Results
A total of 1227 participants (including 758 adults and 469 adolescents) completed the survey questionnaire. Among this sample, the average age was 34(12) years and 15(2) years for adults and adolescents respectively. There was almost an equal proportion of males and females (adults: [376 male and 382 females]; adolescents: [233 boys and 236 girls]). Similarly, a comparable number of adults and adolescents participated in the survey from each of the 5 districts (Table 1 ).
Comparison of Mean Knowledge score by demographic characteristics of participants are presented in Table 1 . Overall there was no significant difference in Mean score between adults and adolescents (13.78 (4.00), 13.55 (3.72) respectively, p = 0.3). Comparisons within the subgroups of adults showed that the Mean score of males 14.42 (3.89) was significantly higher than that of the females 13.16 (4.00) p <0.001. Adult participants with any formal education had more knowledge compared to those who had no formal education 14.92 (3.84) and 13.04 (3.93) respectively, p <0.001). In contrast, both male and female adolescents had similar mean knowledge score (p=0.06). However, adolescents who had any formal education had significantly better knowledge score than the counterparts (p<0.001).
A one way between groups ANOVA was performed to compare the impact of ‘district of residence’ on ‘Mean Knowledge score’ (Table 1 ). Participants were divided into 5 groups according to the district where the participants lived. There was statistically significant difference in the knowledge score amongst the districts in both adults (p<0.001) and adolescents (p=0.001). The magnitude of the difference in the mean score was, however, small. Amongst adults, post hoc comparisons using the Tukey HSD test indicated that the mean score for districts NWTD 15.08 (3.26) and SWTD 15.03 (3.64) were not statistically different from each other, though, these were significantly higher than the mean score of districts Khyber 13.03 (3.46) Kurram 12.36 (4.59) and Orakzai 13.67 (4.18). The mean scores of districts Khyber, Kurram and Orakzai were alike. Amongst adolescents, participants from district NWTD had significantly higher score 13.86 (3.64) compared to all other 4 districts, which had similar scores 12.73 (3.05), 13.05 (4.68), 13 (3.78), 13.86 (3.64) for district Khyber, Kurram, Orakzai and SWTD respectively.
Table 2, 3 and 4 present the gender stratified response of participants (adults and adolescents) for various questions used for assessing the knowledge for COVID 19. Overall, 98 % of the study participants knew about COVID 19. Most of the adult and adolescent participants identified fever (63%) and cough (65%) as the symptoms of COVID 19 (Table 2 ). Another 44% of participants identified sore throat while headache and difficulty in breathing was identified by 32% and 25% of the participants, respectively. Around 8% of participants knew about other symptoms, like gastrointestinal tract symptoms, loss of taste and loss of smell. On average around 71% of the total participants recognized handshake as a mode of transmission (Table 2 ) of COVID19 while the proportion of participants who knew about cough, air borne transmission and overcrowding were 49%, 30% and 18% respectively. When asked about the treatment options for COVID 19, 68% opted for consulting a doctor, 26% for self-cure, 23% for home remedies while 7% for spiritual healers. Around 7% of participants did not know about the treatment (Table 3 ). Typically, 92% participants acknowledged COVID 19 as a preventable infection while 8% thought otherwise. Of those who knew it is preventable, 64% identified hand washing as a method for preventing the infection, 57% identified home stay whereas social distancing and avoiding handshake was identified by 37% of participants as an approach for preventing COVID 19. Approximately, 14% were of view that eating healthy can prevent the infection (Table 3 ). 79% respondents knew that test is available for its diagnosis. Among those who knew, 55% were adults and 45% adolescents, 51% males and 49% females. Amongst both adults and adolescents, main source of information was radio (54%). The proportion of participants who recognized television, health workers, relatives, social media and newspaper as sources of information about COVID 19 were 30%, 29%, 26%, 18% and 7% respectively. Only 4% referred to displayed material (Table 4 ). Knowledge of participants significantly differed across genders amongst both adults and adolescents (Tables 2, 3 and 4 ).
Multiple linear regression analysis, adjusted for demographic variables with Knowledge score as the outcome (Table 5 ), showed that age (β[SE]: 0.03[0.01], P=0.001), formal school education (vs. no education, β[SE]: 1.90[0.27], P<0.001) and belonging to district NWTD and SWTD (vs. the reference district Khyber β[SE]: 2.00 [0.42], p<0.001 and 2.13 [0.42], p<0.001, respectively), were significantly associated with higher knowledge score. Similar results were obtained amongst both adults and adolescents. However, the relationship between age and knowledge score was not significant in adults after adjusting for other demographic variables (Table 5 ).
Multiple logistic regression analysis (Table 6 ) found that female gender (vs. male, OR[95% CI]: 0.43[0.25-0.73], p = 0.002), formal school education (vs. no education, OR[95% CI]: 2.99[1.68-5.30],p<0.001), and belonging to district Kurram, Orakzai and SWTD (vs. the reference district Khyber, OR[95% CI]: 0.04[0.01-0.17, p<0.001; 0.08[0.02-0.36], p=0.001; 0.64[0.01-0.27], p<0.001, respectively) had greater odds of believing that COVID 19 is preventable. Analysis stratified for adults and adolescents showed similar results. Though, there was no significant association between the attitude regarding the preventable nature of COVID 19 and gender in adults and with place of residence in adolescents (Table 6 ).