 Iraq 2092 (2.92) 23 Ireland 1026 (1.43) 24 Jordan 5882 (8.20) 25 Lebanon 3380 (4.70) 26 Libya 4300 (6.00) 27 Morocco 1755 (2.44) 28 Nigeria 3449 (4.80) 29 Nepal 2657 (3.70) 30 Palestine 5993 (8.33) 31 Pakistan 1723 (2.40) 32 Saudi Arabia 1616 (2.24) 33 South Africa 1979 (2.75) http://bmjopen.bmj.com/ 34 Sri-Lanka 1793 (2.50) 35 Sudan 4381 (6.09) 36 Syria 6576 (9.14) 37 UK 2160 (3.00) 38 USA 804 (1.12) 39 Education 40 High School 7577 (10.54) 41

Undergraduate 44436 (61.80) on October 4, 2021 by guest. Protected copyright. 42 Graduated 16269 (22.65) 43 Prefer not to say 3608 (5.01) 44 Residency 45 Urban 57653 (80.2) 46 Rural 14237 (19.8) 47 48 Have you had a confirmed infection with COVID-19? * 49 Yes 1326 (1.84) 50 No 70559 (98.16) 51 Do you know a friend or a family member who had a 52 confirmed COVID-19 infection? * 53 Yes 9935 (13.82) 54 No 61952 (86.18) 55 The presented data are count (valid %) unless otherwise specified. 56 * Confirmed infection was explained to participants as having diagnosis by a licensed healthcare professional. 57 58 18 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 2: Answers to knowledge questions about COVID-19 among survey respondents. 4 5 6 Yes No/I don’t 7 8 know 9 10 COVID-19 is a serious disease. 58121 (80.8) 13769 (19.2) 11 Regarding the mode of transmission of the virus 12 13 Eating wild animals (e.g. bats) 37829 (52.6) 34061 (47.4) 14 15 Droplet transmission 65126 (90.6) 6764 (9.4) 16 Contact with infectedFor surfaces peer then putting review your hand on youronly 68819 (95.7) 3071 (4.3) 17 18 face, mouth, or nose 19 20 The most vulnerable group to infection is 21 Children (0-18) years 32973 (45.9) 38917 (54.1) 22 23 Adults (18 -50) years 29448 (41.0) 42442 (59.0) 24 25 Elderly (more than 50) years 64736 (90.0) 7154 (10.0) 26 Adults with chronic diseases 67282 (93.6) 4608 (6.4) 27 28 The Clinical symptoms of COVID-19 include 29 30 Fever 68565 (95.4) 3325 (4.6) 31 Fatigue 57076 (79.4) 14814 (20.6) 32 33 Dry Cough 66882 (93.0) 5008 (7.0) 34 http://bmjopen.bmj.com/ 35 Myalgia 50672 (70.5) 21218 (29.5) 36 Stuffy Nose 21127 (29.4) 50763 (70.6) 37 38 Runny Nose 23449 (32.6) 48441 (67.4) 39 40 Sneezing 14094 (19.6) 57796 (80.4) 41

Shortness of breath 68589 (95.4) 3301 (4.6) on October 4, 2021 by guest. Protected copyright. 42 43 Diarrhea 35293 (49.1) 36597 (50.9) 44 45 Asymptomatic 49057 (68.2) 22833 (31.8) 46 47 Regarding treatment of COVID-19 48 There is effective cure for it 53148 (73.9) 18742 (26.1) 49 50 The treatment is symptomatic only 51140 (71.1) 20750 (28.9) 51 52 Antibiotics are effective in treatment 32628 (45.4) 39262 (54.6) 53 There are various drugs under trial 58231 (81.0) 13659 (19.0) 54 55 A vaccine has been developed 39798 (55.4) 32092 (44.6) 56 57 58 19 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Regarding prevention of COVID-19 which of the following is effective? 5 6 Wearing medical masks 67365 (93.7) 4524 (6.3) 7 Avoiding crowded places 70509 (98.1) 1380 (1.9) 8 9 Isolation of infected individuals 70551 (98.1) 1338 (1.9) 10 11 Healthy diet and avoiding high-fat containing diet 18159 (25.3) 53730 (74.7) 12 To what extent does COVID-19 cause death? Less than Wrong 13 14 15%: 42522 answers: 15 16 For peer review only(59.1) 29368 (40.9) 17 Data are presented as count (%). 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 20 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 3: Answers to attitudes questions about COVID-19 among survey respondents. 4 5 6 Positive Uncertain Negative 7 8 Attitude Attitude 9 10 Do you believe that COVID-19 is a global 20191 (28.1) 32559 (45.3) 19140 (26.6) 11 conspiracy? 12 13 Do you believe that COVID-19 pandemic will 34053 (47.4) 30851 (42.9) 6986 (9.7) 14 15 finally end? 16 Do you believe thatFor your country peer will be able review 32526 (45.2) only28603 (39.8) 10760 (15.0) 17 18 to control COVID-19 situation soon? 19 20 Since the outbreak, I seek more medical 59215 (82.4) 9090 (12.6) 3585 (5.0) 21 information about COVID-19 to keep updates. 22 23 Since the outbreak, I follow the 66609 (92.7) 4350 (6.1) 931 (1.3) 24 25 recommendations to deal with the pandemic. 26 Since the outbreak, I am afraid to contact 55788 (77.6) 10236 (14.2) 5866 (8.2) 27 28 anyone with ordinary flu symptoms. 29 30 Since the outbreak, I am afraid of contacting 45475 (63.2) 13292 (18.5) 13123 (18.3) 31 any doctors except for the utmost necessity 32 33 Since the outbreak, Are you afraid of eating in 35243 (49.0) 15356 (21.4) 21291 (29.6) 34 http://bmjopen.bmj.com/ 35 Chinese restaurant or contact chinse people? 36 Data are presented as count (%). 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 21 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Table 4: Answers to practices questions about COVID-19 among survey respondents. 4 5 6 Proper Sometimes Wrong 7 8 Practice Practice 9 10 When coughing or sneezing, Do you 11 Cover your mouth and nose with a tissue? 62946 (87.6) 6749 (9.4) 2195 (3.1) 12 13 Throw away the used tissue into the bin? 66291 (92.2) 2731 (3.8) 2868 (4.0) 14 15 Turn your face away from the surrounding 67664 (94.1) 2303 (3.2) 1923 (2.7) 16 people? For peer review only 17 18 As for your hands, you wash them 19 20 Before touching your eye and nose 52267 (72.7) 14516 (20.2) 5107 (7.1) 21 After covering the nose while sneezing 56198 (78.2) 9994 (13.9) 5698 (7.9) 22 23 After coming from outside 67791 (94.3) 2815 (3.9) 1284 (1.8) 24 25 Using soap and water 68337 (95.1) 2299 (3.2) 1254 (1.7) 26 Using concentrated alcohol 39729 (55.3) 16862 (23.5) 15299 (21.3) 27 28 Regarding wearing a face mask, you 29 30 Wear a face mask in crowded places 58939 (82.0) 5082 (7.1) 7869 (10.9) 31 Wear a face mask outside in general (not crowded) 37364 (52.0) 12371 (17.2) 22155 (30.8) 32 33 Never use a face mask 46829 (65.1) 12813 (17.8) 12247 (17.0) 34 http://bmjopen.bmj.com/ 35 Regarding the preventive measures from infection, you 36 Avoid contact with an infected person 69776 (97.1) 1037 (1.4) 1077 (1.5) 37 38 Avoid touching and shaking hands 61981 (86.2) 7044 (9.8) 2865 (4.0) 39 40 Avoid going to crowded places 63201 (87.9) 6684 (9.3) 2005 (2.8) 41 Data are presented as count (%). 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 22 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 For peer review only 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Figure 1: Geographic representation of A) fear of getting COVID-19, B) negative mental health effects of http://bmjopen.bmj.com/ 34 COVID-19 pandemic, and C) compliance with governmental lockdown/traffic ban across the 22 countries. 35 The color gradient (from light to dark) in every map represents country scores (from low to high). 36 37 159x131mm (144 x 144 DPI) 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 43

