Introduction

The coronavirus disease 2019 or well-known as COVID-19, is a newly virus discovered at the end of December 2019, which was first originated in Wuhan, China1,2. The World Health Organization (WHO) has been declared COVID-19 as a global pandemic since it has been spread throughout the world3,4. To date, over 772 million confirmed COVID-19 cases have been reported, and at least 6.9 million deaths recorded globally as a result of this pandemic5.

On January 24, 2020, the first confirmed cases of COVID-19 in Malaysia were identified involving three Chinese tourists6. As of 9th December 2023, Malaysia has recorded more than 5.1 million positive COVID-19 cases involving more than 37.2 thousand deaths7. On March 18, 2020, the Malaysian government announced a Movement Control Order (MCO) with a strict Standard Operating Procedure (SOP) as an initiative to prevent the spread of COVID-19 infection to the community. Additionally, the Malaysian government also actively uses media platforms to give information about the development of COVID-19 infection to the public8.

The indigenous people of Peninsular Malaysia, well-known as Orang Asli, are a minority community that has lagged in terms of socioeconomic status, health, and education. Since the indigenous population is considered as one of the important marginalized populations in Malaysia, it is crucial to investigate their knowledge, attitude, and practice (KAP) towards COVID-19 prevention. Moreover, the indigenous community is also considered vulnerable and have a high risk of being infected with the COVID-19 epidemic9. Based on Rosnon et al. (2022), the findings of their study revealed that the level of awareness and practice of COVID-19 prevention among the indigenous elderly in Peninsular Malaysia was still at the very surface level, and lack of practicing precaution measures10.

On the other hand, a survey conducted among indigenous people in the Brazilian, Peruvian, and Ecuadorian Amazon showed that the level of implementation of prevention practices of COVID-19 was at the bottom level in the community11. Moreover, a group of indigenous people in Malaysia took the pandemic seriously and took proactive actions to keep their community safe. These actions included performing rituals and prayers for health maintenance, building barricades to control movement into their villages, and retreating into the forest12,13. Similar actions have also been seen in other indigenous people in other countries, such as in the Mexico and United States14,15.

Better knowledge, attitude, and practice related to COVID-19 infections could assist the indigenous community to fight against COVID-19 if only the community is given access to resources and services that allow them to take immediate action. Previous experiences with infectious disease outbreaks including those caused by the H1N1, HIV, Zika virus, and SARS have shown that myths and misinformation were also prevalent, making it more challenging for the authorities to implement containment and mitigation strategies16. Misconceptions concerning the disease during the Ebola outbreak in Guinea and Nigeria resulted in a lack of preventive behavior, mistrust, and threats to healthcare professionals17.

Similarly, in order to raise awareness regarding COVID-19 prevention, spread, and treatment among particular population clusters, a locale-specific strategy is imperative18. This is only achievable if it is known whether the community is willing to adopt the behaviors and precautions that health authorities have recommended19. So far, there have been limited studies examining the KAPs towards COVID-19 prevention, especially among the indigenous population in Malaysia. In addition, indigenous people has a complex knowledge of health and disease especially when it comes to the COVID-19 pandemic. Therefore, it is important to conduct research to measure the level of knowledge, attitude, and practice towards COVID-19 prevention. The findings of this study are important to help the Malaysian Government implement strategies for pandemic control among the indigenous community in future crises.

Materials and methods

Study design and participants

In this study, a cross-sectional survey with a quantitative approach was conducted on the indigenous population in Lipis District, Pahang, Malaysia, to assess the knowledge, attitude, and practice towards COVID-19 prevention. The representative sample size needed was calculated with a sample size calculator of two proportions cross-sectional study20. The minimum sample required with a 95% confidence level and 80% power was found to be 258. Anticipating 10% incomplete responses, a minimum of 284 participants were considered. However, a total of 300 participants aged 18 years old and above were involved in this study. The participants were selected based on convenience sampling. The study population included all the indigenous adults of the Semai tribe living in the Pos Sinderut settlement in a remote rural area located in the Lipis district, Pahang, Malaysia.

Study setting and sites

Pos Sinderut is an Aboriginal settlement located approximately 90 km from the town of Kuala Lipis, Pahang and 180 km from Kuala Lumpur (Fig. 1). It is comprised of villages lead by “Tok Batin” and consists of approximately 2,600 villagers. These Aborigines originate from the ethnic group of Semai and most of them can speak Malay (the national language) in addition to their own distinct language.

