This is a descriptive cross-sectional, partially mixed method explanatory sequential
study, following the Good Reporting of A Mixed Methods Study (GRAMMS) guideline. This
study concentrated on the KAP of patients with MS, healthcare professionals and lay
people. The aim was to explain the quantitative survey results with qualitative themes in
an explanatory sequential design. The goal of the quantitative phase was to examine the
COVID-19-related knowledge, attitudes, and practices among healthcare professionals,
laypeople, and patients with multiple sclerosis (MS) during the first 6 months of the
pandemic and to compare the perceived risk of coronavirus infection across these three
groups. The goal of the qualitative phase of this study was to identify and analyze the
emergent themes reflecting participants' perceptions of their risk related to COVID-19.
The goal of the mixed methods phase was to generate integrated support for the
participants knowledge, attitudes, practices, and perceived risk based upon quantitative
and qualitative evidence.

Theoretical Framework. The knowledge-attitude-behavior (KAB) model considers that
knowledge and information gained are fundamental prerequisite for behavioral changes.
People are able to gain knowledge and practical skills through education. Accordingly,
professionals, laypeople, and patients need to learn and get basic and advanced
knowledge, which can lead to the growth of positive beliefs and attitudes that are
fortified with the acceptance of healthy behaviors (Liu et al., 2016; Zulkifli et al.,
2022). Furthermore, the KAB framework highlights the relationship between knowledge,
attitudes and behaviors and their influence on actions (Maleki et al., 2020).

Instruments. The KAP questionnaire consisted of a demographic form, and a KAP
questionnaire. The prequestionnaire solicited basic demographic information such as the
participant's age, gender, education level, and patients' disease related information.
The KAP instrument was adapted from the CDC (CDC; CDC Center for Disease Control; Maike
WintersComments to Author 2017) and used with permission. The KAP survey instrument has
been used nationally and internationally to explore people's health behaviors and their
lifestyle changes (Azlan et al., 2020; CDC; Masoud et al., 2021; Qalati et al., 2023;
Zhong et al., 2020). The survey included 50 close-ended questions that took 20-25 minutes
to complete. It covered demographics (10 items), COVID-19 knowledge (15 items), attitudes
(17 items), and practices (8 items). True/false questions had "I don't know" and
"declined to answer" options, with responses categorized as correct or incorrect (Seninde
& Chambers, 2021; Smyth et al., 2006). Open-ended questions were analyzed to assess the
participants' perceptions qualitatively.

Perceived risk for contracting COVID-19 was assessed using a 5-point scale (0=no risk at
all, 1=a small risk, 2=a moderate risk, 3=a high risk, 4=Don't know). Perceived risk of
COVID was assessed as a categorical variable. It was analyzed as dichotomous variable
(low risk vs. moderate/high risk) and as 4-categorical variable (low risk, moderate risk,
high risk and don't know). Perceived risk was assessed and analyzed in each group,
patients with MS, healthcare professionals and lay people.

Data Collection. The population for this study included healthcare professionals (nurses
and physicians), patients with MS, and lay people from the northeast region in the USA.
It included participants from New York, Connecticut and Massachusetts. A convenience
sampling approach was used to enhance recruitment. The participants were recruited via
blast emails through health centers, MS centers, and community resources. Data were
collected via an online self-reported questionnaire from April 2020 to September 2020.
The surveys were completed online via anonymous and confidential software, i.e., a
'Monkey' survey. The inclusion criteria of the study included adult people (≥18 years),
consisting of patients with MS, healthcare professionals (nurses and physicians), and
adult lay people. The project did not include any exclusion criteria.

Data Analysis. Descriptive analyses were used to characterize the sample. Chi-square and
Kruskal Wallis tests assessed associations between demographics, KAPs, and perceived
risk. Kruskal Wallis test compared KAP across patients with MS, healthcare professionals,
and laypeople. Logistic regression assessed the perceived risk as a dependent
dichotomized variable (low and moderate/high risk), immunocompromised state or
vaccination hesitancy as independent variables controlling for age, sex, and education.
Statistical significance was set at p<.05. A qualitative thematic analysis was performed
and coded on participants' comments by two researchers (AB and JS) to identify key themes
reaching data saturation.