Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey
Authors: Pascal Geldsetzer
Journal: Annals of Internal Medicine (2020)

Letters20 March 2020Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online SurveyFREEPascal Geldsetzer, MBChB, ScD, MPHPascal Geldsetzer, MBChB, ScD, MPHStanford University, Stanford, California (P.G.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-0912 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: The behavior of the general public will probably have an important bearing on the course of the coronavirus disease 2019 (COVID-19) epidemic. Human behavior is influenced by people's knowledge and perceptions (1).Objective: To assess knowledge and perceptions about COVID-19 among a convenience sample of the general public in the United States and United Kingdom.Methods and Findings: This study is a cross-sectional survey conducted on an online platform managed by Prolific Academic Ltd. The platform's pool of participants numbers approximately 80 000 individuals, of whom approximately 43% reside in the United Kingdom and 33% in the United States (2). For this study, Prolific selected a convenience sample of 3000 participants residing in the United States and 3000 participants residing in the United Kingdom who were chosen to have approximately the same distribution of age, sex, and ethnicity (and each combination thereof) as the U.S. and U.K. general population (by using numbers from the last census in each country). Specifically, Prolific established population strata (Table 1) with a predetermined number of open slots into which eligible participants in the online pool could enroll on a first-come, first-served basis.Table 1. Sample CharacteristicsParticipants, who had to have indicated that they were fluent in English, received US$1.50 for completing the survey. They completed the online questionnaire between 23 February and 2 March 2020. The questionnaire (Supplement) consisted of 22 questions on knowledge and perceptions of COVID-19, including specific questions about "myths" or falsehoods listed on the World Health Organization's "myth busters" website (3).To summarize the survey findings, I dichotomized categorical variables and computed the median and interquartile range for continuous variables. For binomial proportions, I used a score interval (Wilson score interval without continuity correction [4]) to construct a 95% CI. No sampling weights were used given that this was not a probabilistic sample.In total, 2986 and 2988 adults residing in the United States and United Kingdom, respectively, completed the questionnaire. Participants' sociodemographic characteristics are shown in Table 1. Although participants generally had good knowledge of the main mode of disease transmission and common symptoms, the survey identified several important misconceptions on how to prevent acquisition of COVID-19, including beliefs in falsehoods that have circulated on social media (Table 2). A substantial proportion of participants also expressed an intent to discriminate against individuals of East Asian ethnicity for fear of acquiring COVID-19. A more detailed analysis and visualization of all survey responses are available (5).Table 2. Summary of Survey FindingsDiscussion: The findings of this study could be used to set priorities in information campaigns on COVID-19 by public health authorities and the media. Such information provision could, for instance, emphasize the comparatively low case-fatality rate, the recommended care-seeking behavior, the low risk posed by individuals of East Asian ethnicity living in the United States and United Kingdom, and that children appear to be at a lower risk for a fatal disease course than adults. In addition, to ensure that individuals focus their attention on those prevention measures that are most effective, this study suggests that it will be important to inform the public about the comparative effectiveness of common surgical masks versus frequent and thorough handwashing and avoiding close contact with people who are sick.This study has several limitations. First and foremost, given that participants had to have both chosen to register with Prolific and to take the survey at the time it was published, this convenience sample of adults is unlikely to be representative of the general U.S. and U.K. population. The generalizability of the findings is, therefore, limited. Second, it is possible that some participants may have randomly selected responses to spend the least amount of time to earn the $1.50 reward. I believe this is unlikely to be an important source of bias because only 2 participants (who were excluded from the analysis) completed the survey in under 2 minutes (while it was physically possible to complete it in well under 90 seconds), there was no bimodal distribution in the time taken to complete the survey, and $1.50 is a relatively small monetary incentive. Third, it is possible that participants looked up the answers to some of the questions online before answering. Participants were asked at the end of the survey (while being reassured that their payment was not influenced by their response) for which, if any, questions they searched for an answer online. These responses were set to missing in the analysis.In conclusion, the general public in the United States and United Kingdom appears to have important misconceptions about COVID-19. Correcting these misconceptions should be targeted in information campaigns organized by government agencies, information provision by clinicians to their patients, and media coverage.References1. