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ORIGINAL ARTICLE
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Knowledge, attitude, and practice regarding COVID-19 among general population


1 Department of General Medicine, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
2 Department of Community Medicine, USM KLE International Medical Programme, Belagavi, Karnataka, India

Date of Submission14-May-2020
Date of Decision07-Aug-2020
Date of Acceptance21-Sep-2020

Correspondence Address:
Jayaprakash Appajigol,
Department of Medicine, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Nehru Nagar, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_257_20

  Abstract 


Context: The war against coronavirus disease-2019 (COVID-19) continuing. Prevention is the best method to deal with the disease. The success of preventive measures is influenced by behavior of the population which in turn depends on knowledge, attitude, and practices (KAP) of the community. Aims: The aim is to evaluate knowledge, attitude, and practices toward COVID-19 of general population who are using internet. Settings and Design: Cross-sectional study in general population using Google Forms. Methods: The KAP questionnaire previously used in Chinese study adopted here after modifying for content and cultural appropriateness. The questionnaire included the following domains: (i) demographic information, (ii) knowledge about COVID-19, (iii) attitude toward COVID-19, and (iv) preventive practices. The questionnaire was circulated through social media to general population through Google forms. Statistical Analysis Used: Chi-square test for association, independent t-test for comparison of two groups, one-way ANOVA for comparison of more than two groups. The statistical significance was set at 5%. Results: A total of 2193 participants took part in the study. Most of our participants were well educated and were either postgraduates or graduates 1913 (87.23%). The mean knowledge score of the participants was 10.36 (standard deviation: 1.27, median: 11.00). Most of the participants avoided crowded places, washed hands repeatedly, did not shake hands with any one. Majority of the participants were not taking any prophylaxis medications. Conclusions: The population has very good KAP about the disease which is helpful for preventive measures. This may be the reason for better control of the disease till now.

Keywords: Attitude, COVID-19, knowledge, practices



How to cite this URL:
Poddar A, Gogate A, Francis Kumbar AS, Francis Cordeiro KS, Appajigol J, Javali SB. Knowledge, attitude, and practice regarding COVID-19 among general population. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=321945




  Introduction Top


A history has witnessed number of pandemics such as cholera, plague, small pox, and influenza. Among them, Spanish flue was the most devastating pandemic, where one-third of world population suffered from disease and about 50 million people lost lives.[1] The most recent one being the one we are experiencing now, the novel coronavirus disease (COVID-19), caused by severe acute respiratory syndrome-related coronavirus (SARS-CoV-2) virus. Human coronavirus is one of the main pathogens to cause respiratory infection. The two highly pathogenic viruses, SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), caused severe respiratory syndrome in humans. The mortality of SARS-CoV was more than 10% and MERS-CoV was more than 35%. COVID-19 is a respiratory disease that is caused by a novel virus SARS-CoV-2. It was first detected in December 2019 in Wuhan, China. COVID-19 is a highly infectious disease, and its main clinical symptoms include fever, cough, fatigue, myalgia, and dyspnea. Early data have shown case mortality rate around 3.3% in China.[2] Soon after that, the virus spread to other countries and continents. The United States of America and Europe have become the epicenters of the disease. The case fatality rate has been higher in an Italian study as compared to a Chinese study with 7.2% deaths. Higher fatality rates are seen among the elderly and patients with comorbidities. On January 30, 2020, the World Health Organization declared it as a public health emergency of international concern.[3],[4] As the war against COVID-19 continues, every day the number of new cases infected with this virus is rising and is spreading to new countries. There is no proven vaccine or antiviral drug available to treat the disease. Therefore, prevention is the best method to deal with this disease. The success of preventive measures is influenced by the behavior of the population which in turn depends on the knowledge, attitude, and practices (KAP) of the community. In this study, we have investigated the KAP toward COVID-19 of the general population.


  Methods Top


It was an internet and smartphone-dependent survey done using Google Forms. Data were collected on participant's knowledge, attitudes, and practices regarding COVID-19 using a Google form which was a predesigned and pretested questionnaire. The KAP questionnaire previously used in China was adapted for our study.[5] The questionnaire was modified for content, wording, and cultural appropriateness. The questionnaire included the following domains: (i) demographic information; (ii) knowledge about COVID-19 symptoms, signs, and mode of transmission; (iii) attitude toward COVID-19 and various disease control measures; and (iv) preventive practices. The questionnaire was validated by a focus group discussion. This questionnaire along with the consent to participate in the survey was translated in the regional language and circulated through social media applications. The study was conducted during the period of a national lockdown to prevent the spread of COVID-19. During this period, it was not possible to approach the study participants for physical interviews, therefore an internet and a smartphone-based survey was chosen.

