Knowledge, Attitudes, and Practices Towards COVID-19 among North Sulawesi Indonesia Residents

Background: Coronavirus Disease 2019 (COVID-19) was declared a global pandemic by WHO. To prevent theCOVID-19 transmission is depend on community compliance with health protocols. Public compliance in implementing health protocols during the new normal period is closely related to the Knowledge, Attitudes, and Practices (KAP) about COVID-19. Method: A cross-sectional online survey was used to survey the people of North Sulawesi Indonesia. Data were collected from September 17 to September 30, 2020, with 705 respondents (Mean age: 23.8 ± 8.7 years; 70.8 % females). Result:From 705 respondents, 23% of them knew the cause of COVID-19, 31.5% knew the symptoms of COVID-19 and 31.5% understood the definition of new normal. However, 50.4% of respondents were not aware of an information site related to COVID-19 provided by the government and only 28.9% of respondents knew about preventions of COVID-19 related to washing hands with soap. Overall, there were 29.2% of respondents had poor knowledge about COVID-19. The majority of respondents hadpositive attitudes and good behaviors regarding the symptoms and prevention of COVID-19. The demographic factor significantly related to the level of knowledge is gender (POR: 1.8; 95% CI = 0.75-0.90, P <0.001). Conclusion: The majority of respondents had good knowledge, positive attitudes, and good practices toward the prevention of COVID-19. However, the knowledge of certain topics was still inadequate.

findings are locally specific which allows health promotion interventions can be done more effectively.

Introduction
Coronavirus Disease 2019 (COVID-19) was declared a global pandemic by WHO. According to the report of WHO, there were 30,675,675 positive cases of COVID-19 with a death rate of 3% on September 20, 2020 (WHO, 2020). At the same time, in Indonesia, COVID-19 cases have been reaching 244,676 cases with a death rate of 4%. The cases of COVID-19 in Indonesia come from all provinces including North Sulawesi with 4,295 cases were recorded and a death rate of 4% (BNPB, 2020).
Indonesia is one of the epicenters for the spread of COVID-19. To prevent COVID-19 transmission in communities, the government implemented a physical distancing policy by establishing PSBB (a Large-Scale Social Restriction policy) in April 2020 (Presiden RI, 2020). At the end of June, the PSBB policy was withdrawn and replaced with a "new normal" which allows people to be able to move outside their homes by implementing health protocols (Kompas, 2020). In this new normal period, the effort of suppressing COVID-19 cases is very dependent on community discipline in implementing health protocols. Therefore, information about people's knowledge, attitudes, and behaviors regarding COVID-19 during the new normal period is very crucial. This information can be an input for the government or related agencies in making policies related to health promotion during the pandemic period.
At the early of the COVID-19 pandemic in Indonesia, the level of knowledge related to COVID-19 among young people was still lacking. However, these results do not represent people's knowledge from all provinces, especially in central and eastern Indonesia. Young people prefer accessing information from social media rather than from websites provided by the government (Halim et al., 2020). North Sulawesi, as one of the provinces affected by COVID-19, which is located in the central part of Indonesia has become the place chosen by researchers. This study aims to determine the information about adult people's knowledge, attitudes, and behaviors regarding COVID-19 during the new normal in North Sulawesi Indonesia. It is hoped that the research in score of 1 -5 where 1 = very unimportant / strongly disagree, 2 = not important / disagree, 3 = less important / less agree, 4 = important / agree, 5 = very important / strongly agree. If the score ≥ 40, it is categorized as agree/important, and if ≤ 40, it is categorized as disagree/not important. Meanwhile, 10 questions are used in the questionnaire to assess COVID-19 prevention behaviors where answers to each question are given in scores of 1 -5. Score 1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always. A score of 40 -50 falls in the good practice category and a score < 40 falls in the category of poor practice.

Result And Discussion
The total sample of this study consists of 705 participants. All participants came from all districts in North Sulawesi. The mean age of the participants is 23.81 ± 8.67 which most of the participants are women (81.1%), 15-29 years old (81.6%), single (78.9%), and the majority of students (67.7%).
The majority of respondents correctly answered questions regarding the mode of transmission of SARS-CoV-2, the occurrence of lung damage due to COVID-19, and prevention by using masks and physical distancing. Only a small proportion of respondents knew about the causes of COVID-19 (K1), clinical symptoms (K3), prevention by washing hands (K8), and not many of them (31.5%) understood about "new normal" (K9), and almost half of the respondents were not aware of any websites provided by the government as sources of information related to COVID-19 (K10) ( Table  1). Most of the information sources used by respondents come from social media (46.3%) and only a small proportion of respondents sought information through government websites. The rest of the respondents obtained information from television, online news, family/friends, and health workers. Overall, 70.8% of respondents had a good level of knowledge.

