Psychometric Properties of the COVID-19 Pandemic Fatigue Scale: Cross-sectional Online Survey Study

Background: Pandemic fatigue is defined as feelings of demotivation to follow preventive measures against COVID-19, together with decreased trust in government and frequency of information-seeking behaviors. Objective: This study aims to analyze the psychometric properties of the COVID-19-specific pandemic fatigue scale according to classical test theory (CTT) and Rasch model approaches in the general Spanish population. Methods: This was a cross-sectional study in a representative sample of 1018 adults who completed an online survey in November 2020 in the framework of the COVID-19 Snapshot Monitoring (COSMO)-Spain project. The assessments included the 6-item COVID-19 Pandemic Fatigue Scale (CPFS) and other COVID-19-related variables: COVID-19 infection, adherence to preventive behaviors, information-seeking behavior, self-efficacy, worry, and cognitive and affective risk perception. Data quality, acceptability, reliability, and validity were analyzed according to CTT, and the fit to the Rasch model, unidimensionality, appropriateness of the response scale, item local independency, reliability (person-separation index [PSI]), and item-person distribution were also calculated. Results: The mean CPFS score was 17.06 (SD 5.04, range 6-30), with higher scores for women, younger participants, participants who never seek information on COVID-19, those who think they would contract a mild disease in case of infection, those with higher level of worry about coronavirus/COVID-19, and those who felt depressed or felt the coronavirus/COVID-19 is spreading slowly (all P<.01). The Cronbach alpha for the CPFS was 0.74. In the confirmatory factor analysis, one factor was identified (root mean square error of approximation [RMSEA]=.02; comparative fit index [CFI]=.99; χ25=8.06, P=.15). The CPFS showed good fit to the Rasch model (χ 224=42.025, P=.01, PSI=.642), unidimensionality (binomial 95% CI -.005 to .045), and item local independency. Conclusions: Our results suggest that the CPFS has moderate reliability and internal consistency and it is composed of a single dimension. It is a useful tool to ascertain the level of pandemic fatigue in the general population, which may help to guide the communication and information strategies to face the COVID-19 pandemic.The research was funded by the Carlos III Health Institute. The funder had no role in the study design; collection, analysis, and interpretation of data; writing of the paper; or decision to submit for publication.S

The COSMO-Spain Survey: Three First Rounds of the WHO Behavioral Insights Tool

Objective: To describe changes in knowledge, attitudes and preventive practices (KAP), risk perception, and psychological variables of Spanish population toward the COVID-19 pandemic from July to November 2020. Methods: Three samples, each of one composed by 1,000+ persons aged 18 years or older, were interviewed online in three rounds, every 2 months, from July to November 2020. Results: The level of knowledge on COVID-19 was high in the three rounds, with percentages above 95% of correct answers related to ways of contagion and correct use of face masks. The most accepted measure was the mandatory use of face masks (80-86% of agreement in the three rounds, p = 0.001), followed by the night curfew (63% of agreement). Most participants (>80%) consistently reported using face masks, ventilating spaces, and washing or disinfecting hands. However, risk perception and self-efficacy were low. Worry about losing a loved one, the health system overload and people who do not wear face masks was high (>85% of the samples). The percentage of respondents who felt depressed due to COVID-19 increased from round 1 to round 3 (p = 0.044). Conclusions: Spanish population has a high degree of KAP, but a relatively low risk perception and self-efficacy. These findings can help health authorities to guide containment measures and campaigns addressed to improve preventive practices.This work was funded by Carlos III Health Institute.S

Factors associated with Chagas screening among immigrants from an endemic country in Madrid, Spain

INTRODUCTION: Approximately 120,000 people live with Chagas disease in Europe, 43% of whom are living in Spain. Early diagnosis and treatment are critical to improve outcomes for those living with Chagas, and also for the prevention of ongoing transmission. The decision to be tested for Chagas is affected by a range of factors. Studies have highlighted the need to consider the wider social determinants of healthcare seeking behaviour related to Chagas. In Madrid, 44% of Bolivians undergo Chagas screening, which is a higher rate than other European regions, but studies concerning the factors which determine testing have not been performed. This study aimed to assess, for a first time, the factors associated with screening for Chagas among Bolivians living in Madrid trying to help in developing strategies and health recommendations. METHODS: This was a cross-sectional survey about knowledge of Chagas and practices of Bolivians living in Madrid, Spain. A structured questionnaire was administered to 376 participants regarding Chagas health-seeking behaviour. Determinants were assessed by multiple logistic regressions adjusted by sex. RESULTS: After adjusting for others variables and sex, the factors shown to be associated with Chagas screening were to have between 35 and 54 years of age; coming from a department with high prevalence of Chagas (OR 2.17 95% CI 0.99-4.76); received information about Chagas in Spain (OR 2.44 95% CI 1.32-4.51); and received any advice to do the test, especially if the advice came from a professional. CONCLUSIONS: Health authorities should coordinate and promote strategies addressed to diagnose and treat Chagas taking into account all factors associated with screening. Our study suggests that professional advice appears to be the cornerstone to encourage Bolivians to undergo Chagas screening in Madrid. It is time to change the burden of the decision of being screened from the patient to the doctor. Being diagnosed for Chagas needs to become an institutional strategy.This study was funding by the Insituto de Salud Carlos III (www.isciii.es)PI15CIII/00047 to TBH. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Tuberculosis Knowledge, Attitudes, and Practice in Middle- and Low-Income Countries: A Systematic Review