1 2 3 Appendix (1) STROBE Statement: Checklist of items that should be included in reports of observational studies 4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 (Cross sectional study) (1). 6 7 Item Page 8 No Recommendation No 9 10 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the 1 11 abstract 12 (b) Provide in the abstract an informative and balanced summary of what was 2 13 14 done and what was found 15 Introduction 16 Background/rationale 2 Explain the scientific background and rationale for the investigation being 3 17 18 Forreported peer review only 19 Objectives 3 State specific objectives, including any prespecified hypotheses 3 20 Methods 21 22 Study design 4 Present key elements of study design early in the paper 4 23 Setting 5 Describe the setting, locations, and relevant dates, including periods of 4 24 recruitment, exposure, follow-up, and data collection 25 26 Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods 4 27 of selection of participants 28 Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and 4-6 29 effect modifiers. Give diagnostic criteria, if applicable 30 31 Data sources/ 8* For each variable of interest, give sources of data and details of methods of 4-6 32 measurement assessment (measurement). Describe comparability of assessment methods if 33 there is more than one group 34 Bias 9 Describe any efforts to address potential sources of bias. 4-6 35 36 Study size 10 Explain how the study size was arrived at. 4 37 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, 7 http://bmjopen.bmj.com/ 38 describe which groupings were chosen and why 39 40 Statistical methods 12 (a) Describe all statistical methods, including those used to control for 7 41 confounding 42 (b) Describe any methods used to examine subgroups and interactions 7 43 (c) Explain how missing data were addressed NA 44 45 (d) Cross-sectional study—If applicable, describe analytical methods taking NA 46 account of sampling strategy on October 4, 2021 by guest. Protected copyright. 47 (e) Describe any sensitivity analyses NA 48 49 50 Results 51 Participants 13* Report numbers of individuals at each stage of study—eg numbers potentially 5 52 53 eligible, examined for eligibility, confirmed eligible, included in the study, 54 completing follow-up, and analysed 55 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and 5 56 information on exposures and potential confounders 57 58 (b) Indicate number of participants with missing data for each variable of interest NA 59 Main results 15 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates 5-6 60 and their precision (e.g., 95% confidence interval). Make clear which confounders

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1 2 were adjusted for and why they were included 3 (b) Report category boundaries when continuous variables were categorized NA 4 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 5 (c) If relevant, consider translating estimates of relative risk into absolute risk for NA 6 a meaningful time period 7 Other analyses 16 Report other analyses done—eg analyses of subgroups and interactions, and 5-6 8 9 sensitivity analyses 10 Discussion 11 Key results 17 Summarise key results with reference to study objectives 11 12 13 Limitations 18 Discuss limitations of the study, taking into account sources of potential bias or 13 14 imprecision. Discuss both direction and magnitude of any potential bias 15 Interpretation 19 Give a cautious overall interpretation of results considering objectives, 11-13 16 limitations, multiplicity of analyses, results from similar studies, and other 17 18 Forrelevant peer evidence review only 19 Generalisability 20 Discuss the generalisability (external validity) of the study results 13 20 21 Other information 22 Funding 21 Give the source of funding and the role of the funders for the present study and, 13 23 if applicable, for the original study on which the present article is based 24 * NA: Not applicable. 25 26 * Give information separately for cases and controls in case-control studies and, if applicable, for exposed and 27 unexposed groups in cohort and cross-sectional studies. 28 . 29 Reference: 30 31 32 1. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the 33 Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational 34 studies. Preventive medicine. 2007;45(4):247-51. 35 36 37 38 http://bmjopen.bmj.com/ 39 40 41 42 43 44 45 46 on October 4, 2021 by guest. Protected copyright. 47 48 49 50 51 52 53 54 55 56 57 58 59 60

2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Appendix file 2 5 6 National leaders : Egypt: Mariam Salah Moris (Faculty of Medicine, Assiut University, Assiut, Egypt.); Syria: 7 8 Ayman Essa Nabhan (Al-Andalus University for Medical Sciences, Qadmus, Syria); Palestine: Mohammed 9 Jehad Al-kfarna (Faculty of Pharmacy, Al-Azhar University, Gaza, Palestine); Jordan: Hala Aladwan (Faculty 10 11 of Pharmacy, The University Of Jordan, Amman, Jordan); Algeria: Amira Yasmine Benmelouka (Faculty of 12 13 Medicine, University of Algiers, Algeria); Sudan: Manar Mohammed Hosny (Faculty of Medicine, Fayoum 14 15 University, Fayoum, Egypt); Libya: Sara Rajab Araara (Faculty of Medicine, Tripoli University, Tripoli, Libya) 16 For peer review only 17 Algeria Collaborators: Nedjima Mouhoubi, Nour Salem (University of Constantine 3); Boutheyna Drid, 18 19 Hamel Asma (Faculty of Medecine, University of Tlemcen); Sara Menzer, Krazdi Asma (Faculty of 20 Medecine, University of Batna 2); Affaf Sahih (Faculty of Medecine, University of Oran); Manal Benatia, 21 22 Wiame Benhabiles (Faculty of Medicine, University of Algiers); Rahmani Meriem, Mohamed Elkhalil 23 24 Bouaich, Benslimane Sahar, Khennoussi Amel, Ahelam Zerga, Yassamine ouerdane (Faculty of Medicine, 25 University of Saad Dahlab) 26 27 28 Egypt Collaborators: Maryam Abd-Elmalak Shafik (Faculty of Medicine, Ain Shams University); Ahmed 29 Bostamy Elsnhory, Aya Mosad Elhelesy, Esraa Ghanem, Mostafa Mahmoud Meshref (Faculty of Medicine, 30 31 Al-Azhar University, Cairo); MennatulRahman Mohamed Daa-ElEnsaf (Faculty of Medicine, Al-Azhar 32 33 University, Assiut); Mohamed Marey Yahya, Salama Ahmed Ali (Faculty of Medicine, Al-Azhar University, http://bmjopen.bmj.com/ 34 Damietta); Alaa Ahmed Elshanbary, Mariam Ahmed Maray (Faculty of Medicine, Alexandria University); 35 36 Mohamed Mahmoud Abdelkarem (Faculty of Medicine, Assiut University); Osama Mohamed Rokaby 37 38 (Faculty of Medicine, Aswan University); Manar Ahmed Kamal (Faculty of Medicine, Benha University); 39 Ahmed Saeed Ahmed (Faculty of Medicine, Fayoum University); Merna Ahmed Riad, Radwa Mohamed 40 41 Awadalla, Ahmed Sultan (Faculty of Medicine, Kasr Alainy Cairo University); Noha Ahmed Ammar (Faculty 42 on October 4, 2021 by guest. Protected copyright. 43 of Medicine, Menoufia University); Mohamed Essam (Faculty of Medicine, South Valley University); Sara 44 Gamal Fayad (Faculty of Medicine, Tanta University); Israa Mohamed Elshahawy (Faculty of Pharmacy, 45 46 Zagazig University); Ahmed Fares Ghannam (Faculty of Medicine, Fayoum University) 47 48 Jordan Collaborators: Hiba Ramadan, Mais Hutham Sabri (Al-Balqa Applied University); Hayat Ghaseb 49 50 Abu-Alkhoun, Malak Eyad Abu-Qaddoura (Yarmouk University); Batool Emad Al-Masri, Israa Ayed Al-Odat, 51 52 Mahmoud Omar Alshneikat (Faculty of Medicine, Jordan University); Mustafa Ismat Aburumman, Hani 53 Adnan Bashir, Tasneem suhail Abu-Alkhair (Hashemite University); Obada Ahmad Al-Jayyousi, Faris Jamal 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Abu-Za'nouneh, Mohammad Hasan Ismail, Mo'men Helmi Suleiman (Jordan University of Science and 4 5 Technology) 6 7 8 9 Libya Collaborators: Reem Khaled Wishah (Faculty of Public Health, Benghazi University); Asma Abubakr 10 Saleh (Faculty of Medicine, Alzawia University); Ahmed Ateia Alzedam, Hamdan Hilan (Faculty of 11 12 Medicine, Misurata University); Alarabi Alsalem Ali Alarabi (Faculty of Medicine, Sebha University); Amal 13 14 Sharif Eljali, Ahmad Bouhuwaish (Faculty of Medicine, Tobruk University); Sahar Azaz (Faculty of 15 Medicine, University of Sabratha); Abdulkarim Aldoukali Babaa, Mabruka Mohamed Algallal, Nawal 16 For peer review only 17 Aldokali Muhammed, Mohaned Mohammed Zlitni, Mohammed Salem Mansour, Islam Ammar, 18 19 Mohammed Salem Mansour (Faculty of Medicine, Tripoli University). 20 21 22 Palestine Collaborators: Roaa Waleed Abu-Ereban (Faculty of Dentistry, Al Azhar University); Ayat Abed- 23 24 Albaset Mahamid (Faculty of Dentistry, Arab American University); Sojoud Saleem Alabed, Omar A. 25 Safarini, Ammar Ahmad Thabaleh (Faculty of Medicine and Health Sciences, An-Najah National 26 27 University); Mahmoud Aref Aldrini, Nataly Mazen Salhab, Qusai N Zreqat (Faculty of Medicine, Al-Quds 28 29 University); Sahar kamel Balasi (Faculty of Medicine, Palestine Polytechnic University); Hala Jamal Redwan 30 (Faculty of Pharmacy, Al Azhar University); Ithar Moufak Barghouthi (Faculty of Pharmacy, Nursing and 31 32 Health Professions, Ramallah); Bushra Majd Barghouthe (Faculty of Science, Birzeit University) 33 34 http://bmjopen.bmj.com/ 35 Sudan Collaborators: Tayseer Hatim Mohammed, Mona Muhe-Eldeen Eshag, Elaf Mohamed Elhassan 36 37 (Faculty of Medicine, Bahri University); Hiba Mahgoub Eltayeb, Arwa F. Hassan (Faculty of Medicine, 38 39 Gezira University); Anfal Mahmoud Alkhalifa, Walaa Elnaiem , Suad Elsadig Yousif, Lina Sameer Ibrahim 40 (Faculty of Medicine, Khartoum University); Sjda Ameen Merghany (Faculty of Medicine, AHFAD 41 42 University for women); Mazen Bashir Ahmed (Faculty of Medicine and Surgery, Shendi University); Tareq on October 4, 2021 by guest. Protected copyright. 43 44 Fouad Neme (Faculty of Medicine, Al-Neelain University) 45

