COVID-19 misinformation: Mere harmless delusions or much more? A knowledge and attitude cross-sectional study among the general public residing in Jordan

Since the emergence of the recent coronavirus disease 2019 (COVID-19) and its spread as a pandemic, media was teeming with misinformation that led to psychologic, social and economic consequences among the global public. Probing knowledge and anxiety regarding this novel infectious disease is necessary to identify gaps in knowledge and sources of misinformation which can help public health efforts to design and implement more focused interventional measures. The aim of this study was to evaluate the knowledge, attitude and effects of misinformation about COVID-19 on anxiety level among the general public residing in Jordan. This cross-sectional study was conducted using an online-based questionnaire that took place in April 2020, which targeted people residing in Jordan, aged 18 and above. The questionnaire included items on the following: demographic characteristics of the participants, knowledge about COVID-19, anxiety level and misconceptions regarding the origin of the pandemic. The total number of participants included in final analysis was 3150. The study population was predominantly females (76.0%), with mean age of 31 years. The overall knowledge of COVID-19 was satisfactory. Older age, males, lower monthly income and educational levels, smoking and history of chronic disease were associated with perceiving COVID-19 as a very dangerous disease. Variables that were associated with a higher anxiety level during the pandemic included: lower monthly income and educational level, residence outside the capital (Amman) and history of smoking. Misinformation about the origin of the pandemic (being part of a conspiracy, biologic warfare and the 5G networks role) was also associated with higher anxiety levels. Social media platforms, TV and news releases were the most common sources of information about the pandemic. The study showed the potential harmful effects of misinformation on the general public and emphasized the need to meticulously deliver timely and accurate information about the pandemic to lessen the health, social and psychological impact of the disease.


Introduction
The entire world is facing an unprecedented challenge in the form of the most recent pandemic caused by severe acute coronavirus 2 (SARS-CoV-2) [1]. Coronavirus disease 2019 (COVID-19) resulted in a massive number of infections throughout the world with a higher mortality rate among high risk groups (elderly, those with comorbidities) [2]. The public is left in a state of disarray due to the socio-economic consequences of the pandemic [3][4][5]. This global phenomenon dominated the media and became part of everyday conversation [6,7]. The emergence of this virus led to a worldwide lockdown, army enforced rules, disruption of education and a shift in the global economy [4]. These events caused public apprehension that raised questions and spread rumors, which demonstrates the significance of providing correct knowledge and reliable information for proper management of this public health emergency [5,8].
The clinical manifestations of COVID-19 vary, but commonly include: fever, cough, shortness of breath, vomiting and diarrhea [9][10][11]. The virus is primarily transmitted via respiratory droplets and close contact with an infected person [11]. SARS-CoV-2 can remain active for hours and even days on surfaces, therefore, touching infected surfaces can lead to the spread of infection [12,13]. This is why frequent hand washing and social distancing are the ideal protective measures [14]. To date, there are limited therapeutic options and no vaccine available for COVID-19 infection, and management hinges on supportive therapy [15].
Conspiracy theories regarding the origins of COVID-19 might be a way for the public to make sense of this pandemic. However, dangerous speculations about the virus might diminish the efforts in controlling the spread of infection [8,16]. Thus, it is important to assess the misconceptions and misbeliefs among the public which can reveal defects that should be targeted by awareness tools [17].
The potential negative effects of COVID-19 misinformation have been the subject of active research since the onset of the pandemic [8,[18][19][20][21][22]. Our previous investigation of this topic entailed students at the University of Jordan (UJ) with results pointed to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Study design
This cross-sectional study was conducted using an online-based questionnaire that took place between April 11, 2020 (21:00) to April 14, 2020 (00:00), thus spanning 75 hours and targeting residents in Jordan aged 18 years and above. Participation in the study was voluntary and an informed consent was included. The questionnaire was sent through Facebook, WhatsApp, Twitter and other social media platforms. The questionnaire comprised six sections with a total of 39 items addressing various subjects regarding knowledge, attitude, misinformation, sources of knowledge, and anxiety of participants regarding COVID-19. The language used to conduct the survey was Arabic (S1 Appendix).
The questionnaire contained items on socio-demographic information (age, nationality, gender, governorate of residence, marital status, monthly family income, educational level, history of smoking, and the presence of any chronic disease). Four items were used to assess the attitude towards the quarantine period (perception of the danger of the disease, adherence to quarantine measures, spending quality time with the family, and annoyance by the inability to attend religious houses of worship).
Two items were used to assess the sources of information, and three items were included to determine the role of conspiracy theories, biological warfare, and 5G networks in the origin and the spread of the pandemic. An additional item was also included to examine the belief in a divine role in the origin of the disease (S1 Appendix).