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11:1-47. [PMID: 6392204] CrossrefMedlineGoogle Scholar2. Prolific Academic Ltd. Explore our participant pool demographics. Accessed at www.prolific.co/demographics on 4 March 2020. Google Scholar3. World Health Organization. Coronavirus disease (COVID-19) advice for the public: myth busters. January 2020. Accessed at www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters on 5 March 2020. Google Scholar4. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med. 1998;17:857-72. [PMID: 9595616] CrossrefMedlineGoogle Scholar5. Geldsetzer P. Knowledge and perceptions of coronavirus disease 2019 among the general public in the United States and the United Kingdom: a cross-sectional online survey. medRxiv. 2020. doi:10.1101/2020.03.13.20035568. Accessed at https://medrxiv.org/cgi/content/short/2020.03.13.20035568v1 on 17 March 2020. Google Scholar Comments0 CommentsSign In to Submit A Comment 1. Chong Yau Ong, 2. Jin Lee Lim1. SingHealth Community Hospitals, Singapore 2. Hospital Sultanah Aminah Johor, Malaysia5 April 2020 Dynamicity of Knowledge and Perception of Public on COVID-19 We read with interest the survey conducted by Geldsetzer [1] on the public's general knowledge and perception on COVID-19. One of the most striking concerns was found in the subscale of the current state of the disease whereby estimation of number of death in US/UK given by the majority was less than 500. It is very likely that this survey was done during the epidemic when the cases outside China was not alarming enough for the public in both countries to be adequately concerned. Prospectively, even before the day WHO declared this as virus as pandemic; the numbers of affected and succumbed victim has been doubling in every few days for many countries, showing no signs of slowing down since. Today the death tolls reported in US and UK has exceeded 8400 and 4300 respectively [2]. These numbers surpassed the deaths in China, the first affected epicentre. Given the crisis situation now in both countries, it would be interesting if the same survey is to be conducted again to know the public's latest understanding. The healthcare-seeking behaviour could have been changed by now that the public is more informed presently than before through the media. Likewise, change is also likely to be noticed in the perception and behaviour in the preventive subscales such as mask-wearing, and measures government would take. It is with great effort that the survey captured the perceived risk imposed by East Asia community. Although the fatality from COVID-19 has been severely underestimated, a significant proportion of the responders would want to avoid contact (direct, and indirectly via parcel received) with the East Asia community. While it may beyond the scope of the survey to expound the reasons behind the perceived risk, future studies could look into this issue. It is important to address and mitigate fear before it ripples into xenophobia and social stigma [3, 4].Qualitative and narrative documentation of the public's perception can also help in understanding readiness to cooperate with measurements placed by the authorities, their coping strategies, and challenges faced.It will be also helpful if the knowledge and perception of COVID-19 of the public outside the world's biggest English-speaking community is made available. References:1. Geldsetzer P. Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey. Annals Int Med. 2020 Mar 20. [PMID: 32196071]2. John Hopkins University and Medicine. Covid-19 Data Visualisation Center. Mortality Analyses. March 2020. Accessed at https://coronavirus.jhu.edu/data/mortality on 5 April 2020.3. Person B, Sy F, Holton K, Govert B, Liang A. Fear and stigma: the epidemic within the SARS outbreak. Emerg Infect Dis. 2004;10(2):358. [PMID: 15030713]4. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Reducing Stigma. March 2020. Accessed at https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/reducing-stigma.html on 5 April 2020. Richard M Fleming, PhD, MD, JD (FHHI-OI-Camelot); Matthew R Fleming, BS, NRP (FHHI-OI-Camelot); Tapan K Chaudhuri, MD (Eastern Virginia Medical School)FHHI-OI-Camelot & EVMS25 March 2020 Increasing our Knowledge, Understanding and Treatment of CoVid-19 and CoVid-19 pneumonia (CVP). The sensitivity of CoVid-19 PCR throat and nasal swabs has been reported as ranging between 30 and 73%, which means that only 30-73% of the people with CoVid-19 will test positive [1,2] - at least initially. Part of the reason for this is the inclusion of people with low probability of having CoVid-19. The likelihood of these tests having a greater positive predictive value (PPV), and therefore being more meaningful, increases as we limit the use of this tool to those who are more likely to have CoVid-19, rather than merely testing everyone.Testing everyone might make people feel safer, but it will only reduce the PPV of this screening test while providing misinformation and decreasing the sensitivity and specificity of CoVid-19 screening. By focusing our screening on those who present with symptoms consistent with CoVid-19, we will reduce the numbers of errors made by screening for CoVid-19 and increase the accuracy and our understanding of CoVid-19; including the associated morbidity and mortality.The greatest concern for most people is not acquiring CoVid-19 - but dying from CVP. With multiple potential treatments being recommended, and with no prior evidence to direct our treatment of patients, it is critical that we quantify the treatment response [3,4] to determine which treatment is best tolerated - thereby saving time, money, resources and lives. References:1. Radiological Society of North America. "CT provides best diagnosis for COVID-19." ScienceDaily. ScienceDaily, 26 February 2020. www.sciencedaily.com/releases/2020/02/200226151951.htm.2. Ai T, Yang Z, Hou H, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology 2020;200642. DOI:10.1148/radiol.2020200642.3. The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) using same state single or sequential quantification comparisons. Patent Number 9566037. Issued 02/14/2017. 4. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. 2020;47(4):753-755. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019- 04668-y https://rdcu.be/b22Dd Disclosures: FMTVDM issued to first author. Stephen Thomas Green, Lorenzo CladiUniversity of Sheffield28 June 2020 Covid-19: Governments must ensure that national & international Public Health & Epidemiology Services are adequately resourced & fit for purpose Geldsetzer's survey conducted across both the USA & the UK has produced data of potentially enormous public health & epidemiological value in the battle against covid-19. (1) However, such data is only of practical value if there is a functioning public health & epidemiology service in place to analyse, interpret, & act upon it. Unfortunately, covid-19's appearance in December 2019 took place against a worldwide background of years of serious disinvestment in many aspects of public health medicine & epidemiology. Repeated budget cuts in both the USA & UK have over time badly damaged essential elements of the capacity to respond effectively to life-threatening infectious diseases, such as pandemic preparation, (2,3) contact tracing & testing. (4) For example, that a decade of budget cuts in the UK had resulted in "disempowered & fragmented infrastructures of its public health system" has been remarked upon with dismay. (5) According to the Terence Higgins Trust, "Local authority public health grant funding…(has been)…cut by £700 million in real terms between 2014/15 & 2019/20, & delivering the public health functions is now unsustainable with current funding." (6) With respect to resources of direct value in the struggle to roll back covid-19, prior to March 12 2020 - when widespread community tracing was stopped by the UK government - there were, across the entirety of England (population 56 million), just 290 individuals employed to undertake contact tracing for Public Health England health protection teams.(7) Since then, & under severe media pressure, Westminster politicians hastily promised 18,000 more recruits, although that recruitment process has been progressing slowly. (8) Things don't seem to be all that much better in the USA, if at all, with substantial cuts to public health funding having been proposed for 2021, (9) this coming on a background of an existing deficit of more than 250,000 public health workers. (10) In 2018, an axe was taken to the NSC pandemic preparedness teams & the CDC's ability to work effectively on preventive work in many countries outside of the USA. (11) At the time of writing, the USA had sadly sustained over 130,000 deaths caused by covid-19 & the UK over 43,000. (12) For any surveillance & prevention system to be able to perform properly, all the essential elements need to be present & functioning, & the systems in different sovereign states across the world certainly need to be in a position to cooperate & to synergise. Sadly the collection of data, however high the quality, is not enough by itself to take the fight against covid-19 forward. There is no question that adequate & reliable investment in the right places by governments is absolutely essential. REFERENCES https://www.acpjournals.org/doi/10.7326/M20-0912 https://theconversation.com/the-trump-administration-has-made-the-us-less-ready-for-infectious-disease-outbreaks-like-coronavirus-130983 https://www.theguardian.com/commentisfree/2020/may/01/uk-global-leader-pandemics-coronavirus-covid-19-crisis-britain https://www.bmj.com/content/bmj/369/bmj.m1591.full.pdf https://www.newstatesman.com/2020/05/too-little-too-late-too-flawed-bmj-uk-response-covid-19 https://www.tht.org.uk/sites/default/files/2018-11/Public%20health%20and%20sexual%20health%20funding%20updated%20Oct%20FINAL.pdf https://www.politicshome.com/news/article/minister-admits-just-1500-of-promised-18000-coronavirus-contact-tracers-hired-so-far https://www.bmj.com/content/bmj/369/bmj.m2471.full.pdf https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30182-1/fulltext https://www.statnews.com/2020/04/05/deficit-public-health-workers-no-way-to-fight-covid-19/ https://www.snopes.com/fact-check/trump-fire-pandemic-team/ https://www.worldometers.info/coronavirus/ Author, Article, and Disclosure InformationAuthors: Pascal Geldsetzer, MBChB, ScD, MPHAffiliations: Stanford University, Stanford, California (P.G.)Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0912.Reproducible Research Statement: Study protocol: Available from Dr. Geldsetzer (e-mail, pgeldsetzer@stanford.edu). Statistical code and data set: Available from https://purl.stanford.edu/zx357dw0759.Previous Posting: This manuscript was posted as a preprint on medRxiv on 17 March 2020. doi:10.1101/2020.03.13.20035568This article was published at Annals.org on 20 March 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDo knowledge, trust in source content, and magnitude of information influence COVID-19 risk perceptions? 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