46 47 Syria Collaborators: Salam Muhammad Sharif, Houssein Deeb, Katrina Taha Al-Bank (Albaath University); 48 49 Farah AL Bakkar, Bana Zuhair Alafandi, Mohamad AlHashemi, Hasan Hassan Raslan (Faculty of Medicine, 50 Aleppo University); Raghad Dannan, Sabah Refaieh, Sami Jomaa, Laith Alsabek (Damascus University); 51 52 Tarek Al Soufi, Yara Issa, Danny Salem Knaizeh (Faculty of Medicine, Tishreen University); Mohammad 53 54 Yaser Haidar (Faculty of Medicine, University of Kalamoon) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Brazil Collaborators: Victor Carlos Nuvunga (Instituto Superior de Ciências e Educação a Distância) 4 5 6 Ghana Collaborators: Priscilla Sarfo Adu, Attah Al-Hassan Dawuni, Eliham Salifu, Isaac Mawunyega Kwaku, 7 8 Faisal Tikuma Abdallah, Rachel Laadi Sulia (Kwame Nkrumah University of Science and Technology) 9 10 India Collaborators: Avantika Pandey (Darshan Dental College and Hospital); Neetish Patel, Motilal Nehru 11 12 (National Institute of Technology, Allahabad); Shweta Patel (Galgotias University); Kamni raj Bavoria, 13 14 (University of Jammu); Avantika Pandey (Rajasthan University of Health and Science); Neetish Rani Patel 15 (National Institute of Technology Allahabad); Sreenath Sreekantan (District Health Services, Kollam) 16 For peer review only 17 18 Iraq Collaborators: Mohammed J Al-Awady (College of Biotechnology - Al Qasim Green University); Renas 19 20 Husain Isa (College of Agricultural Engineering Sciences, University of Duhok); Mohanad Jawad Kadhim 21 22 (College of Biotechnology, Al-Qasim Green University); Raad A. Alharmoosh (Medical Laboratory 23 Techniques, Altoosi University College) 24 25 26 Saudi Arabia Collaborators: Maram Al-Enzi (Kuwait University, Kuwait); Fatemah Alalawi (Emergency 27 28 Medicine, Dammam Medical Complex, Dammam, Saudi Arabia) 29 30 Ireland Collaborators: Osman Kamal Osman Elmahi (National University of Ireland); Muhammad 31 32 Mahmoud (Trinity College Dublin)

33 34 http://bmjopen.bmj.com/ 35 USA Collaborators: Dhouha Daassi (Massachusetts General Hospital, Harvard Medical School, MA); 36 Mohamed M. Khodeiry (Bascom Palmer Eye Institute, FL); Hasan Mirza (Beth Israel Deaconess Medical 37 38 Center, Harvard Medical School, MA); Pratha Rajesh Taiwade (Smolensk State Medical University, Russia)

39 40 41 Indonesia Collaborators: Sanju gautam (University of Southern Denmark, Denmark); Febtrias Mandeabuti on October 4, 2021 by guest. Protected copyright. 42 Prasetio (Dondo Primary and Public Healthcare Center, Central Sulawesi); Dewi Anggraini (Faculty of 43 44 Mathematical and Natural Sciences, Lambung Mangkurat University); Dini Setyowati (Faculty of Dental 45 46 Medicine, Universitas Airlangga); Ninuk Hariyani (Faculty of Dental Medicine, Universitas Airlangga); Risa 47 Haryati Tambunan (Maratua Public Health Center, Berau Regency); Bernike Yuriska Metabuti Prasetio 48 49 (Maranatha Christian University); Theresia Pakaedith Lodang Hurint (Puskesmas Paga, Sikka, East Nusa 50 51 Tenggara); Dewi Ayu Ratna Sari (Puskesmas Cancar, Manggarai); Bernike Yuriska Metabuti Prasetio 52 (Maranatha Christian University); Mulia Daniel Sihotang (University of North Sumatera); Oktavia 53 54 Manuama (MEAL Officer, Indonesia) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Nepal Collaborators: Kuber Bajgain (Institute of Medicine, Tribhuvan University); Suresh Panthee 4 5 (Sustainable Study and Research Institute, Kathmandu); Buddha Bahadur Basnet (Academy of Science and 6 7 Technology, Patan); Bimala Panthee (School of Nursing and Midwifery, Patan Academy of Health 8 Sciences); Nanda Kumar Tharu (Department of Statistics, Tribhuvan University); Rakesh Kumar Lama 9 10 (Management, Tribhuvan University); Ramesh Kumar Yadav (Faculty of Medical and Allied Sciences, 11 12 Purbanchal University); Sandeep Khattri (Kathmandu University); Amrita Acharya (Kathmandu University, 13 Dhulikhel, Nepal); Nashib Pandey (Kantipur Dental College Teaching Hospital & Research Center) 14 15 16 For peer review only 17 Lebanon Collaborators: Hanane Amer Chamma (Institute of Human Genetics, Montpellier, France); Hadi 18 Mohammad Fateh Shammaa, Tarek Abdulkarim Baroud, Marc Samir Machaalani, Bachir Toufik Zrayka, 19 20 Amir Rabih Al Ayoubi, Lemir Majed Lemir Ahmad El Ayoubi, Ilham Hassan Said-Salman, Jad Samer Al Masri 21 22 (Lebanese University); Anthony Dany Daher, Fouad Mario Assaf, Diala Samer Al Masri (Balamand 23 University); Miguel Michel Farraj (Antonine University); Manal Ali El Ahmar (University of Saint Joseph); 24 25 Louna Karam (Lebanese American University) 26

27 28 Sri Lanka Collaborators: Apareka Gamage Dinusha Madhubhashini Perera (Faculty of Graduate Studies, 29 30 University of Kelaniya); Uchini Shermilie Bandaranayake (Sabaragamuwa University of Sri Lanka); Miyuru 31 Chandradasa (Faculty of Medicine, University of Kelaniya); Jayaweera Arachchige Asela Sampath 32 33 Jayaweera (Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka); Ayesha Lakmali 34 http://bmjopen.bmj.com/ 35 Weerasingha (Faculty of Agriculture, Eastern University); Ayesha Lakmali Weerasingha (Eastern University 36 Sri Lanka); Veranga Kavithri Wickramasinghe (University of Colombo); Jayakodi Arachchige Isuru Sohan 37 38 (District Project Coordinator, Good Neighbors International) 39 40 41