Ethical permission
The study was approved by the Department of Pathology, Microbiology and Forensic Medicine and by the Scientific Research Committee at the School of Medicine/UJ, (using WhatsApp conference call) which was later registered under the reference number 2479/2020/67 at the School of Medicine/UJ. Participation in the study was voluntary and anonymous. An informed consent was ensured by the presence of an . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint introductory section of the questionnaire, with submission of responses implying the agreement to participate. All collected data were treated confidentially.

COVID-19 knowledge score (K-score) calculation
Thirteen items were used to assess the overall COVID-19 knowledge among the study participants. These items included knowledge of symptoms of the disease (fever, cough, vomiting and diarrhea, and shortness of breath), knowledge of virus transmission (touching infected surfaces, close contact with an infected person, and transmission via blood), infectivity of the virus on surfaces for long periods of time, use of antibiotics for treating the disease, availability of a vaccine, remedial effect of garlic, onion and ginger on the infection, ability of summer heat to inactivate the virus, and possibility of reinfection by the virus (S1 Appendix). Each correct answer was recorded as a single point and a valid K-score was considered upon having responses to all 13 items.

Assessment of the anxiety score
The final section of seven items was used to measure the level of anxiety during the government-enforced quarantine period using the General Anxiety Disorder-7 (GAD-7) scale [24]. This scale is a reliable method for anxiety assessment and included four possible responses to each item. A valid anxiety score was considered upon having responses to all seven items. The maximum possible anxiety score was 21 with the minimum being zero.

Statistical analysis
All statistical analyses were conducted in IBM SPSS v22.0 for Windows. Significance was considered for P-values <0.050. Chi-squared (χ 2 ), Mann-Whitney U (M-W) and Kruskal Wallis (K-W) tests were used as appropriate.
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Characteristics of the study population
The total number of individuals who participated in the survey and that were included in final analysis was 3150 after filtering out responses from those who were less than 18 years old. This resulted in 1.75% margin of error considering the 95% confidence interval and the current total population of Jordan (10,184,790 people) [25,26]. General features of the study participants are summarized in ( . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 15, 2020. to the existence of partial response to some survey items.
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COVID-19 knowledge
The overall knowledge of the study participants regarding COVID-19 is illustrated in (Figure 1). The majority of the study participants correctly responded to eleven out of the thirteen items, with the least percentage of correct responses observed in the following two items: the virus can remain active on surfaces for few hours (49.7%) and reinfection by COVID-19 is not possible (23.7%, Figure 1). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Figure 2. Demographic features correlated with differences in COVID-19
knowledge score (K-score) among the study participants.
Higher K-score was seen among residents of Amman (A), participants with higher monthly income (B), non-smokers (C), and among participants with higher educational level (D). M-W: Mann-Whitney U test, K-W: Kruskal-Wallis test, CI: confidence interval of the mean Kscore, JOD: Jordanian dinar.
In addition, participants who felt annoyed by the inability to attend places of worship is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint COVID-19 is a spiritual divine test showed a lower K-score compared to those who did not hold such a belief (10.1 vs. 10.4, p<0.001; M-W, Figure 3). Lower K-score was seen among participants who stated that COVID-19 is part of a global conspiracy plot (A), participants who stated that COVID-19 is related to biologic warfare (B), participants who believed in the role of 5G networks in COVID-19 spread (C), and participants who thought that COVID-19 is a divine test (D). P-values were calculated using Mann-Whitney U test, CI: confidence interval of the mean K-score.
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Anxiety regarding COVID-19
The total number of participants who had a valid anxiety score was 3035, with mean score of 9.2 (range: zero-21.0). Variables with significant association to higher anxiety level were female gender (mean anxiety score: 9.3 vs 8.7, p=0.007, M-W), residence outside Amman (9.5 vs. 9.0, p=0.006; M-W), lower educational level (10.1 vs. 9.1 vs. 8.5, p<0.001; K-W), lower monthly income (9.9 vs. 9.0 vs. 8.3, p<0.001; K-W), and smoking (9.9 vs. 9.0, p<0.001; M-W, Figure 4). In addition, those who felt annoyed by the inability to attend places of worship had a higher mean anxiety score (9.7 vs. 8.2, p<0.001; M-W). While those who thought that the quarantine gave them an opportunity to spend a quality time with their families had a lower mean anxiety score  Figure   5).
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(which was not certified by peer review)
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Higher anxiety score was seen among participants who stated that COVID-19 is part of a global conspiracy plot (A), participants who stated that COVID-19 is related to biologic warfare (B), participants who believed in the role of 5G networks in COVID-19 spread (C), and participants who thought that COVID-19 is a divine test (D). P-values were calculated using Mann-Whitney U test, CI: confidence interval of the mean anxiety.
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Perception of COVID-19 danger and attitude towards quarantine
The majority of study population felt that the disease is moderately dangerous (n=1896, 60.3%), followed by 1152 participants who perceived the disease as very dangerous (36.6%). Older participants (more than or equal to 27 [the median age of the whole study population]) perceived the disease as very dangerous (40.6% compared to 31.7%) among the younger participants (less than 27 years old, p<0.001;  Table 2). The vast majority of study participants reported adhering to the quarantine measures (n=3072, 97.9%). Variables that were associated with higher likelihood to break the quarantine measures included male gender (4.3% vs. 1.3%, p<0.001; χ 2 ) and history of smoking (3.7% vs. 1.4%, p<0.001; χ 2 ).
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Is COVID-19 part of a global conspiracy?
Overall, a total of 1501 of the study participants believed that COVID-19 is part of a global conspiracy (47.9%, Figure 6). This belief was more common among females p=0.019; χ 2 ). For educational level, the belief in conspiracy was the highest among . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint those with a lower educational level (50.4% among those with high school or less degree vs. 48.5% among those with an undergraduate degree, vs. 40.8% among those with postgraduate degrees, p=0.016; χ 2 ).