Fig. 1
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Study site.

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Study instrument

The questionnaire was adapted originally from previous studies that have both English and Malay versions21,22. The face validity of the questionnaire was evaluated involving ten indigenous adults to determine if any items were unclear or confusing. The comprehension of every single item was checked to achieve understanding of the targeted participants. Further, the questionnaire was validated among 30 indigenous participants from different settlements in Lipis District, Pahang, Malaysia to assess the construct validity and reliability of the questionnaire.

The construct validity testing for knowledge, attitude, and practice was performed through an analysis of Kaiser–Meyer–Olkin (KMO) and exploratory factor analysis (EFA)23,24. In EFA, factor extraction was performed using principal component analysis (PCA) and varimax rotation. Factors were retained based on Kaiser criteria with eigenvalues > 1. As a result, four items from the KAP questionnaire were removed during the process due to low factor loading (< 0.05). Finally, the internal consistency reliability was determined by calculating the Cronbach coefficient alpha. The reliability analysis for the knowledge, attitude, and practice questionnaires was 0.695, 0.711, and 0.782, respectively. Taber et al. (2018) stated that Cronbach’s Alpha value greater than 0.6 is considered acceptable and indicates good internal consistency25.

The final questionnaire administered in this study consisted of five main sections: 1) socio-demographic section that include age, gender, religion, education level, occupation, and household income.; 2) sources of COVID-19 infections 3) the knowledge regarding COVID-19; 4) attitude towards COVID-19; and 5) practice towards COVID-19 prevention. The survey was offered only in the Malay language since the indigenous population in this study can understand Malay language very well compared to the English language.

To measure the knowledge regarding COVID-19, five items were adapted from the previous study21. This section comprised of five questions regarding general knowledge about COVID-19 prevention with three options for the answers: “Yes”, “No” and “Don’t Know”. Participants with correct answers were given 1 mark, while participants with incorrect answers or do not know answers were given 0 mark. Accordingly, the total score for this section ranged from 0 – 5, in which participants with a higher score indicate a higher knowledge regarding COVID-19. The overall correct response rate of knowledge regarding COVID-19 was calculated (average correct answers/ total questions × 100)22.

To measure the attitude towards COVID-19, eight items were adapted from previous research22. This section comprised of eight questions regarding the attitude towards the prevention measures of COVID-19 with a five-point Likert scale which are “strongly disagree” to “strongly agree” ranging from “1” to “5” marks. Reverse scoring was given to the negative statements. Accordingly, the total score for this section ranged from 8 – 40, in which participants with a higher score indicate a more positive attitude towards COVID-19 prevention. The overall positive attitude towards COVID-19 was calculated (average correct answers/ total questions × 100)22.

To measure the practice of COVID-19 prevention, five items were adapted from previous research21. This section comprised of five questions regarding the practice towards the prevention of COVID-19 disease with four options for the answers: “Every time (3), “Frequent (2)”, “Sometimes (1)” and “Never (0)”. Accordingly, the total score for this section ranged from 0 – 15, in which participants with a higher score indicate a better practice on COVID-19 prevention. The overall good practice of COVID-19 prevention was calculated (average correct answers/ total questions × 100)22.

Data collection

The data was gathered by 10 trained enumerators by face-to-face interviews. The enumerators were fluent in Malay and informed about the background and objectives of the study before the survey was conducted.

Study duration

The study was conducted between 12th August 2023 to 16th August 2023.

Ethical approval and consent to participate

The study was carried out after the protocol was approved by the ethics committee of the Universiti Kebangsaan Malaysia (FF-2023–193). Permission was also obtained from the Department of Orang Asli Development (JAKOA). It was confirmed that all the methods were performed in accordance with the relevant guidelines. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Informed consent was obtained from all the study participants.