Tuberculosis (TB) is the leading cause of death from an infectious agent in the world. Most tuberculosis cases are concentrated in low- and middle-income countries. The aim of this study is to better understand tuberculosis-related knowledge about TB disease, prevention, treatment and sources of information, attitudes towards TB patients and their stigmatization and prevention, diagnosis and treatment practices in the general population of middle- and low-income countries, with a high tuberculosis burden, and provide evidence for policy development and decision-making. A systematic review of 30 studies was performed. Studies reporting on knowledge, attitudes, and practices surveys were selected for systematic review through database searching. Population knowledge about TB signs and symptoms, prevention practices, and treatment means was found inadequate. Stigmatization is frequent, and the reactions to possible diagnoses are negative. Access to health services is limited due to difficulties in transportation, distance, and economic cost. Deficiencies in knowledge and TB health-seeking practices were present regardless of the living area, gender, or country; however, it seems that there is a frequent association between less knowledge about TB and a lower socioeconomic and educational level. This study revealed gaps in knowledge, attitude, and practices in focused in middle- and low-income countries. Policymakers could take into account the evidence provided by the KAP surveys and adapt their strategies based on the identified gaps, promoting innovative approaches and empowering the communities as key stakeholders. It is necessary to develop education programs on symptoms, preventive practices, and treatment for TB, to reduce transmission and stigmatization. It becomes also necessary to provide communities with innovative healthcare solutions to reduce their barriers to access to diagnosis and treatment.Tuberculosis (TB) is the leading cause of death from an infectious agent in the world. Most tuberculosis cases are concentrated in low- and middle-income countries. The aim of this study is to better understand tuberculosis-related knowledge about TB disease, prevention, treatment and sources of information, attitudes towards TB patients and their stigmatization and prevention, diagnosis and treatment practices in the general population of middle- and low-income countries, with a high tuberculosis burden, and provide evidence for policy development and decision-making. A systematic review of 30 studies was performed. Studies reporting on knowledge, attitudes, and practices surveys were selected for systematic review through database searching. Population knowledge about TB signs and symptoms, prevention practices, and treatment means was found inadequate. Stigmatization is frequent, and the reactions to possible diagnoses are negative. Access to health services is limited due to difficulties in transportation, distance, and economic cost. Deficiencies in knowledge and TB health-seeking practices were present regardless of the living area, gender, or country; however, it seems that there is a frequent association between less knowledge about TB and a lower socioeconomic and educational level. This study revealed gaps in knowledge, attitude, and practices in focused in middle- and low-income countries. Policymakers could take into account the evidence provided by the KAP surveys and adapt their strategies based on the identified gaps, promoting innovative approaches and empowering the communities as key stakeholders. It is necessary to develop education programs on symptoms, preventive practices, and treatment for TB, to reduce transmission and stigmatization. It becomes also necessary to provide communities with innovative healthcare solutions to reduce their barriers to access to diagnosis and treatment.S

Diagnostic pathways of Chagas disease in Spain: a qualitative study

Background: Due to the mobility of the population in recent years and the spread of Chagas disease (CD) to non-endemic regions, early diagnosis and treatment of CD has become increasingly relevant in non-endemic countries. In order for screening to be effective, health system accessibility must be taken into consideration. This study uses Tanahashi's Health Service Coverage model to gain a deeper understanding of the main diagnostic pathways for Chagas disease in a non-endemic country and the barriers and bottlenecks present in each pathway. Methods: This study used a qualitative design with a phenomenological approach. Twenty-one interviews, two focus group sessions, and two triangular group sessions were conducted between 2015 and 2018 with 37 Bolivian men and women diagnosed with CD in Madrid, Spain. A topic guide was designed to ensure that the interviewers obtained the data concerning knowledge of CD (transmission, symptoms, and treatment), attitudes towards CD, and health behaviour (practices in relation to CD). All interviews, focus groups and triangular groups were recorded and transcribed. A thematic, inductive analysis based on Grounded Theory was performed by two researchers. Results: Three main pathways to CD diagnosis were identified: 1) pregnancy or blood/organ donation, with no bottlenecks in effective coverage; 2) an individual actively seeking CD testing, with bottlenecks relating to administrative, physical, and time-related accessibility, and effectiveness based on the healthcare professional's knowledge of CD; 3) an individual not actively seeking CD testing, who expresses psychological discomfort or embarrassment about visiting a physician, with a low perception of risk, afraid of stigma, and testing positive, and with little confidence in physicians' knowledge of CD. Conclusions: Existing bottlenecks in the three main diagnostic pathways for CD are less prevalent during pregnancy and blood donation, but are more prevalent in individuals who do not voluntarily seek serological testing for CD. Future screening protocols will need to take these bottlenecks into consideration to achieve effective coverage.This study was funded by the Carlos III Institute of Health (www.isciii.es) PI15CIII/00047. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors received no specific funding for this work.S