Do 5G networks have a role in COVID-19 spread?
The overall belief in 5G networks role in the spread of COVID-19 was generally less compared to the previously mentioned items (conspiracy and biological warfare) (n=641, 21.0%, Figure 6). This misbelief was higher among females (23.6% vs. 12.8% in . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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The main media and other sources of information about the pandemic
The most common source of information for study participants regarding the pandemic were social media platforms (n=1075, 34.4%), followed by TV and news releases (n=850, 27.2%), the official Ministry of Health website on COVID-19 (n=771, 24.6%) and finally scientific journals and opinion of medical doctors (n=432, 13.8%).
The participants who relied on TV and news releases as the main source of knowledge about the virus were older in age compared to those who used other sources combined . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Discussion
The key results of this study can be summarized as follows: the overall knowledge of COVID-19 among residents in Jordan was satisfactory. More than 87% correct responses were found for eight items and more than 63% correct responses for eleven items out of thirteen total items that were used to assess COVID-19 knowledge in this study. The participants scored less for two items: SARS-CoV-2 can remain active on surfaces for few days rather than few hours (50%) and re-infection by COVID-19 is not possible (24%). The lower knowledge in relation to these two items can be attributed to ongoing research that has not achieved a widespread outreach for the public yet.
Such research indicated the stability of SARS-CoV-2 on surfaces for more than 24 hours depending on the nature of the surface [13,27]. For the possibility of re-infection, the current evidence points to unlikely occurrence of such a phenomenon despite the need for more research tackling this aim [28][29][30][31].
The high overall knowledge might be attributed to general interest of the public in this pandemic that became a global phenomenon and such high knowledge has been reported recently by several studies around the globe [32][33][34][35][36][37]. However, upon further dissecting COVID-19 knowledge, in relation to possible origins of the pandemic, severe gaps in knowledge were revealed. This was manifested by high prevalence of belief in conspiracy (48%), biologic warfare role (57%) and 5G networks' role (21%) in the origin and spread of the virus. In our previous work among university students, we found a significant association between higher anxiety during the current pandemic and the belief in conspiracy in COVID-19 origin [23]. The results of the current study clearly delineate the existence of an association between misinformation about COVID-19 and the combination of higher anxiety and lower knowledge about the disease among the public in Jordan.
Even though the natural origin of SARS-CoV-2 was scientifically determined to a large extent, which further discredits the role of a conspiracy in the origin of the disease, many people still grasp to such delusions [38,39]. The current climate of fear and uncertainty seems as a fertile soil from which conspiracy beliefs are born and thrive [40,41]. Thus, the high prevalence of inaccurate beliefs about COVID-19 origins seems . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint a plausible result. In addition, the link that was demonstrated between higher anxiety levels and conspiracy belief in this study, is not unique and can augment the previous evidence that such belief is harmful [23,42,43].
The clearest variable associated with lower overall knowledge about the disease, belief in conspiracy and higher anxiety level was the lower socio-economic status (lower educational level and lower monthly income). This result is consistent with findings from various recent studies, and points to the importance of targeting such groups with intensified awareness campaigns [33,34,[44][45][46].
The most common main source of information about COVID-19 reported by the participants were the social media platforms. The role of social media in fueling and spreading implausible notions cannot be overlooked [47][48][49]. The spread of such misinformation via social media outlets is not a recent phenomenon that accompanied the current crisis, but also involved several health-related aspects (e.g. vaccination, AIDS denialism, Zika fever outbreak, etc.) in the last decade [49][50][51]. To fight against the spread of harmful misinformation, the correct public health messages should be delivered in a user-friendly style with emphasis on fact-checking tools [52]. The prime role relies on experts, physicians and the policy makers to advocate for social media campaigns that can aid in establishing a culture of fact-checking [53].
Regarding the anxiety level of the study participants and taking into account that the survey was conducted in April 2020, the overall mean anxiety score showed a mild anxiety among the study participants. Females showed a higher anxiety level compared to males and this can be partly explained by the differences in physiology which increase females' susceptibility to develop anxiety and stress [54,55]. Also, the lower socio-economic status was associated with a higher anxiety level which can be attributed to the lack of income security during the crisis. Moreover, participants living outside Amman had higher anxiety; this might be due to certain hardships accompanying inhabitants of rural areas and more isolated areas, like financial strains and social isolation. Such results are in line with recent research pointing to similar associations [7,34,[56][57][58]. Furthermore, smokers had higher mean anxiety score compared to non-smokers; this is because of the rising emphasis on how smokers are . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
For the perception of COVID-19 degree of threat, males, participants with a lower socio-economic status, smokers and those with a history of chronic disease were likely to perceive the disease as very dangerous. This result appears plausible, particularly for individuals with comorbidities, considering the high-risk of severe disease and mortality among this group [61].
Finally, one observation in this study warrants further and meticulous exploration.
This entails the attitude and belief towards the origin of the disease and the government-enforced public health measures from a religious perspective. Feeling annoyed by the inability to perform religious practices due to forced closure of mosques and churches was seen in the majority of study participants (67.3%). Another observation was that about 83% of the study population believed that the origin of the pandemic is a form of test or trial by God. A higher level of anxiety among the aforementioned groups can be attributed to the inability of a majority of participants to worship in large gatherings in either mosques or churches during the lockdown period in the country. A large sum of previous reports showed that religious belief can reduce anxiety in various health-related conditions [62][63][64][65]. Further research is needed to establish the role of religious belief in coping at time of crisis.