Nigeria Collaborators: Oloyede Oyedibu Oyebayo (Faculty of Science, University of Ibadan); Adewuyi A. on October 4, 2021 by guest. Protected copyright. 42 43 Tunde (Faculty of Environmental, Nigeria Defence Academy); Anwar Jamal Abdulnasir (King Saud 44 45 University, Saudi Arabia); Jamal Raihan Abdulnasir, Salisu Danjuma Gezawa, Shuaibu Omeiza Salawudeen 46 (Bayero University Kano); Kazeem Bidemi Okesina (University of Ilorin); Nuraddeen Wada (Al-Qalam 47 48 University Katsina); Yakubu Egigogo Raji (Ibrahim Badamasi Babangida University) 49 50 51 South Africa Collaborators: Anthonia Omotola Ishabiyi, Patrick Hosea Olayiwola, Muhammed 52 Olatunbosun Ogunlola (University of KwaZulu-Natal); Abdultaofeek Abayomi (Faculty of Natural Sciences, 53 54 Mangosuthu University of Technology) 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Morocco Collaborators: Bouya ilyass (Faculty of Medicine Paris 13, Paris, France); Othmane Lamoihi 4 5 (Faculte de Medecine et de Pharmacie de Marrakech); Achraf Hafdi, Hiba Lazrek (Faculty of Medicine, 6 7 Caddi Ayad University); Lahmouz Nouhaila (Faculty of Medicine and Pharmacy of Rabat) 8 9 10 Pakistan Collaborators: Irfan Ullah (Kabir Medical College, Gandhara University); Asma Nawaz (Faculty of 11 12 Sciences, Virtual University of Pakistan); Khayam ul haq, (NCS University system); Abdul Rafay (Ameer-ud- 13 din Medical College/Lahore General Hospital); Kainat Khan (Burns ward, Civil hospital, Hyderabad); Latif 14 15 ullah khattak (Nutrition and public health, Alelaj hospital wah cantt Pakistan); Noreen Aslam (Islamia 16 For peer review only 17 University Bshawalpur) 18 19 20 UK Collaborators: Ei Cho Lin (Dorset County Hospital, Dorchester); Taghreed Saud Almansouri (Faculty of 21 22 Medicine, University of Sheffield); Maheswaran Warren Archunan (Norfolk and Norwich University 23 Hospital); Hasan Hazim Alsararatee (Northampton General Hospital); Asif Mahmood (The Queen Elizabeth 24 25 Hospital King’s Lynn); Doaa Hamed Sobeih (London School of Hygiene and Tropical Medicine, University 26 27 of London) 28

29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 4 Appendix 3: Supplementary Tables 5

6 7 Supplementary Table 1: Association of scores with demographic characteristics. 8 9 Knowledge Scores Attitude Scores Practices scores 10 Score P value Score P value Score P value 11 Age 12 13 ≤ 30 years 19.25 ± 3.53 3.66 ± 2.32 12.05 ± 1.84 14 31 to 50 years 19.23 ± 3.71 0.001 3.90 ± 2.28 <0.001 12.31 ± 1.75 0.006 15 > 50 years 18.99 ± 3.95 3.80 ± 2.34 12.14 ± 1.98 16 Gender For peer review only 17 Male 18.94 ± 3.78 <0.001 3.59 ± 2.36 0.002 11.96 ± 2.0 <0.001 18 Female 19.40 ± 3.44 3.84 ± 2.26 12.22 ± 1.72 19 Education 20 High School 17.58 ± 3.72 3.84 ± 2.46 12.11 ± 2.01 21 22 Undergraduate 19.43 ± 3.48 <0.001 3.72 ± 2.28 <0.001 12.10 ± 1.80 <0.001 23 Graduated 19.52 ± 3.58 3.67 ± 2.30 12.21 ± 1.76 24 Residency 25 Urban 19.32 ± 3.55 0.001 3.71 ± 2.31 0.07 12.16 ± 1.80 <0.001 26 Rural 18.90 ± 3.73 3.76 ± 2.35 11.92 ± 1.98 27 Previous confirmed COVID-19 diagnosis 28 Yes 17.10 ± 4.35 <0.001 3.42 ± 2.61 <0.001 11.64 ± 2.70 <0.001 29 No 19.28 ± 3.56 3.73 ± 2.31 12.12 ± 1.81 30 31 Knowing someone with confirmed 32 COVID-19 diagnosis 33 Yes 19.84 ± 3.50 <0.001 3.39 ± 2.36 0.003 12.47 ± 1.83 0.001 34 No 19.15 ± 3.60 3.77 ± 2.30 12.11 ± 1.83 http://bmjopen.bmj.com/ 35 Data are presented as mean ± standard deviation. Analysis was conducted using independent t-test or ANOVA test 36 with post-hoc Hochberg test. 37 38 39 40 41

on October 4, 2021 by guest. Protected copyright. 42

43 44 45 46 47 48 49 50 51

52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 2: Knowledge cut-off scores per country 4 5 6 Poor Fair Good N 7 8 (<16.8) (16.8 - 22.1) (22.2 - 28) 9 10 Algeria 656 (13.38) 3207 (65.45) 1037 (21.16) 4900 11 Brazil 55 (6.55) 511 (60.90) 273 (32.54) 839 12 13 Egypt 716 (10.48) 4391 (64.28) 1723 (25.22) 6830 14 15 Ghana 507 (27.45) 1175 (63.62) 165 (8.93) 1847 16 For peer review only 17 India 498 (34.02) 888 (60.66) 78 (5.32) 1464 18 Indonesia 1362 (30.65) 2883 (64.87) 199 (4.47) 4444 19 20 Iraq 340 (16.25) 1370 (65.48) 382 (18.26) 2092 21 22 Ireland 265 (25.83) 539 (52.53) 222 (21.64) 1026 23 24 Jordan 731 (12.41) 3737 (63.54) 1414 (24.04) 5881 25 Lebanon 441 (13.05) 2263 (66.95) 676 (20.00) 3380 26 27 Libya 1115 (25.93) 2511 (58.40) 674 (15.67) 4300 28 29 Morocco 400 (22.79) 1048 (59.72) 307 (17.49) 1755 30 31 Nepal 769 (28.94) 1666 (62.70) 222 (8.35) 2657 32 Nigeria 1330 (38.54) 1959 (56.82) 160 (4.64) 3448 33 http://bmjopen.bmj.com/ 34 Pakistan 627 (36.40) 963 (55.90) 133 (7.72) 1723 35 36 Palestine 1010 (16.85) 3950 (65.91) 1033 (17.24) 5993 37 38 Saudi Arabia 249 (15.41) 1064 (65.84) 303 (18.75) 1616 39 40 South Africa 576 (29.11) 1201 (60.69) 202 (10.21) 1979 41