Data analysis

The collected data were entered into Microsoft Excel 2007 and analyzed using the software SPSS. The following statistical procedures were applied. Chi-square test used for association, independent t-test for comparison of two groups, one-way ANOVA was applied for comparison of more than two groups, Karl Pearson's correlation for relationship between two variables and a multiple linear regression model was applied to assess the combined effect of independent variables on dependent variable. The statistical significance was set at 5% level of significance (P < 0.05).


  Results Top


A total of 2193 participants took part in the study. The survey was open from March 28, 2020 to April 7, 2020. Among these participants, 1215 (55.40%) were male and 978 (44.60%) were female. Place of residence of the participants varied all over India. Participants from Belagavi were 832 (37.94%) compared to non-Belagavi residents 1361 (62.06%). Majority of the participants were unmarried 1144 (52.17) compared to married participants 967 (44.09%). Some of the participants did not disclose their marital status 82 (3.74%). Our study participants were relatively young. The age group from 20 years to 30 years constituted 1247 (56.86%) participants. The same is depicted in [Table 1]. Most of our participants were well educated and were either postgraduates or graduates 1913 (87.23%) [Table 2].
Table 1: Frequencies of Age Groups

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Table 2: Education Qualification

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There were 12 questions to assess the knowledge of the participants toward COVID-19. Each correct answer was given one mark and for a wrong answer zero mark. The mean knowledge score of the participants was 10.36 (standard deviation [SD]:1.27, median: 11.00). There were 1123 (51.21%) participants who had a knowledge score more than the mean knowledge score of the study participants. We arbitrarily defined a knowledge score of 9 or more (which corresponds to 70% or more correct answers) as a higher score and got 2040 (93.02%) participants having higher knowledge scores. Knowledge questions and frequency of correct responses are shown in [Table 3]. Comparison of demographic profile of participants with mean knowledge scores by one-way ANOVA showed that the females had significant higher scores as compared to males (t = −2.0819, P < 0.05) [Table 4]. Multiple linear regression analysis showed that the combined effect of sex is found to be positive and significant on knowledge scores. In other words, the sex and marital status are significant predictors of knowledge scores [Table 5]. Women were more likely to have higher knowledge scores than men (χ2 (1, n = 2193) =5.06, P = 0.02).
Table 3: Knowledge related questions with frequency of correct responses

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Table 4: Comparison of demographic profile of participants with mean knowledge scores by one way ANOVA

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Table 5: Multiple linear regression analysis of knowledge scores as dependent variables

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Attitude toward the disease was assessed by two questions. Majority of them expressed a positive attitude. Most of the participants agreed that social distancing is an effective way to fight COVID-19 (2112, 96.31%). Majority of participants (1547, 70.54%) agreed that our country will finally be successful in controlling COVID-19. There is a significant association between attitudes and knowledge scores. Participants who agreed that social distancing is an effective way to fight COVID-19, are more likely to have higher knowledge scores than those who did not agree (χ2 (1, n = 2193) =6.76, P = 0.01). In addition, the participants who agreed that, COVID-19 will finally be successfully controlled in India, are more likely to have higher knowledge scores than those who did not agree (χ2 (2, n = 2193) =18, P < 0.01).

Most participants avoided crowded places. Only 163 (7.43%) of the respondents went to crowded places and most of them (1773, 80.85%) wore masks while going out [Table 6]. Participants with higher educational qualifications, unmarried participants and participants with higher knowledge scores used masks significantly more often (P < 0.05). Gender did not have an effect. Younger age group participants wore masks more often as compared to older age group participants (P < 0.05%). Most of the participants washed their hands repeatedly. Around 73% (1604) of the participants washed their hands at least 6 times a day. Marital status, gender, and educational qualifications had a significant effect on the frequency of hand washing. Married participants, females, and participants with higher educational qualification washed their hands more often. Knowledge score did not have a significant effect on this practice. Vast majority of them (1697, 77.38%) did not shake hands with anyone during the previous 1 week duration. Marital status, gender, and educational qualifications had a significant effect on the frequency of shaking hands. Males, unmarried, and participants with higher educational qualifications practiced shaking hands less often. Knowledge score did not have a significant effect on this practice. While sneezing or coughing most of them (1221, 55.68%) covered their face and nose. Marital status and gender had a significant effect on the frequency of sneezing or coughing without covering their face and nose. Married individuals and females less often sneezed or coughed without covering their nose and mouth. Knowledge score did not have an effect on this practice. Most of them maintained social distancing. Majority of the participants rarely failed to maintain social distancing of one meter in a week. Approximately 77% (1695) of the participants never failed or rarely failed to maintain social distancing in the past 1 week. Males and unmarried individuals failed to maintain a distance of one meter, more often as compared to females and married participants, respectively. Majority of the participants were not taking any prophylactic medication to prevent COVID-19. The number of participants taking prophylactic medications was 122 (5.56%). Most commonly used medication was hydroxychloroquine (74, 3.37%). More unmarried participants used prophylaxis to prevent the disease as compared to the married participants.
Table 6: Practices Questionnaire and responses