Statistical analysis

The collected data in this study were analyzed using the Statistical Package for the Social Sciences (SPSS), version 26.0. Descriptive analysis was presented as frequencies, percentages, and mean ± standard deviation. The bivariable analysis namely independent sample t-test, Pearson correlation, and Spearman rho correlation was used to determine the association between dependent and independent variables. Finally, before multivariable linear regression analysis was performed, several assumptions needed to be fulfilled for the variables tested. Multicollinearity was performed before the final model was selected. The value of the Variance Inflation Factor (VIF) between 1 to 10 and the value of Tolerance above 0.1, indicate that there are no multicollinearity. Multiple linear regression was used to assess the factors influencing the knowledge, attitude, and practice towards COVID-19 prevention. Data analysis for variables that have more than two categories were recategorized into dichotomous variables for bivariable analysis and multivariable analysis in this study. The significance level was set as p ≤ 0.05, two-sided26,27.

Results

Demographic characteristics

A total of 300 participants were involved in this study. Out of the total, the mean age of the participants was 36.18 ± 15.23 years old ranging from 18 to 90 years old. Of this, 53.0% were female, the majority were Christian (78.0%), and 34.7% had a secondary education level. Among all the participants, 48.0% were unemployed and the mean of household income of the participants was RM 158.07 ± 283.75. The details of the demographic characteristics are presented in Table 1.

Table 1 Demographic characteristics of participants (N = 300).
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The main source of COVID-19 information was television (85.7%), followed by government clinics (52.7%), and Tok Batin (village headman) (45.3%). The other sources of COVID-19 information reported by participants were WhatsApp, the Department of Orang Asli Development (JAKOA), radio, Telegram, and newspapers. Figure 2 shows the details of the source of COVID-19 information.

Fig. 2
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Source of COVID-19 information.

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Knowledge regarding COVID-19 among participants

The mean (SD) knowledge score regarding COVID-19 was 2.35 (1.104) ranging from 0 to 4 scores. The overall correct response rate of the knowledge on COVID-19 questions was 47.0% (2.35/5*100), while the range of correct response rates for all participants was between 18.7% to 87.0%. Most participants knew all the signs and symptoms of COVID-19 (71.4%). However, only 18.7% of participants answered correctly when asked that influenza vaccination may prevent COVID-19, and also 18.7% answered correctly when asked about the World Health Organization has declared COVID-19 as a pandemic, respectively. Moreover, 31.7% of the participants answered correctly that the COVID-19 virus that sticks to a surface made of plastic has a life span of up to a few days, followed by the majority of participants (87.0%) answered correctly when asked about Movement Control Order (MCO) may prevent the spread of the COVID-19 outbreak. The details of the responses of the participants to the knowledge questionnaire are shown in Table 2.

Table 2 Knowledge regarding COVID-19. *Indicates yes is the correct answer.
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The differences in mean knowledge scores among different sociodemographic characteristics were analyzed using independent t-tests (Tables 3, 4, 5) and Spearman rho correlation (Table 6). The results showed that the knowledge scores were significantly associated with age and education levels. The knowledge scores were significantly higher with the younger age (p < 0.001). Additionally, higher knowledge scores were obtained among those participants who have primary and secondary education as compared to those without education (p = 0.001) (Table 7).

Table 3 Attitude towards COVID-19. *Refers to negative statements.
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Table 4 Practice towards COVID-19 prevention.
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Table 5 Correlation between knowledge, attitude, and practice scores among participants.
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Table 6 The bivariable analysis of the sociodemographic factors associated with knowledge, attitude, and practice towards COVID-19 prevention. € “Has religion” includes Islam and Christian.
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Table 7 The multivariable linear regression analysis to determine sociodemographic factors influencing knowledge, attitude, and practice towards COVID-19 prevention.
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Attitude of participants towards COVID-19

The mean (SD) attitudes score regarding COVID-19 for participants was 32.84 (4.756) ranging from 19 to 40 scores. The overall positive attitude for the questionnaire was 82.1% (32.84/40*100). The majority of the participants (95.0%) agreed that wearing face masks when going out is important to prevent COVID-19, followed by 94.3% agreed that frequent hand wash with water and soap or hand sanitizer is important to prevent COVID-19, respectively. Moreover, most of the participants (92.0%) agreed that not going to crowded places is important to prevent COVID-19. The details of the responses of the participants to the attitude towards the COVID-19 questionnaire are shown in Table 3.

The bivariable analysis shows that the mean attitude scores were significantly associated with gender and household income (Table 6). The female participants showed a higher attitude score compared to male participants (p = 0.043), meanwhile the higher the household income, the higher the attitude scores of the participants (p = 0.006).