Sri-Lanka 475 (26.50) 1136 (63.36) 182 (10.15) 1793 on October 4, 2021 by guest. Protected copyright. 42 43 Sudan 481 (10.98) 3033 (69.23) 867 (19.80) 4381 44 45 Syria 908 (13.81) 4059 (61.72) 1609 (24.47) 6576 46 47 UK 474 (21.94) 1167 (54.03) 519 (24.03) 2160 48 USA 236 (29.35) 366 (45.52) 202 (25.12) 804 49 50 Total 14221 (19.78) 45087 (62.72) 12582 (17.50) 71890 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 43 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 3: Mean knowledge, attitudes, and practices scores and rate questions for each 4 country 5 6 7 N Knowledge Attitudes Practices Fear of Compliance Negative 8 getting with mental 9 10 COVID-19 lockdown effects 11 Algeria 4900 19.94 ± 3.22 3.78 ± 2.13 12.21 ± 1.66 5.39 ± 2.78 8.28 ± 2.21 5.14 ± 3.01 12 13 Brazil 839 21.09 ± 3.04 2.17 ± 2.17 11.74 ± 1.46 6.72 ± 2.57 6.72 ± 2.95 5.68 ± 2.96 14 15 Egypt 6830 20.35 ± 3.10 3.68 ± 2.25 11.79 ± 1.85 6.14 ± 2.81 7.70 ± 2.32 6.02 ± 2.97 16 For peer review only 17 Ghana 1847 18.28 ± 3.24 3.36 ± 2.30 12.64 ± 1.48 5.62 ± 3.00 7.77 ± 2.25 3.88 ± 2.76 18 India 1464 17.45 ± 3.55 4.18 ± 2.15 12.66 ± 1.50 6.38 ± 2.57 7.10 ± 2.76 5.60 ± 2.87 19 20 Indonesia 4444 17.74 ± 3.24 3.49 ± 2.33 12.90 ± 1.42 6.57 ± 2.18 8.14 ± 1.74 5.77 ± 2.56 21 22 Iraq 2092 19.52 ± 3.42 4.51 ± 2.00 12.35 ± 1.57 5.26 ± 2.94 7.88 ± 2.28 4.80 ± 3.06 23 24 Ireland 1026 19.00 ± 4.06 2.94 ± 2.40 11.98 ± 1.66 5.85 ± 2.62 7.98 ± 2.12 4.76 ± 2.85 25 26 Jordan 5581 20.13 ± 3.32 4.53 ± 2.10 12.58 ± 1.58 4.89 ± 2.85 8.57 ± 2.03 5.69 ± 3.14 27 28 Lebanon 3380 19.91 ± 3.19 3.17 ± 2.31 12.29 ± 1.66 5.12 ± 2.71 7.55 ± 2.20 5.23 ± 2.93 29 Libya 4300 18.69 ± 4.01 4.04 ± 2.36 11.58 ± 2.23 4.50 ± 2.92 6.89 ± 2.82 5.09 ± 3.25 30 31 Morocco 1755 19.05 ± 3.61 2.33 ± 2.41 12.59 ± 1.49 5.55 ± 2.58 8.65 ± 1.92 5.53 ± 2.87 32 33 Nepal 2657 18.07 ± 3.51 3.76 ± 2.31 12.60 ± 1.50 6.17 ± 2.53 7.54 ± 2.42 4.93 ± 2.76 34 http://bmjopen.bmj.com/ 35 Nigeria 3448 17.12 ± 3.80 3.82 ± 2.25 11.94 ± 2.21 6.18 ± 3.01 7.29 ± 2.50 5.26 ± 3.02 36 37 Pakistan 1723 17.49 ± 3.94 3.82 ± 2.43 12.39 ± 1.81 5.77 ± 2.64 6.06 ± 2.73 5.59 ± 2.87 38 39 Palestine 5993 19.42 ± 3.31 3.95 ± 2.28 11.50 ± 2.03 4.43 ± 2.75 7.22 ± 2.67 5.56 ± 3.16 40 Saudi Arabia 1616 19.63 ± 3.33 4.76 ± 1.93 12.54 ± 1.31 5.26 ± 2.75 8.68 ± 2.01 4.40 ± 2.94 41 on October 4, 2021 by guest. Protected copyright. 42 South Africa 1979 18.20 ± 3.62 3.55 ± 2.28 12.60 ± 1.56 5.93 ± 3.09 7.84 ± 2.36 5.16 ± 2.94 43 44 SriLanka 1793 18.40 ± 3.16 3.31 ± 2.24 12.34 ± 1.50 4.52 ± 2.41 8.28 ± 2.45 4.29 ± 2.80 45 46 Sudan 4381 20.05 ± 3.04 3.70 ± 2.16 12.01 ± 1.90 5.36 ± 3.05 8.13 ± 2.30 4.88 ± 3.19 47 48 Syria 6576 20.02 ± 3.45 3.66 ± 2.34 11.55 ± 1.86 4.27 ± 2.56 7.10 ± 2.50 5.06 ± 3.06 49 50 UK 2160 19.29 ± 4.33 2.92 ± 2.49 11.69 ± 2.09 5.70 ± 2.48 7.64 ± 2.52 5.09 ± 2.79 51 52 USA 804 19.00 ± 4.28 2.66 ± 2.40 12.31 ± 1.42 5.51 ± 2.30 7.79 ± 2.23 5.11 ± 2.66 53 Total 71890 19.24 ± 3.59 3.72 ± 2.31 12.12 ± 1.83 5.37 ± 2.83 7.70 ± 2.43 5.27 ± 3.02 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 43 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from 1 2 3 Supplementary Table 4: Correlations between knowledge, attitudes, and practices scores 4 5 Knowledge Score Attitude Score Practice Score 6 Knowledge Score r 1 0.058** .124** 7 p <0.001 <0.001 8 Attitude Score r 0.058** 1 0.276** 9 p <0.001 <0.001 10 r 0.124** 0.276** 1 11 Practice Score 12 p <0.001 <0.001 13 Fear of getting COVID-19 r -0.044 0.126 0.167 14 p 0.000 0.000 0.000 15 Compliance with lockdown r 16 For peer review0.111 only0.081 0.225 17 p 0.000 0.000 0.000 18 Negative mental effects of r -0.019 -0.013 0.002 19 lockdown p 20 0.000 0.001 0.598 21 **. Correlation is significant at the 0.01 level (2-tailed). 22 Analysis was performed using Kendall's tau_b test. 23 24 25 26 27 28 29 30 31 32 33 34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on October 4, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 4 Appendix file 4: Other KAP studies on COVID-19 5 6Study ID Country Survey Sample Summary of Results 7 Month Size 8 9Azlan Malaysia March, 4850 “The overall correct rate of the knowledge questionnaire was 80.5%. Most participants held positive attitudes toward the 102020 1 April successful control of COVID-19 (83.1%), the ability of Malaysia to conquer the disease (95.9%) and the way the Malaysian 11 government was handling the crisis (89.9%). Most participants were also taking precautions such as avoiding crowds (83.4%) 12 andFor practicing peerproper hand hygiene review (87.8%) in the week beforeonly the movement control order started. However, wearing face 13 masks was less common (51.2%)”. 14 15Hanafiah Malaysia April 1075 “A total of 1075 individuals responded to the survey with average completion time of 5 minutes and 90% completion rate 2 162020 (96-99% for Demographic items, 92% for Knowledge & Perception items, and 89% for Communication items)”. 17Clements USA March 1034 “For every point increase in knowledge, the odds of participation in purchasing more goods (odds ratio [OR] 0.88, 95% CI 182020 3 0.81-0.95), attending large gatherings (OR 0.87, 95% CI 0.81-0.93), and using medical masks (OR 0.56, 95% CI 0.50-0.62) 19 decreased by 12%, 13%, and 44%, respectively. Gen X and millennial participantshttp://bmjopen.bmj.com/ had 56% and 76% higher odds, 20 respectively, of increased purchasing behavior compared to baby boomers. The results suggest that there is a politicization 21 of response recommendations. Democrats had 30% lower odds of attending large gatherings (OR 0.70, 95% CI 0.50-0.97) 22 and 48% lower odds of using medical masks (OR 0.52, 95% CI 0.34-0.78) compared to Republicans”. 23 4 24Roy 2020 India March 662 “The anxiety levels identified in the study were high. More than 80 % of the people were preoccupied with the thoughts of 25 COVID-19 and 72 % reported the need to use gloves, and sanitizers. In this study, sleep difficulties, paranoia about acquiring 26 COVID-19 infection and distress related social media were reported in 12.5 %, 37.8 %, and 36.4 % participants respectively. 27 The perceived mental healthcare need was seen in more than 80 % of participants”. on October 4, 2021 by guest. Protected copyright. 28Reuben Nigeria June 589 “Respondents had good knowledge (99.5%) of COVID-19, gained mainly through the internet/social media (55.7%) and 292020 5 Television (27.5%). The majority of the respondents (79.5%) had positive attitudes toward the adherence of government IPC 30 measures with 92.7, 96.4 and 82.3% practicing social distancing/self-isolation, improved personal hygiene and using face 31 32 mask respectively. However, 52.1% of the respondents perceived that the government is not doing enough to curtail COVID- 33 19 in Nigeria. Pearson’s correlation showed significant relationship between knowledge of COVID-19 and attitude towards 34 preventive measures (r = 0.177, p = 0.004, r = 0.137, p = 0.001). Although 61.8% of the respondents have no confidence in 35 the present intervention by Chinese doctors, only 29.0% would accept COVID-19 vaccines when available” 36Zhong China February 6910 “Among the survey completers (n=6910), 65.7% were women, 63.5% held a bachelor degree or above, and 56.2% engaged 372020 6 in mental labor. The overall correct rate of the knowledge questionnaire was 90%. The majority of the respondents (97.1%) 38 had confidence that China can win the battle against COVID-19. Nearly all of the participants (98.0%) wore masks when 39 going out in recent days. In multiple logistic regression analyses, the COVID-19 knowledge score (OR: 0.75-0.90, P<0.001) 40 41 was significantly associated with a lower likelihood of negative attitudes and preventive practices towards COVID-2019”. 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3Abdelhafiz Egypt March 559 “The mean knowledge score was 16.39 out of 23, gained mainly though social media (66.9%), and the internet (58.3%). 4 2020 7 Knowledge was significantly lower among older, less educated, lower income participants, and rural residents. Most 5 6 participants (86.9%) were concerned about the risk of infection. While 37.6% thought that their salary will be continued if 7 they become isolated, 68.5% believed that it should be continued during this period. About 73.0% were looking forward to 8 get the vaccine when available” 9Serwaa Ghana March 350 “Regarding COVID-19, 62.7% had “good” knowledge about the outbreak, 68.3% had a high risk of contracting the COVID-19 102020 8 infection and 81.4% had a moderate preparedness skill to prevent and control the disease. Internet (77.1%) was the major 11 sources of information. Knowledge of COVID-19 was significantly associated with education (p<0.001), age (p=0.018), 12 employmentFor (p=0.011)peer and health-related review occupation (P=0.001) only but only religion was associated with risk perception”. 13 Lin 2020 9 China April 2446 “The mean and SD for the total knowledge score was 20.3 (SD ± 2.9) out of a possible score of 23. The social disruption and 14 15 household economic impact were notable, particularly in provinces with higher cumulative confirmed cases. The majority of 16 responses indicated a low perceived susceptibility of being infected (86.7% [95%CI 85.4–88.1]), with a fair proportion of 17 respondents perceiving a higher severity (62.9% [95% CI 61.0–64.8]). The mean total impact score was 9.9 (SD ± 3.8) out of a 18 possible score of 15. The mean score for STAI-S was 48.7 (SD ± 10.8), whereas the mean STAI-T score was 45.7 (SD ± 8.5). By 19 demographics, women reported significantly higher odds for higher levels of both STAI-Shttp://bmjopen.bmj.com/ (OR = 1.67) and STAI-T (OR = 1.30) 20 compared to men. People of a younger age were also more likely to experience higher STAI-S and STAI-T. Higher perceived 21 susceptibility and severity and impact were strong predictors of higher levels of STAI-S and STAI-T”. 22 Gharpure USA May 502 “1. (39 %) of respondents reported engaging in not recommended high-risk practices as washing food products with bleach, 23 10 242020 applying household cleaning or disinfectant products to bare skin, and intentionally inhaling or ingesting these products 25 2. Respondents who engaged in high-risk practices reported more adverse health effects as a result of using disinfectants 26 than those who did not report engaging in these practices”. 