Mapping health behaviour related to Chagas diagnosis in a non-endemic country: Application of Andersen's Behavioural Model

Background: Chagas disease has become a challenge for non-endemic countries since population mobility has increased in recent years and it has spread to these regions. In order to prevent vertical transmission and improve the prognosis of the disease, it is important to make an early diagnosis. And to develop strategies that improve access to diagnosis, it is important to know the factors that most influence the decision of the population to know their serological status. For this reason, this study uses Andersen's Behavioural Model and its proposed strategies to explore the health behaviours of Bolivian population. Methods: Twenty-three interviews, two focus groups, and two triangular groups were performed with Bolivian men and women, involving a total of 39 participants. In addition, four interviews were conducted with key informants in contact with Bolivian population to delve into possible strategies to improve the Chagas diagnosis. Results: The most relevant facts for the decision to being diagnosed pointed out by participants were having relatives who were sick or deceased from Chagas disease or, for men, having their pregnant wife with a positive result. After living in Spain more than ten years, population at risk no longer feels identified with their former rural origin and the vector. Moreover, their knowledge and awareness about diagnosis and treatment still remains low, especially in younger people. Limitations on access to healthcare professionals and services were also mentioned, and proposed strategies focused on eliminating these barriers and educating the population in preventive behaviours. Conclusions: Based on Andersen's Behavioural Model, the results obtained regarding the factors that most influence the decision to carry out Chagas diagnosis provide information that could help to develop strategies to improve access to health services and modify health behaviours related to Chagas screening.This study was funded by the Instituto de Salud Carlos III (www.isciii.es) PI15CIII/00047 to TBH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors received no specific funding for this work.S

Measuring COVID-19 health literacy: validation of the COVID-19 HL questionnaire in Spain

Background: The COVID-19 pandemic has highlighted the importance of health literacy to make informed preventive decisions. A specifc COVID-19 health literacy questionnaire (CHL-Q) is included in the COVID-19 Snapshot Monitoring WHO initiative to conduct behavioral insights studies related to COVID-19. The objective was to assess the psychometric properties of a Spanish version of the COVID-19 Health Literacy Questionnaire (CHL-Q). Methods: Data quality, acceptability, internal consistency, and construct and structural validity were analyzed. A Rasch analysis was also performed. This cross-sectional, observational study was conducted on the Spanish general population after the frst wave of the pandemic and after the end of the general lockdown by an online survey agency. 1033 participants (inclusion criteria were being 18 years or older and living in Spain), was extracted from a panel of approximately 982,000 participants. The sampling was stratifed matching the Spanish general population in terms of age, gender, and area of residence. The CHL-Q includes 9 items and assesses people’s knowledge, motivation and competencies to access, understand, evaluate, and apply information about COVID-19 in order to make informed decisions. Results: CHL-Q index presented a mean of 33.89 (SD=9.4), and good ft to the Rasch model (χ2(32)=34.672, p=0.342, person separation index=0.77), with ordered thresholds, unidimensionality, item local independence, and no item bias by sex, age or education level. The CHL-Q showed signifcant diferent scores by level of education, experience of infection, confusion related to COVID-19 information and adherence to preventive measures. We found a statistically signifcant correlation between the CHL-Q index and the total number of preventive measures adopted, COVID-19 knowledge, and information seeking behaviour. The Cronbach´s alpha was 0.87 and the item total corrected correlation, 0.49–0.68. Conclusions: The Spanish version of CHL-Q is a short, adequate, and reliable instrument to measure COVID-19 related health literacy in the Spanish general population. Measuring the CHL in the population can be useful to evaluate whether public authorities, media and the medical and scientifc community have been able to reach the population to ofer the information in the terms they need it.This work was supported by Carlos III Health Institute.S

Evolution of the concerns, perceptions and attitudes of the Spanish population during the COVID-19 pandemic