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  Discussions Top


The novel corona virus, SARS-CoV-2 is spreading relentlessly worldwide. It is causing more damage in the western world compared to India. To date, it has infected 2,883,603 people and caused 1,98,842 deaths.[6] Number of new cases and deaths in India are increasing day by day. The Government of India announced a complete lock down from March 24, 2020, to prevent the spread of the disease. Currently, there is no vaccine available for the prevention of this disease. Therefore, we need to depend on general infection preventive measures. Along with the World Health Organization, many government and nongovernment organizations are circulating general infection prevention advices through various mediums of communication. KAP of the general population is critical for the implementation of these general infection prevention measures. This survey has been conducted during the period of lock down announced by the Government of India, and to the best of our knowledge, it is the first KAP assessment survey about COVID-19 in the country.

The knowledge of the respondents was excellent. Most of them recognized common symptoms of the disease (89.69%), seriousness of the disease when associated with comorbidities (78.80%), mode of transmission (93.71%), common preventive measures such as isolation (98.50%), avoiding crowded places (98.86%), and usefulness of masks (58.46%). Majority of our participants were better educated and the knowledge scores were better in women than in men. Higher knowledge scores may be attributed to better educational qualifications of participants. This was an internet- and smartphone-based survey. Hence, many of the participants who use internet and smartphones also have good access to electronic news and news from social media. Therefore, better knowledge might also be attributable to access to smartphones and internet. The mean knowledge score was 10.36 (SD: 1.27) in our study. It is comparable to the study done in Wuhan, China, where the mean knowledge score was 10.8 (SD: 1.6). Their study has also attributed higher knowledge score to better educational qualifications of the participants.[5] A study conducted in the bordered population of northern Thailand revealed poor knowledge about this disease. Participants as high as 73.4% had poor knowledge about disease prevention. This may be because of the participant's characteristics such as rural, poor, and less educated people.[7] In a study conducted in the United States and the United Kingdom, the participants were more educated, economically better and of white ethnicity. Majority of the United States (79.8%) and United Kingdom (84.6%) participants recognized the symptoms of COVID-19 correctly. General infection preventive measures like, avoiding close contact with sick people, hand washing, avoiding touching eyes, nose, and mouth with unwashed hands were well recognized by both the United States (92.6%) and United Kingdom (86.0%) participants. Mode of transmission of the virus was also correctly understood by most of the United States (74.8%) and United Kingdom (81.2%) participants. Effectiveness of using face mask was not well supported by both the United States (37.8%) and United Kingdom (29.7%) participants.[8]

Social distancing is an important behavioral change. The World Health Organization has advised to maintain at least 1 meter (3 feet) distance with anyone who is coughing or sneezing.[6] Studies have shown social distancing is effective in controlling the outbreaks.[9] Participants of our study showed a positive attitude toward social distancing. Better knowledge about the disease, influenced positive attitude toward social distancing. Majority of the participants also have the attitude and confidence that COVID-19 will finally be eliminated from our country. This attitude is positively associated with better knowledge score.

The practices of our participants towards the COVID-19 were favorable. Most of them did not visit crowded places, wore mask most of time, washed hands frequently, did not shake hands, did not sneeze or cough without covering their nose and mouth and maintained a distance of one meter most of times. Most of them were not taking any medications for prophylaxis against COVID-2019. The WHO recommends the use of masks if a person is taking care of a COVID-19 patient or if he himself is experiencing flu-like symptoms. Further, masks are effective only when used along with repeated handwashing with alcohol-based hand rub or soap and water.[6] Centers for Disease Control and Prevention (CDC) recommends the use of cloth face masks in public places such as grocery and medical stores, where social distancing methods are difficult to adopt.[10] In this study, we did not assess the correct technique of wearing and disposing of face masks. Most of our study participants practiced wearing masks while leaving home. Repeated hand washing has been recommended by the WHO. Furthermore, it is an established fact that repeated hand washing reduces respiratory illnesses in the general population by about 16%–21%.[11] Majority of our study participants washed their hands frequently. Most of them avoided the shaking of hands. CDC recommends avoiding shaking hands to prevent the spread of the virus and transmission of the disease.

