|Year : 2020 | Volume
| Issue : 2 | Page : 107-115
Knowledge, attitude and practices towards COVID-19 among Indian residents during the pandemic: A cross-sectional online survey
A S Veeramani Kartheek1, K Himavathy Gara2, Dharma Rao Vanamali1
1 Department of General Medicine, Gayatri Vidya Parishad Institute of Healthcare and Medical Technology, Visakhapatnam, Andhra Pradesh, India
2 Department of Physiology, Gayatri Vidya Parishad Institute of Healthcare and Medical Technology, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||19-May-2020|
|Date of Decision||19-Jun-2020|
|Date of Acceptance||02-Jul-2020|
|Date of Web Publication||18-Jul-2020|
Dr. K Himavathy Gara
SF304, VGR Towers, Siddhartha Nagar, BITS Road, Near Last Bus Stop PM Palem, Visakhapatnam, Andhra Pradesh - 530 041
Source of Support: None, Conflict of Interest: None
Background and Aims: Infection prevention and control measures were enforced to contain COVID-19 pandemic. Public adherence to these measures profoundly influences transmission dynamics. The study aimed to evaluate knowledge, attitude and practices (KAP) towards COVID-19 among Indian residents.
Methods: An online semi-structured questionnaire was developed using Google Forms. Total 751 respondents were recruited for the survey based on snowball sampling technique. Survey constituted sequential questions on socio-demographic variables and KAP with a total score of 22. Mean knowledge score was compared among different groups. Regression analyses were used to determine association between various factors and KAP.
Results: Participation was almost equal in both genders with mean age of 27.3 ± 9.5 years. The accuracy rate for responses was 74%. 87.2%, 84.42% and 90.5% participants agreed for adequate control, win against COVID-19 and lockdown being an effective containment method respectively. Though 97.6% respondents agreed about frequent hand washing, only 77.87% confirmed about washing hands ≥20 secs. The adherence to social distancing and lockdown restrictions was confirmed by 97.3% and 97.3%, respectively. 13.18% respondents agreed for Hydroxychloroquine purchase. Higher knowledge score was positively associated with Healthcare workers, upper socio-economic class and adherence to appropriate preventive practices.
Conclusion: Knowledge score had significant association with optimism and adherence. Accuracy rate of 74% reflected inadequate awareness. Around 75% followed hand hygiene guidelines and few (5%) didn't follow lockdown restrictions suggesting gap between information and implementation. For effective containment of the pandemic and adequate protection of our health care system, existing barriers need to be addressed by promoting behavioural changes.
Keywords: Attitude, COVID-19, knowledge, practices
|How to cite this article:|
Kartheek A S, Gara K H, Vanamali DR. Knowledge, attitude and practices towards COVID-19 among Indian residents during the pandemic: A cross-sectional online survey. J NTR Univ Health Sci 2020;9:107-15
|How to cite this URL:|
Kartheek A S, Gara K H, Vanamali DR. Knowledge, attitude and practices towards COVID-19 among Indian residents during the pandemic: A cross-sectional online survey. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Aug 5];9:107-15. Available from: http://www.jdrntruhs.org/text.asp?2020/9/2/107/289897
| Introduction|| |
World Health Organization (WHO) had declared Coronavirus disease 2019 (COVID-19) as global pandemic on 11th March 2020. Initially identified as novel beta-coronavirus (2019 nCoV) by Centre for Disease Control (CDC), International Committee on Taxonomy of Viruses officially renamed it as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS COV-2). Since the onset of 1st cluster of unusual pneumonia cases in Wuhan in late December 2019, the rapid human to human transmission of virus via droplets and close contacts resulted in unprecedented, swift and frantic global spread affecting 215 countries and territories with confirmed cases globally more than 45 lacs and in India more than 90000 (as on 17th May 2020).