[ES] En la pandemia de COVID-19, tanto el comportamiento individual como el colectivo son determinantes en el control de la propagación de la enfermedad, pero las restricciones adoptadas para atajar esta crisis de salud pública han afectado al bienestar físico y mental de la población. Conocer las percepciones y actitudes de los ciudadanos ayuda a identificar las necesidades de la población y adoptar medidas de respuesta a la pandemia más efectivas y participativas. El estudio COSMO-Spain analiza las preocupaciones, percepciones y actitudes de la población en relación a la pandemia, el grado de adherencia a las medidas preventivas y otras variables relacionadas, como la percepción de riesgo. Este estudio, impulsado por la OMS, se ha realizado desde julio de 2020 cada dos meses, a través de un cuestionario online a muestras representativas de la población española. Los resultados muestran que las actitudes de la población han ido cambiando en el tiempo influenciadas por factores individuales y contextuales. Debido la naturaleza evolutiva de esta pandemia, las campañas de educación y sensibilización deben ser dinámicas y actualizarse continuamente en función de los datos. [EN] Both individual and population behavior are determining factors in controlling the spread of the COVID-19 pandemic. However, the restrictions have impacted the mental and physical well-being of citizens, the social cohesion, the economic stability, as well as the community resilience. In this complex scenario, understanding the feelings and attitudes of the population helps us to identify their needs and adopt response measures to control the pandemic in a more consensual and effective way. The COSMO-Spain study explores the concerns, perceptions, and attitudes of the population about the pandemic to find out the acceptance and adherence to behavioral prevention measures, as well as to analyze the citizens’ risk perception, well-being and trust in information sources and institutions. The COSMO-Spain study has been carried out every two months since July 2020, through an online questionnaire to representative cross-sectional samples of the Spanish population, composed by 1000 people each. The results up to December 2021 show that the attitudes of the population are dynamic and evolve over time, influenced not only by individual factors, but also by contextual ones. Due to the changing nature of this pandemic, education and awareness campaigns need to be dynamic and continually updated based on real data.El estudio COSMO-Spain ha sido financiado por el Instituto de Salud Carlos III.S

Compliance with the main preventive measures of COVID-19 in Spain: The role of knowledge, attitudes, practices, and risk perception

In epidemics such as COVID-19, major changes need to be made to the population's behavior to prevent infection and stop disease transmission. The three most recommended preventive measures are wearing a mask, washing hands with soap or hydroalcoholic gel, and watching an interpersonal distance of at least two meters (3W) from other people. This study aimed to assess adherence to these COVID-19-related three preventive measures and its association with knowledge, attitudes, risk perception, and practices in Spain. The COSMO-Spain survey, based on the WHO Behavioral Insights questionnaire on COVID-19, was conducted in the general Spanish population using an online questionnaire (n = 1,033). Sociodemographic, knowledge, attitudes, practices, and risk perception variables were included. A multivariable logistic regression model was carried out to evaluate the factors associated with compliance with the three preventive measures. Half of the respondents (49.8%) were women with a median age of 45 (Inter-quartile Range, IR = 21) years. In the logistic regression, the factors associated with 3W compliance were being over 45 years; knowing about how COVID-19 spreads and wearing masks properly; appropriate attitudes towards COVID-19 (greater agreement with mandatory mask use); high risk perception (feeling that the coronavirus is spreading rapidly, being concerned about non-mask wearers), and adherence to other preventive measures against COVID-19, such as staying at home. Adequate knowledge, attitudes and risk perception are determinants of 3W compliance. Developing effective health education programs and frequent communication strategies are necessary, particularly for those who adhere less to preventive measures.S

Association Between Pandemic Fatigue and Disease Knowledge, Attitudes, Concerns, and Vaccination Intention at Two Key Moments of the COVID-19 Pandemic

Objective: This study aimed to describe the change in knowledge, attitudes, concerns, perceptions, preventive practices, and vaccination intention at two key time points of the COVID-19 pandemic and to assess whether these changes varied by level of pandemic fatigue. Methods: Data included in this study came from the third and the ninth round of the COSMO-Spain cross-sectional study. A general linear model was used to investigate the interaction terms between rounds and levels of pandemic fatigue. Results: Changes between rounds were observed in knowledge, attitudes, concerns, perceptions, behaviours, and vaccination intention. Significant interactions between rounds indicated that those with low levels of pandemic fatigue had a greater increase in knowledge, lower decrease in concerns, greater decrease in agreement with the decisions made, and lower increase in vaccination intention compared with those with high pandemic fatigue. Conclusion: As a pandemic evolves, it becomes necessary to consider the level of pandemic fatigue of the population and how this affects knowledge, concerns, and agreement with the measures adopted, as they influence the population's adherence to public health recommendations aimed at controlling infections and protecting the most vulnerable.The research was funded by the Carlos III Health Institute. The funder had no role in the study design, the collection, analysis, and interpretation of data, writing of the paper, and/or decision to submit for publication.S