There is an ongoing controversy over the use of prophylactic medications to prevent the COVID-19 infection. Most of the study participants were not taking hydroxychloroquine or any other medications as a prophylaxis. The Indian Council of Medical Research recommends use of oral hydroxychloroquine to prevent the disease in high risk individuals only after advice from a qualified doctor.[12] Interestingly, some of the participants were using nonallopathic medications as prophylaxis.

Major strengths of our study include a large population and its execution during the critical period of a nationwide lockdown. Being an internet and smartphone based survey, the study participants may not represent the general population. This study did not involve the illiterate and people of low socioeconomic class who did not have access to internet and smartphones. This study also over represents well educated and younger age group of the population. We did not include questions regarding loss of smell and taste, because these were not the established symptoms during the period when we were conducting the study. On the contrary, during this period of lockdown, internet and smartphone-based survey was the only safest way to conduct this survey. Further studies are required incorporating rural, lower socioeconomical, and less educated individuals to understand their needs and to plan appropriate health education methods for them.


  Conclusions Top


The population has a very good KAP about the disease which is helpful for effective implementation of preventive measures. This may be the reason for better control of the disease in India till now. The positive attitude of the participants toward the ultimate control of COVID-19 in India can play a major factor in this long battle against this viral disease. In a period of a nationwide lockdown, this study further enforces the importance of online campaigns and awareness to further strengthen knowledge about COVID-19 and maintain the general public's attitude toward a positive outcome of this pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jester B, Uyeki TM, Jernigan DB, Tumpey TM. Historical and clinical aspects of the 1918 H1N1 pandemic in the United States. Virology 2019;527:32-7.  Back to cited text no. 1
    
2.
Park M, Thwaites RS, Openshaw PJM. COVID-19: Lessons from SARS and MERS. Eur J Immunol 2020;50:308-11.  Back to cited text no. 2
    
3.
Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA 2020;323:1335. [Doi: 10.1001/jama. 2020.4344].  Back to cited text no. 3
    
4.
Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV). Available from: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting- of-the-international-health-regulations-(2005)-emergency- committee-regarding-the-outbreak-of-novel- coronavirus-(2019-ncov). [Last accessed on 2020 Apr 19].  Back to cited text no. 4
    
5.
Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci 2020;16:1745-52.  Back to cited text no. 5
    
6.
Advice for Public. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public. [Last accessed on 2020 Apr 22].  Back to cited text no. 6
    
7.
Srichan P, Apidechkul T, Tamornpark R, Yeemard F, Khunthason S, Kitchanapaiboon S, et al. Knowledge, attitude and preparedness to respond to the 2019 novel coronavirus (COVID-19) among the bordered population of Northern Thailand in the early period of the outbreak: A cross-sectional study. SSRN Electron J 2020. Available from: https://www.ssrn.com/abstract=3546046. [Last accessed on 2020 Apr 23].  Back to cited text no. 7
    
8.
Geldsetzer P. Knowledge and perceptions of COVID-19 among the general public in the United States and the United Kingdom: A cross-sectional online survey. Ann Intern Med 2020;173:157-160. [Epub ahead of print 20 March 2020]. Doi: 10.7326/M20-0912.  Back to cited text no. 8
    
9.
Shim E, Tariq A, Choi W, Lee Y, Chowell G. Transmission potential and severity of COVID-19 in South Korea. Int J Infect Dis 2020;93:339-44.  Back to cited text no. 9
    
10.
CDC. Coronavirus Disease 2019 (COVID-19)-Interim Guidance for Businesses and Employers. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html. [Last accessed on 2020 Apr 18].  Back to cited text no. 10
    
11.
When and How to Wash Your Hands | Handwashing | CDC; 2020. Available from: https://www.cdc.gov/handwashing/when-how-handwashing.html. [Last accessed on 2020 Apr 17].  Back to cited text no. 11
    
12.
COVID-19 | Indian Council of Medical Research | Government of India; 2020. Available from: https://www.icmr.nic.in/node/39071. [Last accessed on 2020 Mar 30].  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

 
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