In dearth of pharmaceutical interventions and limited contagion data, WHO recommends following infection prevention and control (IPC) measures to mitigate COVID-19 spread: 1. Hand washing; 2. Social distancing of 6 feet; 3. Avoid touching mucus membrane of mouth, eyes and nose; 4. Respiratory protection and hygiene by using personal protective equipment (PPE), masks; 5. Identification of infected personnel and contact tracings; 6. Travel restrictions. In India, the first case of COVID-19 was reported on 30th Jan 2020 in Thrissur, Kerala. With outbreak of cases within various states and union territories, the largest COVID-19 national lockdown was enforced from 24th March 2020 onwards, with exception to those associated with essential commodities. Parallel establishment of isolation and quarantine centres, lab services, research and development, deployment of medical staff and procurement of PPEs were streamlined., These stringent drastic IPC measures were intended to flatten epidemic curve as well as prepare for possible surge.,
With the population of 1.3 billion, implementation of social distancing faces a generic challenge in industrial zones accommodating gig-economy workers and slums that have unequal access to basic necessities including food, water, medicine, and sanitation supplies. Often, socio-political factors, economic interests, feasibility for implementation, and panic emotion influence decision-making process for any proposed measure. The adherence to IPC measures both at individual as well as community level profoundly influences contagion transmission dynamics. In view of emerging health crisis as well as the national lockdown, online survey was attempted to evaluate the knowledge, attitude and practices (KAP) among citizens towards COVID-19.
| Methods|| |
An observational, cross-sectional survey was conducted to assess KAP among Indian citizens towards COVID-19 form 4th April to 14th April 2020. Due to the national lockdown, social media was used to conduct the survey across various states of India. The Institutional Ethical Committee approval was obtained for the survey. The snowball sampling technique was used to pool the initial eligible respondents who could potentially recruit more respondents from their acquaintances. By using Google forms, an online semi-structured questionnaire with annexed informed consent form was developed. The survey link was generated and was sent through online platforms like WhatsApp, e-mails and Facebook to the contacts of the investigators. The respondents were motivated to refer links to their contacts for participation. The participants were auto-directed to the survey on clicking the link. The participation was voluntary in nature and no incentives were rewarded.
As it was an online survey in English, individuals with age ≥18 years, internet access and able to read and understand English were recruited. The questionnaire consisted of 2 sections with several questions appearing sequentially in order of (1) Socio-demographic variables and (2) KAP towards COVID-19. The KAP questions were framed in accordance with Public health information & COVID-19 Guidelines given by Government of India. The socio-demographic information consisted of age, gender, educational qualification, occupation, marital status, city of residence and socioeconomic status (as per modified Kuppuswamy scale 2019).
The KAP consisted of 10 questions on the knowledge of COVID-19 which embraced(a) Clinical presentation (2 items); (b) Transmission of COVID-19 (2 items); (c) Treatment (3 items); (d) Preventive measures (3 items); (e) Attitudes (4 items) and (f) Practices (4 items). Some knowledge questions had multiple response questions with 1 mark allotted to each correct response. The total COVID-19 knowledge score ranged from 0-22, a higher score indicating better knowledge.
Ethical committee approval
Verbal approval was obtained on 27th March 2020. Due to lockdown and unavailability of ethical committee members in college, there was delay in issuing approval certificate. Hence Institutional ethical committee letter no: IEC/22052020 is dated on 22-05-2020.
| Data Analysis|| |
Statistical data analysis was done using SPSS (version-26) software. The descriptive data was expressed as Mean, standard deviation (SD), frequency (n) and percentages (%). Mean knowledge score was compared among different groups based on demographic characteristics using one way analysis of variance (ANOVA). Multiple linear regression analysis was used to determine the demographic factors associated with the COVID knowledge score. Logistic regression (binomial and multinomial) was used to identify factors associated with attitudes and practices. Odds ratio (OR) with 95% Confidence intervals (CI) was calculated to quantify the association among different variables and KAP. P value <0.05 was set as statistically significant.
| Results|| |
Across various states, a total of 751 individuals participated in the online survey which had almost equal proportions of male (49.8%) and female (50.2%) participation. As per [Table 1], the mean age of the participants was 27.3 ± 9.5 yrs (range: 18 yrs-75 yrs). 679 (90.4%) had an education level of above intermediate, majority 342 (45.6%) belonged to upper middle class and 419 (55.4%) were residents of Visakhapatnam.
|Table 1: Socio-Demographic Characteristics & Mean COVID Knowledge Score of the Participants|
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The mean COVID knowledge score was 16.28 (74%), the highest score being 22 (100%). 46% participants had a score of 80% or above. Mean COVID knowledge score differed significantly across gender, age group, marital status, socioeconomic status and occupations. The knowledge score of residents of Visakhapatnam was significantly higher compared to other cities (p = 0.003)
Among the factors associated with knowledge score, multiple linear regression analysis, as per [Table 2], showed statistically significant positive association with HCW (β = 0.127, P = 0.010) and upper socioeconomic class (β = 0.112, P = 0.004), when compared with other occupations and socioeconomic classes, respectively. The association of knowledge score was significantly negative among students (β = -0.127, P = 0.002) and non-working group (β = -0.101, P = 0.006) as compared to other occupations and working group, respectively.
|Table 2: Multiple Linear Regression Analysis of Factors Associated with COVID Knowledge Score|
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Majority [n = 655 (87.2%)] of the participants were confident that COVID-19 can be controlled by adequate preventive measures as per [Table 3]. 634 (84.42%) participants were optimistic that India would win the war against COVID. Almost all the participants (98.5%) agreed that every individual must feel responsible to prevent the spread of COVID 19. Majority [n = 680 (90.5%)] felt that lockdown was an effective IPC method. Participants with a positive attitude towards COVID-19 IPC measures had a higher mean knowledge score compared to others.