27Al-Hanawi Saudi March 3388 “The mean knowledge score was 17.96 (SD= 2.24) Which is a high knowledge level. The on October 4, 2021 by guest. Protected copyright. score attitude was 28.23 (SD = 2.76 282020 11 Arabia range = 6 - 30) which is optimistic attitude. The practice score was 4.34 (SD = 0.87, range: 0–5), indicating good practices. 29 Men have less knowledge, less optimistic attitudes, and less good practice toward COVID-19, than women. Older adults are 30 likely to have better knowledge and practices, than younger people”. 31 March 32Faasse Australia 3086 “1. Two thirds of respondents were at least moderately worried about a widespread COVID-19 outbreak in Australia 12 332020 2. Health-behavior engagement over the previous month was lower in some demographic groups, including males and 34 younger individuals (18-29 age group) 35 3. These was a substantial mismatch between respondents’ expected symptoms of infection and emerging evidence that a 36 meaningful proportion of people who contract the novel coronavirus will experience asymptomatic infection 37 4. Only 0.3% believed that they personally would not experience any symptoms if they were infected 38 5. Uncertainty and misconceptions about COVID-19 were common, including one third of respondents who reported being 39 unsure whether people are likely have natural or existing immunity 40 41 6. There was also uncertainty around whether specific home remedies (e.g., vitamins, saline rinses) would offer protection, 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 whether the virus could spread via the airborne route, and whether the virus was human made and deliberately released”. 4 Naser Jordan, March, 1208 “1. Moderate overall COVID-19 knowledge with a mean score of 7.93 (SD = 1.72) out of 12, 66.1%. 5 13 April 62020 Saudi 2. Participants had better knowledge about disease prevention and control with 83.0%, 7 Arabia, 3. The lowest sub-scale scores were for questions about disease transmission routes (43.3%). 8 Kuwait 4. High education level was an important predictor of greater COVID-19 knowledge scores (p<0.01)” 9Saqlain Pakistan April, 689 “1. More than half had good knowledge; 80% had good practices regarding COVID-19 and majority seek knowledge from 102020 14 May social media. 11 2. Knowledge was significantly higher (OR>1.00, p<0.05) among educated and higher income participants. 12 3.For Positive practices peer were significantly review (OR>1.00, p<0.05) only related to the older age (≥50 years), higher education, higher 13 income and good knowledge regarding COVID-19” 14 15Olapegba Nigeria March, 1357 “1. Approximately half of the respondents opined that COVID-19 was “a biological weapon designed by Chinese 15 162020 April government. 17 2. About 94% of the respondents identified “contact with airborne droplets via breathing, sneezing, or coughing” as the 18 most common mode of transmission 19 3. most respondents associated COVID-19 with coughing (81.13%), shortness of breathhttp://bmjopen.bmj.com/ (73.47%) and fever (62.79%). 20 4. “Regular hand washing and social distancing” was selected by most respondents (94.25%) as a way of preventing 21 infection 22 5. 11.86% reported “consuming gins, garlic, ginger, herbal mixtures and African foods/soups” as preventive measures 23 24 against COVID-19. 25 6. Majority of the respondents (91.73%) thought COVID-19 is deadly; and most respondents (84.3%) got ≥ 4 answers 26 correctly. 27 7. It was also observed that the traditional media (TV/Radio) are the most common on October 4, 2021 by guest. Protected copyright. source of health information about 28 COVID-19 (93.5%)”. 29Lau 2020 Philippin February 2224 “1. 94.0% heard of COVID-19. 3016 es , March 2. Traditional media sources such as television (85.5%) and radio (56.1%) were reported as the main sources of information 31 32 about the virus. 33 3. Coughing and sneezing were identified as a transmission route by 89.5% of respondents, while indirect hand contact was 34 the least common by 72.6% of respondents. 35 4. Hand washing was identified by 82.2% of respondents as a preventive measure against the virus, but social distancing by 36 32.4% and avoiding crowds by 40.6%. 37 5. A greater number of preventive measures were taken by those with more knowledge of potential transmission routes.” 38Mannan Banglade March 435 “1. All of the participants agreed that they heard about COVID-19 (97.8%). 392020 17 sh 2. Most of population used social media to obtain regarding the COVID-19 information. 40 41 3. A significant proportion of had poor knowledge of its transmission and symptoms onset and showed a positive perception 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 of COVID-19 prevention and control. 4 4. Factors such as profession and age are correlated with inadequate knowledge of COVID-19” 5 6Meier Netherla March 9796 “Participants indicated support for governmental measures related to avoiding social gatherings, selective closure of public 18 72020 nds, places, and hand hygiene and respiratory measures (range for all measures: 95.0%-99.7%). Respondents from the 8 Germany Netherlands were less likely to consider a complete social lockdown effective (59.2%), compared to respondents in Germany 9 , Italy (76.6%) or Italy (87.2%). Italian residents did not only apply enforced social distancing measures more frequently (range: 10 90.2%-99.3%, German and Dutch residents: 67.5%-97.0%), but also self-initiated hygienic and social distancing behaviors 11 (range: 36.3%- 96.6%, German and Dutch residents: 28.3%-95.7%). Respondents largely reported being sufficiently informed 12 aboutFor the COVID-19 peer outbreak and review about behaviors to avoid only infection (range across countries: 90.2%-91.1%). Information 13 channels most commonly reported included television (range: 53.0%-82.0%), newspapers (range: 31.0%-63.0%), official 14 15 health websites (range: 39.0%-54.1%), and social media (range: 40.0%-55.8%). We observed no major changes in answers 16 over time”. 17Abir 2020 Banglade March & 1005 “The mean knowledge (8.4 vs. 8.1, P=0.022) and risk perception (11.2 vs. 10.6, P < 0.001) scores differ significantly between 1819 sh May early and late lockdown. Compared to the early lockdown period, the scores for perceived risk of contracting COVID-19 19 decreased significantly while public knowledge about COVID-19 was lower but not statisticallyhttp://bmjopen.bmj.com/ significant”. 20Li 2020 20 China February 4607 “The participants indicated that they had medium level of knowledge about the COVID-19 (3.56 out of 5). Moreover, 21 participants perceived the COVID-19 to be highly severe (4.09 out of 5) and modestly controllable (3.25 out of 5). Regarding 22 their emotional and behavioral reactions, the results showed that the COVID-19 did not change much of the frequency of 23 24 participants’ positive and negative feelings and a range of behavior, with the mean score ranging from 2.61 to 3.77. In fact, 25 participants indicated that the frequencies of sleep problem, aggression, and substance use after the outbreak were slightly 26 lower compared to the ones before the outbreak of the COVID-19. As for social participation, participants appeared to not 27 very actively participate in the social events regarding the COVID-19 (1.75 out of on October 4, 2021 by guest. Protected copyright. 4). However, participants reported that 28 they displayed intensive precautionary behavior to prevent the COVID-19 (3.33 out of 4)”. 29Kwok January- 1715 “Analysis from 1715 complete responses indicated high perceived susceptibility (89%) and high perceived severity (97%). 302020 21 February Most respondents were worried about COVID-19 (97%), and had their daily routines disrupted (slightly/greatly: 98%). The 31 32 anxiety level, measured by the Hospital Anxiety and Depression Scale, was borderline abnormal (9.01). Nearly all 33 respondents were alert to the disease progression (99.5%). The most trusted information sources were doctors (84%), 34 followed by broadcast (57%) and newspaper (54%), but they were not common information sources (doctor: 5%; broadcast: 35 34%; newspaper: 40%). Only 16% respondents found official websites reliable. Enhanced personal hygiene practices and 36 travel avoidance to China were frequently adopted (>77%) and considered effective (>90%). The adoption of social- 37 distancing measures was lower (39%-88%), and their drivers for greater adoption include: being female (adjusted odds ratio 38 [aOR]:1.27), living in the New Territories (aOR:1.32-1.55), perceived as having good understanding of COVID-19 (aOR:1.84) 39 and being more anxious (aOR:1.07)”. 40 March 41Geldsetze United 5974 “US and UK participants’ median estimate for the probability of a fatal disease course among those infected with severe 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3r 2020 22 States acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was 5.0% (IQR 2.0%-15.0%) and 3.0% (IQR 2.0%-10.0%), 4 and respectively. Participants generally had good knowledge of the main mode of disease transmission and common symptoms 5 6 United of COVID-19. However, a substantial proportion of participants had misconceptions about how to prevent an infection and 7 Kingdom the recommended care-seeking behavior. For instance, 37.8% (95% CI 36.1%-39.6%) of US participants and 29.7% (95% CI 8 28.1%-31.4%) of UK participants thought that wearing a common surgical mask was “highly effective” in protecting them 9 from acquiring COVID-19, and 25.6% (95% CI 24.1%-27.2%) of US participants and 29.6% (95% CI 28.0%-31.3%) of UK 10 participants thought it was prudent to refrain from eating at Chinese restaurants. Around half (53.8%, 95% CI 52.1%-55.6%) 11 of US participants and 39.1% (95% CI 37.4%-40.9%) of UK participants thought that children were at an especially high risk 12 ofFor death when peerinfected with SARS-CoV-2”. review only 13 Islam Banglade N/A 190 “The respondents (n=189) who took part in the survey seems to be aware of the facts of COVID-19. 73.4% responded that 14 23 152020 sh they have good knowledge on COVID-19, whereas 3.2% of respondent have low level of knowledge. 23% have an average 16 knowledge. The respondents were mainly professionals and students over 18. That is why, most of them were aware of 17 the facts of COVID-19 through different media. Among the respondents, nearly 99% are maintaining social distancing 18 corresponding the government’s request”. 19Qian 2020 China February 1011 “The prevalence rates of moderate or severe anxiety (score ≥10 on GAD-7) were 32.7%http://bmjopen.bmj.com/ (n=167) among Wuhan participants 2024 and 20.4% (n=102) among Shanghai participants. 