**Background:** The COVID-19 pandemic has posed unprecedented public health challenges globally. By mid-December 2022, over 640 million cases and 6 million deaths were reported worldwide. In China, despite achieving regular prevention and control, sporadic outbreaks continued. Public adherence to preventive measures is critical, and this adherence is influenced by knowledge, attitudes, practices (KAP), and risk perceptions. This study aimed to assess these factors among Chinese residents 1.5 years after the pandemic began, providing evidence for future epidemic control and health education.
**Methods:** A descriptive cross-sectional study was conducted in Henan and Zhejiang provinces, China, in October 2021. Data were collected via online and paper questionnaires administered by trained graduate students, clinicians, and researchers. The minimum required sample size was 422 (calculated with 50% proportion, 95% CI, 5% margin of error, 10% nonresponse rate). The questionnaire covered demographics, 15 knowledge items (yes/no), 10 attitude items (5-point Likert scale), 2 risk perception questions (yes/no), and practice items. Cronbach's alpha was acceptable. Covariates included age, sex, education, retirement status, COVID-19 diagnosis among self/friends/family, and vaccination status. Binary multivariable logistic regression was used to identify factors associated with risk perception and KAP levels. A score ≤ P50 for knowledge, attitudes, and practices was defined as a positive event (poor KAP). Statistical significance was set at P<0.05. Analyses were performed using SAS 9.4.
**Key Results:** A total of 3,588 participants responded. Mean age was 53.49±18.88 years; 44.7% were male; 52.03% had high school or above education; 59.69% were non-retired; 96.17% were vaccinated; 0.89% reported a COVID-19 diagnosis in self/friends/family. Median knowledge score was 10 (IQR 9-12), attitude score 45 (IQR 38-46), practice score 9 (IQR 8-9). Over 90% answered most knowledge items correctly, except for transmission via domestic animals (53.82% correct) and antibiotics as treatment (56.43% correct). About 90.92% agreed COVID-19 is severe, 92.06% believed it can be prevented, and over 90% expressed confidence in government measures. For practices, >90% correctly identified hand washing, mask use, and social distancing, but 74.41% incorrectly thought washing nose with salty solution is preventive. Regarding risk perception, 59.9% feared contracting COVID-19, but only 18.63% felt more susceptible than others. Common reasons for fear included high transmissibility (88.64%) and potential fatality (80.30%). For perceived susceptibility, top reasons were new disease with limited data (60.66%) and lack of PPE availability (56.48%).
Multivariable logistic regression showed that age ≤45 years (adjusted OR=1.464, 95% CI 1.196-1.794, P=0.0002), female sex (adjusted OR=1.224, 95% CI 1.063-1.408, P=0.0048), and higher education (junior high: adjusted OR=1.885, 95% CI 1.486-2.315, P<0.0001; high school or above: adjusted OR=1.730, 95% CI 1.422-2.104, P<0.0001) were associated with greater fear of contracting COVID-19. Not being vaccinated (adjusted OR=0.563, 95% CI 0.395-0.802, P=0.0015) and high attitude score (adjusted OR=0.495, 95% CI 0.430-0.570, P<0.0001) were associated with reduced fear. For perceived higher susceptibility, predictors included age ≤45 years (adjusted OR=2.019, 95% CI 1.587-2.569, P<0.0001), high school or above education (adjusted OR=1.503, 95% CI 1.187-1.904, P=0.0007), non-retired status (adjusted OR=1.679, 95% CI 1.354-2.083, P<0.0001), and high knowledge score (adjusted OR=1.554, 95% CI 1.298-1.862, P<0.0001). High attitude score was associated with lower perceived susceptibility (adjusted OR=0.616, 95% CI 0.517-0.734, P<0.0001).
In the fully adjusted model for KAP, high school education or above, non-retired status, and not perceiving oneself as more susceptible were associated with higher knowledge level. Younger age (≤45 years) was associated with higher attitude score, while high school education or above, non-retired status, not fearing contracting, and not perceiving oneself as more susceptible were associated with lower attitude score. Non-retired status, not being vaccinated, and not fearing contracting were associated with lower practice level, while not feeling susceptible was associated with higher practice level.
**Clinical Implications:** The study demonstrates that 1.5 years into the pandemic, Chinese residents maintained high levels of knowledge, positive attitudes, and good practices regarding COVID-19, with strong trust in government and vaccines. However, gaps remain in understanding transmission via animals and antibiotic use. Younger, more educated, and non-retired individuals had higher risk perception but lower practice scores, suggesting that workplace-based interventions (e.g., remote work, ventilation, staggered shifts) are needed for this group. Older adults and those with chronic diseases should be prioritized in outbreak responses. Health education campaigns should address specific knowledge gaps and aim to sustain optimistic attitudes and safe practices.