Practice of participants towards COVID-19 prevention

The mean (SD) practice score towards COVID-19 prevention for participants was 9.64 (3.227) ranging from 1 to 15 scores. The overall good practice for the questionnaire was 64.3% (9.64/15*100). Overall, the majority of the participants (85.0%) wear a face mask when having a cough or flu when leaving the house, followed by 82.7% wash their hands with soap and water, respectively. In addition, a greater portion (81.6%) of the participants practice social distancing while in public. However, only 59.4% of the participants avoid participating in mass gatherings every time. The least practiced COVID-19 prevention was clean and disinfect the households using disinfectant (37.7%). The details of the responses of the participants to the practice towards the COVID-19 questionnaire are shown in Table 4.

The bivariable analysis shows that the mean practice scores were significantly associated with age, gender, religion, occupation, and household income (Table 6). The practice scores were significantly higher in younger age participants (p = 0.013), female participants compared to males (p < 0.001), and participants with no religion compared to those with religion (p = 0.026). Additionally, higher practice scores were obtained among participants who were unemployed (p < 0.001) and having higher household income (p = 0.012).

Correlation between knowledge, attitude, and practices towards COVID-19 prevention

Table 5 demonstrates the correlation between the knowledge, attitude, and practice towards COVID-19 prevention among the indigenous population in Lipis district, Pahang, Malaysia. The results showed that the knowledge scores have a weak positive correlation with the attitude scores (r = 0.012, p = 0.830), however, it is not significant. The knowledge scores have a significant weak positive correlation with practice scores, respectively (r = 0.194, p = 0.001). Additionally, the attitude scores showed a moderate positive correlation with practice scores (r = 0.470, p < 0.001) as shown in Table 5.

Factors associated with knowledge, attitude, and practice towards COVID-19 prevention

Table 7 demonstrates the multivariable linear regression analysis on factors associated with knowledge, attitude, and practice towards COVID-19 prevention. Regarding the knowledge scores as the outcome variable, the results showed that only age was significantly associated with knowledge regarding COVID-19. The younger the age of the participants (B = 0.017, p < 0.001), the higher the knowledge scores regarding COVID-19. The results also showed that none of the sociodemographic factors were associated with the attitude scores.

Meanwhile, the regression analysis on practice scores as outcome variable showed that female participants (B = 0.827, p = 0.018) were more likely to have higher practice scores towards COVID-19 prevention compared to male participants. In terms of occupation, unemployed participants (B = 1.205, p = 0.001) had a significantly higher practice scores towards COVID-19 prevention compared to those participants who were employed. Moreover, the higher the knowledge scores (B = 0.550, p < 0.001) and the higher the attitude scores (B = 0.296, p < 0.001) the higher the practice scores among the participants, respectively.

Discussion

The infectious virus known as the coronavirus disease (COVID-19) was recognized as a worldwide pandemic in March 2020 and has been declared as a public health crisis. Indigenous peoples are among the most vulnerable populations around the world, particularly when they are dealing with the COVID-19 pandemic28. Indigenous people are at a higher risk of getting an infection considering that they rarely have access to clean water and basic sanitation supplies like soap and sanitizer28,29. In addition, it is vital to ascertain the community’s preparedness for adopting recommended behavior practices and precautions from health authorities in order to prevent the spread of COVID-19 infection. Therefore, in this study, we assessed the knowledge, attitude, and practice towards COVID-19 prevention among the adult indigenous population in Lipis district, Pahang, Malaysia.

The findings of this study showed that the main sources of COVID-19 information were television, government clinics, and Tok Batin (village headman). A study conducted among the indigenous population in the Republic of Congo revealed that the majority of participants used radio and television as their main source of COVID-19 information during the pandemic30. Compared to a study conducted among the general population in Malaysia, the main source of information regarding COVID-19 was smartphone applications such as WhatsApp and Telegram29. This is similar to a survey conducted in Bhutan where the majority of participants reported television is among the main sources of COVID-19 information31. However, according to Cheng & Cheng (2020), indigenous people may not evaluate information appropriately compared to the urban population32. Therefore, it is vital to strengthen awareness among this at-risk population through exposure to health promotion and accessing information sources.