78.6% (n=401) of Wuhan participants and 63.9% (n=320) of Shanghai 21 participants had carried out all six precautionary behaviors. For both measures, Wuhan participants were more responsive 22 to the outbreak (p<0.001). Controlling for personal characteristics, logistic regression results suggested that risks of 23 24 moderate or severe anxiety were positively associated with perceived susceptibility (odds ratio 1.6, 95% confidence interval 25 1.3-1.8) and severity of the disease (1.6, 1.4-1.9) and confusion about information reliability (1.6, 1.5-1.9). Having 26 confidence in taking measures to protect oneself against the disease was associated with a lower risk (0.6, 0.5-0.7). The 27 strongest predictor of behavioral change was perceived severity, followed by confusion on October 4, 2021 by guest. Protected copyright. about information reliability”. 28Mubeen Pakistan January- 399 "There is lack of knowledge and awareness about coronavirus as 226 (56.6%) participants claimed that coronavirus is 29et al 2020 February actually the most dangerous virus in the world, and 171 (43%) did know that the common flu virus is potentially more lethal 3025 than coronavirus. Although a large majority of participants correctly identified sources of transmission, measures and 31 precautions to be taken for coronavirus, their knowledge for symptom identification was deficient. The most pursued 32 33 platform for information for coronavirus was found to be social media, followed by television and print media" 34Salman et Pakistan February 417 "Mean scores were 10.12 ± 2.20 for knowledge (good, moderate and poor knowledge in 50.2%, 42.8% and 7.0% of 35al 2020 26 - March participants, respectively); 5.74 ± 1.28 for attitude (65.4% of individuals had a positive attitude); and 11.04 ± 3.34 for COVID- 36 19 preventative practices (only 36.5% of participants had good preventive practices)." 37Gallè et al Italy March 2125 "A good level of knowledge about the epidemic and its control was registered in the sample, mainly among students 382020 27 attending life sciences degree courses. The majority of the students did not modify their diet and smoking habits, while a 39 great part of the sample reported a decrease in physical activity" 40 41Dkhar et India April 934 "A total of 934 (61%) respondents had heard details on COVID-19 from the social media, 1358 (89%) knew all ways of 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3al 2020 28 2020 coronavirus transmission, 602 (40%) felt that COVID-19 is a serious disease, 1184 (78%) responded that they totally agree 4 with the lockdown decision, and 1296 (85%) responded that lockdown is helping in reducing the number of cases. The 5 6 majority, i.e. 1318 (87%), followed advisories and reported washing hands with soap and water regularly, 1108 (73%) 7 reported regularly wearing masks, 1344 (89%) reported following lockdown guidelines, and 1306 (87%) reported 8 maintaining social distancing. The respondents exhibited good knowledge, positive attitude, and sensible practices 9 regarding COVID-19. " 10Taghrir et Iran February 240 "A total of 240 medical students completed the questionnaire. The mean age of participants was 23.67 years. The average 11al 2020 29 of correct answers of knowledge was 86.96%; and 79.60% had high level of related knowledge. The average rate of 12 practicingFor preventive peer behaviors review was 94.47%; and 94.2% only had high level of performance in preventive behaviors. The 13 cumulative score of risk perception was 4.08 out of 8 which was in moderate range. Risk perception was significantly 14 15 different between stagers and interns and between those being trained in emergency room (ER) and non-ER wards. There 16 was a significant negative correlation between preventive behaviors and risk perception." 17Bates et al Ecuador April 2399 "A total of 2399 individuals participated. Participants had moderate to high levels of knowledge. Participants expressed 182020 30 mixed attitudes about the eventual control of COVID-19 in Ecuador. Participants reported high levels of adoption of 19 preventive practices. Binomial regression analysis suggests unemployed individuals,http://bmjopen.bmj.com/ househusbands/housewives, or manual 20 laborers, as well as those with an elementary school education, have lower levels of knowledge. Women, people over 50 21 years of age, and those with higher levels of schooling were the most optimistic. Men, individuals 18–29, single, and 22 unemployed people took the riskiest behaviors. " 23 24Bates et al Colombia April 482 " A total of 482 individuals completed the questionnaire. Participants had low to moderate levels of knowledge about 31 252020 COVID-19. They expressed mixed levels of optimism about the world eventually controlling COVID-19, but they were very 26 optimistic about Colombia’s ability to control the disease. They reported extremely high levels of adoption of preventive 27 practices. Binomial regression suggests few demographic factors associated with on October 4, 2021 by guest. Protected copyright. KAPs. Generally, knowledge had no 28 association with optimism and little association with self-reported adoption of recommended practices." 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 4 References 5 1. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional 6 7 study in Malaysia. Plos one. 2020;15(5):e0233668. 8 2. Mohd Hanafiah K, Wan CD. Public knowledge, perception and communication behavior surrounding COVID-19 in Malaysia. 2020. 9 10 3. Clements JM. Knowledge and Behaviors Toward COVID-19 Among US Residents During the Early Days of the Pandemic: Cross-Sectional 11 Online Questionnaire. JMIR Public Health and Surveillance. 2020;6(2):e19161. 12 For peer review only 13 4. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in 14 Indian population during COVID-19 pandemic. Asian Journal of Psychiatry. 2020:102083. 15 16 5. Reuben RC, Danladi MM, Saleh DA, Ejembi PE. Knowledge, Attitudes and Practices Towards COVID-19: An Epidemiological Survey in 17 North-Central Nigeria. Journal of community health. 2020:1-14. 18 19 6. Zhong B-L, Luo W, Li H-M, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese http://bmjopen.bmj.com/ residents during the rapid rise 20 period of the COVID-19 outbreak: a quick online cross-sectional survey. International journal of biological sciences. 2020;16(10):1745. 21 22 7. Abdelhafiz AS, Mohammed Z, Ibrahim ME, et al. Knowledge, perceptions, and attitude of egyptians towards the novel coronavirus 23 disease (COVID-19). Journal of Community Health. 2020:1-10. 24 25 8. Serwaa D, Lamptey E, Appiah AB, Senkyire EK, Ameyaw JK. Knowledge, risk perception and preparedness towards coronavirus disease- 26 2019 (COVID-19) outbreak among Ghanaians: a quick online cross-sectional survey. The Pan African medical journal. 2020;35(44). 27 on October 4, 2021 by guest. Protected copyright. 28 9. Lin Y, Hu Z, Alias H, Wong LP. Knowledge, Attitudes, Impact, and Anxiety Regarding COVID-19 Infection Among the Public in China. 29 Frontiers in Public Health. 2020;8:236. 30 31 10. Gharpure R, Hunter CM, Schnall AH, et al. Knowledge and practices regarding safe household cleaning and disinfection for COVID-19 32 prevention—United States, May 2020. Morbidity and Mortality Weekly Report. 2020;69(23):705. 33 11. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of 34 35 Saudi Arabia: A Cross-Sectional Study. Frontiers in Public Health. 2020;8. 36 12. Faasse K, Newby JM. Public perceptions of COVID-19 in Australia: perceived risk, knowledge, health-protective behaviours, and vaccine 37 intentions.medRxiv. 2020. 38 39 13. Naser AY, Dahmash EZ, Alwafi H, et al. Knowledge and practices towards COVID-19 during its outbreak: a multinational cross-sectional 40 study. medRxiv. 2020. 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 14. Saqlain M, Ahmed A, Gulzar A, et al. Public Knowledge and Practices regarding COVID-19: A cross-sectional survey from Pakistan. 4 medRxiv. 2020. 5 6 15. Olapegba PO, Ayandele O, Kolawole SO, et al. A Preliminary Assessment of Novel Coronavirus (COVID-19) Knowledge and Perceptions in 7 Nigeria. 2020. 8 9 16. Lau LL, Hung N, Go DJ, et al. Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: A cross- 10 sectional study. Journal of global health. 2020;10(1). 11 12 17. Mannan DKA, Mannan KA.For Knowledge peer and perception reviewtowards Novel Coronavirus only (COVID 19) in Bangladesh. International Research 13 Journal of Business and Social Science. 2020;6(2). 14 15 18. Meier K, Glatz T, Guijt MC, et al. Public perspectives on social distancing and other protective measures in Europe: a cross-sectional 16 survey study during the COVID-19 pandemic. medRxiv. 2020. 17 18 19. Abir T, Kalimullah NA, Osuagwu UL, et al. Factors Associated with the Perception of Risk and Knowledge of Contracting the SARS-Cov-2 19 among Adults in Bangladesh: Analysis of Online Surveys. International journal of environmental researchhttp://bmjopen.bmj.com/ and public health. 20 2020;17(14):5252. 21 22 20. Li J-B, Yang A, Dou K, Wang L-X, Zhang M-C, Lin X-Q. Chinese public’s knowledge, perceived severity, and perceived controllability of the 23 COVID-19 and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: A national 24 survey. 2020. 25 26 21. Kwok KO, Li KK, Chan HH, et al. Community responses during the early phase of the COVID-19 epidemic in Hong Kong: risk perception, 27 information exposure and preventive measures. MedRxiv. 2020. on October 4, 2021 by guest. Protected copyright. 28 29 22. Geldsetzer P. Use of rapid online surveys to assess People's perceptions during infectious disease outbreaks: a cross-sectional survey on 30 COVID-19. Journal of medical Internet research. 2020;22(4):e18790. 31 32 23. Islam MD, Siddika A. COVID-19 and Bangladesh: A study of the public perception on the measures taken by the government. 2020. 33 24. Qian M, Wu Q, Wu P, et al. Psychological responses, behavioral changes and public perceptions during the early phase of the COVID-19 34 35 outbreak in China: a population based cross-sectional survey. medRxiv. 2020. 36 37 25. Mubeen SM, Kamal S, Kamal S, Balkhi F. Knowledge and awareness regarding spread and prevention of COVID-19 among the young adults of 38 Karachi. J Pak Med Assoc. 2020;70(Suppl 3)(5):S169-S174. 39 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2020-043971 on 23 February 2021. Downloaded from