Study limitations
Despite the relatively large sample size, bias was observed for gender (a majority of females) and for age. However, age seems to reflect the age distribution among the residents of Jordan at least to some extent. In addition, it was justified to have predominance of residents in the Central region as it harbours roughly two-thirds of population in Jordan including the Capital, Amman. Furthermore, we should clearly state that the results of the current study might not be representative of the Jordanian population. This is partly related to survey distribution via contacts and networks of the authors, which make sampling bias inevitable. Thus, further studies are needed to confirm our findings at different national and cultural levels. The study validity can be another limitation despite having a majority of items adopted from previously . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 15, 2020. . https://doi.org/10.1101/2020.07.13.20152694 doi: medRxiv preprint published work [35]. Finally, we have to state the inherent limitations of surveys including the response of the participants in a way they think would please the researchers, in addition to the problem of incomplete response.

Conclusions
COVID-19 poses a crisis that drastically changed the world; this is illustrated by the social, psychological and economic impact of the disease. This pandemic is framed with endless streams of misinformation and fake news, which has its own consequences and spreads even more confusion. The results of this study showed satisfactory knowledge about the disease among residents in Jordan, with lack of knowledge in certain aspects of the disease regarding origin and conspiracy surrounding this pandemic. Individuals with a lower socio-economic status showed higher anxiety, lower COVID-19 knowledge and belief in misinformation. Focused awareness and proper delivery of correct information is mandatory, particularly for this group to reduce the negative impact of the pandemic on their lives. An association was seen between belief in the role of conspiracies, biological warfare, and 5G networks in the origin and spread of the disease with lower levels of knowledge regarding COVID-19 and higher level of anxiety. The spread of misinformation and conspiracies is exacerbated by different media outlets, which is why proper management and close monitoring of posted content is necessary.
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Supporting information S1 Appendix
Consent Form and Questionnaire Translated to English (the original form in Arabic is provided as well).

Funding
We declare that we received no funding nor financial support/grants by any institutional, private or corporate entity.

Conflicts of Interest
We declare that we have no competing interest nor conflict of interest. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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