In the present study, the mean knowledge score among participants was 2.35 (SD 1.104) ranging from 0 to 4 scores with overall correct answer rate of 47.0%, while the range of correct response rates for all participants was between 18.7% to 87.0%. The findings of this study are in line with the study done in central India33, eastern India34, and Bangladesh35, which reported a higher knowledge mean score among the tribal population. However, this finding is in contrast with other studies conducted among indigenous population in Nigeria36 and Peninsular Malaysia10, which reported low knowledge scores among the participants involved. This could be due to inaccurate information regarding COVID-19 and limited access to information such as the internet and social media, making it difficult for these indigenous populations to understand the accurate knowledge regarding COVID-1937.

The mean knowledge scores in this study are significantly higher in younger participants. Previous research conducted in Bhutan31, Saudi Arabia38, and Ethiopia39 also showed that young people were more likely to have higher knowledge scores. This could be due to the fact that, in comparison to older people, younger people have greater exposure and easy access to information on various social media platforms27. On the other hand, participants who have primary and secondary education scored among the highest knowledge scores as compared to participants without formal education in this study. The present study corresponds to a study among indigenous populations in the Republic of Congo that also reported primary education level has a significant association with a higher level of knowledge as compared to participants without formal education30. However, the study conducted among general population in Turkey40, Southeast and South Asia41, and Indonesia42 reported higher knowledge with those participants who have tertiary education. This happened because the dropout of indigenous people from school is high among them due to the geographical factors of indigenous settlement. The indigenous population has a negative view of education in which the parents emphasized their children to be working to continue their lives without thinking about future plans43,44. Therefore, it is suggested that in order to improve the public knowledge of COVID-19 infection, the public health authorities should implement an educational programme for individuals or groups in the community with lower educational levels39,43.

In this study, the mean attitude score for participants was found to be higher at 32.84 (SD 4.756), ranging from 19 to 40 scores with an overall positive attitude of 82.1%. These findings were much higher than the previous study in Northwest Ethiopia39, Southeast and South Asia41, Vietnam45, and Malawi46. However, the current study corresponds to a study done among the indigenous people in Malaysia10 and India47, which reported optimistic mean attitude scores towards COVID-19. This may be the result of the government’s extraordinary measures and immediate implementation of best practices from around the world to ensure their people’s health and safety, as well as ongoing information on COVID-19 updates across various kinds of media platforms27.

Additionally, the current study showed that attitude scores are significantly associated with gender and household income. Female participants were found to have a higher attitude score compared to males. Similar results were found in a study conducted in Bangladesh48, Iran49, and Sudan50 that reported females have a higher attitude score compared to male participants. Meanwhile, this study also showed that the higher the household income, the higher the attitude scores among the participants. This contradicts other research done in Malaysia, in which the attitude scores were not significantly associated with household income51. However, a previous study conducted in Bangladesh found that a higher household income contributed to a lower attitude which could be explained by differences in the country currencies, backgrounds, and periods of the data collection52.

Concerning the practice, our results revealed that the mean practice score towards COVID-19 prevention for participants was 9.64 (3.227) ranging from 1 to 15 scores with overall good practice for the questionnaire was 64.3%. The present study contradicts a study conducted among the indigenous population in Eastern India34 and Northwest Ethiopia27 which showed the mean practice score towards COVID-19 prevention was lower than the present study. However, higher mean scores of practice and higher overall practice were reported among the general population in Malaysia22, Bhutan31, India53, Indonesia54, and Pakistan55. Meanwhile, a lower practice score than the current study was revealed in a study conducted in India56 and Saudi Arabia57.

The findings of this study showed that practice scores are significantly associated with age, gender, religion, occupation, and household income. Younger age was more likely to have higher practice scores compared to older age participants which could be explained by the increased usage of different social media platforms compared to older group58. These findings are in accordance with a study conducted in South India59, which reported younger age was significantly associated with higher practice. However, research conducted among poor and marginalized communities in central India, showed that the older age more than 55 years old have higher practice scores compared to younger age47. Moreover, our results demonstrated female participants were more likely to have higher practice scores compared to male participants. This study is similar to a study conducted in South India59, central Iran60, Saudi Arabia58, China61, and Pakistan62 that reported females have higher practice scores compared to male participants. However, research conducted in Pakistan63 revealed that males are more likely to have higher practice scores compared to females. Additionally, participants in this study who were of no religion, unemployed, and had a higher household income were more likely to have a higher practice score. The previous study done in Pakistan63 and rural areas in India64 revealed that employed and having higher household incomes have higher practice scores among participants.