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1 2 3 26. Salman, M., Mustafa, Z. U., Asif, N., Zaidi, H. A., Hussain, K., Shehzadi, N., Khan, T. M., & Saleem, Z. Knowledge, attitude and preventive 4 practices related to COVID-19: a cross-sectional study in two Pakistani university populations. Drugs & therapy perspectives : for rational drug 5 6 selection and use. 2020: 1–7. 7 8 27. Gallè, F., Sabella, E. A., Da Molin, G., De Giglio, O., Caggiano, G., Di Onofrio, V., Ferracuti, S., Montagna, M. T., Liguori, G., Orsi, G. B., & Napoli, 9 C. Understanding Knowledge and Behaviors Related to CoViD-19 Epidemic in Italian Undergraduate Students: The EPICO Study. International 10 journal of environmental research and public health. 2020; 17(10), 3481. 11 12 28. Dkhar SA, Quansar R, Saleem ForSM, Khan SMS. peer Knowledge, attitude, review and practices related only to COVID-19 pandemic among social media users in 13 J&K, India. Indian J Public Health. 2020;64(Supplement):S205-S210. 14 15 29. Taghrir MH, Borazjani R, Shiraly R. COVID-19 and Iranian Medical Students; A Survey on Their Related-Knowledge, Preventive Behaviors and 16 Risk Perception. Arch Iran Med. 2020;23(4):249-254. 17 18 30. Bates, B. R., Moncayo, A. L., Costales, J. A., Herrera-Cespedes, C. A., & Grijalva, M. J. Knowledge, Attitudes, and Practices Towards COVID-19 http://bmjopen.bmj.com/ 19 Among Ecuadorians During the Outbreak: An Online Cross-Sectional Survey. Journal of community health. 2020; 45(6): 1158–1167. 20 21 31. Benjamin R. Bates, Adriana Villegas Botero & Mario J. Grijalva. Knowledge, attitudes, and practices towards COVID-19 among Colombians 22 during the outbreak: an online cross-sectional survey. Journal of Communication in Healthcare. 2020. 23 24 25 26 27 on October 4, 2021 by guest. Protected copyright. 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60