Questions
Options Knowledge (correct rate, % of the total sample) K1. COVID-19 is caused by bacteria that enter the body (23%) True, false, I don't know K2. Sneezing can transmit the SARS-CoV-2 (94.2%) True, false, I don't know K3. Diarrhea is not one of the symptoms that may be found in COVID-19 (48.5%) True, false, I don't know K4. COVID-19 can damage the lungs (72.5%) True, false, I don't know K5. Objects that are often held by many people can be a source of transmission of COVID-19 (92.8%) True, false, I don't know K6. Using a mask is one way to prevent transmission of COVID-19 (98.4%) True, false, I don't know K7. Physical distancing space between people was 2 meters (81.7%) True, false, I don't know K8. It is recommended that you wash your hands with soap for at least 10 seconds (28.9%) True, false, I don't know K9. "New Normal" means being able to resume activities outside the home as before the COVID-19 pandemic (31.5%) True, false, I don't know K10. There is a government's official website for COVID-19 (50.4%) True, false, I don't know K = Knowledge

Table 1. Questionnaire of knowledge towards COVID-19
The statement about attitudes consists of 10 items where the majority of respondents considered that using masks, maintaining distance, and washing hands are important / very important to prevent transmission of COVID-19 (

Tabel 3. Practices of COVID-19 prevention among respondents.
Based on bivariate (chi-square) analysis, it is found that several variables have a significant association with the level of knowledge, namely gender, marital status, occupation, education, and income (p<0.05). The proportion of good knowledge is mostly possessed by respondents with characteristics: women, age of 30-49 years old, married, having a high education, working as professional/businessman and having a high income (Table 4). From multiple logistic regression analysis, it is found that the odds of knowledge in females are 1.8 times higher than that of males which is statistically significant (POR = 1.8; 95% CI: 1.2-2.5). (Table 5    This study shows that most respondents (70.8%) had a good understanding of COVID-19. The previous study has shown a high level of knowledge score about COVID-19 (Al-Hanawi, 2020;Bates et al., 2021;). Another study showed different results where the proportion of good knowledge in this study is better than in Mizan(47%), Beret (41.4%),India (40%), Ethiopia (23.5%) and Bangladesh (48.3%) (Angelo et al., 2021;Hani et al., 2020;Jagajeet et al., 2020;Handebo et al., 2021;Ferdous et al., 2020).
However, the knowledge of certain topics was still inadequate. The majority of respondents did not understand the definition of "new normal", the majority of respondents did not know the existence of any government websites related to COVID-19, and the majority of respondents did not understand the length of time needed to wash hands with soap and had a lack of knowledge about the causes of COVID-19. The findings of this study are similar to the findings of the study at the beginning of the COVID-19 outbreak with a population of young people in western Indonesia which the majority of respondents had a lack of knowledge about washing hands practice (Halimet al., 2020).
Although they already know that washing hands is one way to prevent transmission of COVID-19, the majority of respondents did not know how long it takes to wash their hands properly. Thus, it can be concluded that the behavior of washing hands by the majority of respondents may not match the ideal time of washing hands recommended by the government, which is 20 seconds (KementrianKesehatan, 2020). In this study, the proportion of respondents who washed their hands reached 70.2%. (Table 3). The high compliance with handwashing despite insufficient knowledge could be due to fear of the pandemic atmosphere.Previous research has shown that fear can motivate healthy behavior among people individuals especially during epidemics, but such behavior may not be sustainable (Ufuwa et al., 2020). The result of different from research in Nigeria which found that good hand washing practice only reached 22%, in Ethiopia 57.5% and 36,9%, (Ilesanmi, O. and Afolabi, A., 2020;Feleke et al., 2021;Molla and Abegas, 2021).
Most of the respondents had the wrong understanding that the new normal is a condition where people can return to their activities outside the home as before the pandemic (without strict health protocols). Lack of understanding of the definition of new normal can be the basis for the government to use other phrases for the same purpose. For example, the government uses the phrase "adaptation to new habits period".
Most respondents were not aware of the existence of an official government website that provides information related to COVID-19, and as a result, very few respondents seek information through the government website. Most respondents were looking for information about COVID-19 through social media. This is in line with the research conducted in India, Jordan, and among health workers (Dkhar et al., 2020;Singh et al., 2020;Olaimat et al., 2020;Baghavathula et al., 2020). It indicates that social media can be the best alternative for health promotion targeting the young to an adult population.
Most of the respondents had good knowledge regarding the prevention of COVID-19, had positive attitudes and good behaviors regarding the prevention of COVID-19. Following the theory of behavior where good health behavior is preceded by good knowledge and attitudes (Notoadmodjo, 2010). Another factor is likely due to the existence of a government policy that requires people to comply with health protocols in doing their activities. Likewise, research results in Malaysia and India at the start of the pandemic show that the majority of respondents had good knowledge, attitudes, and behaviors regarding COVID-19 (Azlan et al., 2020).
Based on demographic characteristics, the proportion of respondents who have good knowledge is dominated by females, age of 30-49 years, highly educated, and with an income >3.5 million IDR. It is in line with the research conducted in China which shows that the majority of respondents who answered the questionnaire correctly were female and welleducated.From the logistic regression analysis, gender and level of knowledge are significantly related where the odds of knowledge in women are 1.8 times higher compared to men (95% CI=1.25-2.59). Studies in Thailand showed that the odds of knowledge in women were 2.52 times higher than men (95% CI= 1.36-4.68) (Srichan et al., 2020). The results of research in China, Japan, and Ethiopia also show that the male gender is associated with risky behaviors (Zhong et al., 2020;Hatabu et al., 2020;Walle et al., 2021). This finding is consistent with another recent study in several countries (Bekele et al., 2020;Hatabu et al., 2020;Lee et al., 2021;Arslanca et al., 2021).
The weakness of this study is that respondents are limited to only those who can access the internet. The population at the rural level and parents who usually have poor knowledge cannot be reached maximally in this study. Another limitation is that the questionnaire is filled in by the respondents themselves so that the answers regarding attitudes and behaviors may be filled in according to what the respondents expect them to be. Not what they feel and do.

Conclusion
Overall, the majority of respondents had good knowledge, positive attitudes, and good practices toward the prevention of COVID-19. However, the knowledge of certain topics such as causes, symptoms, definitions of new normal, availability of information on government websites, and about prevention of transmission by washing hands with soap was still inadequate.