Multivariable linear regression analysis confirmed that a higher knowledge score on COVID-19 was associated with younger age among the participants. Our result is consistent with a study conducted in rural areas in India64, that younger age had the highest knowledge score. However, these findings contradict the study done in Saudi Arabia65, and the United Arab Emirates66 which reported older age had higher knowledge scores, which is possibly due to a higher perceived risk of acquiring COVID-19 and its complications.

In terms of practice, multivariable linear regression analysis showed that a higher practice score on COVID-19 prevention were influenced by employment status, a higher knowledge score, and a higher attitude score among the participants. This study corresponds to a study among the indigenous population in Thailand which reported the practice of COVID-19 prevention was influenced by employment status67. Unemployed participants had higher practice scores towards COVID-19 prevention. The findings are similar to a study conducted in South India56, which reported unemployed respondents have higher practice scores compared to employed participants. However, the previous study among the indigenous population revealed that the employed participants have higher practice towards COVID-19 prevention compared to the unemployed participants68.

Furthermore, the higher knowledge and the higher attitude scores were associated with the higher scores of practice among the participants in this study. These findings were similar to a study conducted among Indian indigenous people in Eastern India33, the general population in the United Arab Emirates66, and Saudi Arabia65 which reported the higher the knowledge score, the higher the practice of COVID-19 prevention. However, research done among the indigenous people in Ebonyi, Nigeria reported that participants who showed negative attitudes were more likely to have poor preventive practices36. These may be due to wrong information as well as inaccurate communication, especially among the indigenous communities lead to a negative attitude towards COVID-19, thus contributing to poor prevention practices towards COVID-1969. These results emphasized the significance of knowledge in altering behavior, and practice and reinforcing funding for successful educational efforts66.

Overall, the majority of participants in this study showed adequate knowledge levels, positive attitudes, and good practices of COVID-19 prevention. These findings demonstrated that the adult indigenous population in Malaysia had higher positive attitude scores and appropriate practice regarding COVID-19 prevention, which may indicate they have a valuable role to play as role models for the indigenous population for future health crises in Malaysia. Finally, it is imperative that the Ministry of Health in collaboration with its State Health Department, and with support from the Department of Orang Asli Development (JAKOA) and other non-governmental organizations (NGOs), maintain and expand their ongoing efforts towards delivering the information, knowledge, practice prevention, and health campaign regarding COVID-19 infection for the indigenous community across Malaysia (Supplementary information).

Strength and limitation

As far as our concern, this is the first study assessing the knowledge, attitude, and practice towards COVID-19 prevention among the adult indigenous population in Malaysia. Additionally, the result of this study provides significant implications for the Malaysian government and the Department of Orang Asli Development (JAKOA) to strengthen the awareness efforts in the face of the COVID-19 pandemic and other diseases in the future. On top of that, this study contributes to the development of strategies by public health authorities to recognize vulnerable populations, especially indigenous population, as well as enhance their understanding of infectious diseases such as COVID-19.

Meanwhile, this study has a few limitations. First, since the current study was a cross-sectional study and only measures data at a single time point, it is incapable of assessing the changes in KAPs related to COVID-19 over the course of the pandemic. Second, due to social desirability bias, some participants might have failed to provide accurate information in this survey since it was based on their self-reported data, which is not representative of the real situation. Finally, the questionnaire’s administration tended to increase the likelihood and impact of social desirability due to the enumerator being a non-indigenous individual.

Conclusion

In summary, the present study was able to contribute a comprehensive examination of the knowledge, attitude, and practice towards COVID-19 prevention among the adult indigenous population in Malaysia. Overall, the findings of this study demonstrated that indigenous people in Malaysia have adequate knowledge levels, positive attitudes, and good practices of COVID-19 prevention. Our findings also suggested that a higher level of knowledge and attitude scores contributed to higher practice levels of COVID-19 prevention among the indigenous adults in Malaysia. In order to ensure that the standard level of knowledge, attitude, and practice regarding COVID-19 and its preventive measures is achieved, particular measures must be taken especially among Malaysia’s indigenous population. Finally, this study delivers guidance to public health officials and policymakers on how to identify the most vulnerable groups for immediate preventative measures and health education campaigns to prevent future potential health crises.