Multinomial regression analysis of factors associated with attitude was depicted in [Table 4]. Educational status of intermediate or below showed significant negative association (β = -0.892, OR = 0.4, P = 0.006) with the agreement that preventive measures could control the disease. Higher knowledge score showed significant positive association with the agreement of preventive measures (β = 0.135, OR = 1.14, P < 0.001) and responsibility of each individual (β = 0.211, OR = 1.234, P = 0.005) for control the disease. The agreement for lockdown being an effective containment method did not differ significantly across gender, education, socio-economic status, occupation and knowledge scores. The confidence about India winning war against COVID was significantly positively reflected amongst healthcare workers (HCWs) (β = 1.00, OR = 2.718, P < 0.001) as compared to other occupation
|Table 4: Logistic Regression Analysis on Factors Associated with Attitudes|
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Though 733 (97.6%) respondents agreed about frequent hand washing, but only 585 (77.87%) confirmed about washing hand ≥20 secs. The adherence to social distancing and lockdown restrictions was confirmed by 721 (97.3%) and 731 (97.3%), respectively, as per [Table 5] Liquid soap, followed by soap and water and sanitizer was utilized for hand-wash by 530 (41.60%), 389 (30.60%) and 354 (27.80%) participants respectively as per [Figure 1]. Higher knowledge score was significantly associated with the practice of hand washing for >20 secs (β = 0.061, OR = 1.063, P = 0.023) and maintaining social distance (β = 0.138, OR = 1.148, P = 0.007) [Table 6]. The practice of hand hygiene and social distancing did not have significant association with gender, education, occupation and socioeconomic class. Adherence to lockdown restriction was negatively associated with females (β = -1.902, OR = 0.149, P = 0.003) and occupation other than HCWs (β = -1.336, OR = 0.263, P = 0.007).
|Table 6: Logistic Regression Analysis on Factors Associated with Practices|
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Among total participants, 99 (13.18%) agreed for hydroxychloroquine (HCQ) purchase for prophylaxis against COVID-19, of which majority were HCWs [57 (57.57%)], followed by students [31 (31.31%)]. The major proportion of Hydroxychloroquine (HCQ) consumption was observed in age group 18-30 years, singles, upper socioeconomic status, post graduates. Also, HCQ purchase showed significant negative association with educational status intermediate and below (β = -0.814, OR = 0.443, P = 0.037) and occupation other than HCWs (β = -1.764, OR = 0.171, P < 0.001). Higher COVID knowledge score was positively associated with HCQ purchase with statistical significance (β = 0.102, OR = 1.108, P = 0.003).
| Discussion|| |
The survey was an initiative to understand KAP among the Indian citizens towards COVID-19. Though there was predominance of age group 18-40 years, students and higher qualification who had access to real-time information via social media, the correct response rate was 74% for knowledge score, reflecting incomplete awareness regarding COVID-19. It could be attributed to the spread of myths and misinformation driven by fear, blame and stigma. HCWs, being the frontline warriors, had higher knowledge score in view of better access to knowledge, reinforcements, updates and training pertaining to disease prevention and management. Comparative lesser knowledge among other participants needs to be addressed as they are equally responsible to execute IPC measures.
Despite inadequate knowledge, majority of participants were optimistic about disease control and India wining war against COVID-19. In a similar study done in China, 90.8% were confident about COVID control and 97.1% believed that China would win the war against COVID. The optimistic attitude of respondents could be attributed to IPC measures adopted by the Government of India. Even though overcrowding, poverty and cluster zones with inadequate hygiene and sanitation poses a major challenge for implementation, almost 90% respondents extended their support for lockdown and followed restrictive policies thus reflecting trust in political and scientific leadership.
Despite the lockdown, around 80% of participants came out of their houses for either discharging their duties or buying essential commodities with all preventive measures. Going for leisure walk/ exercise or getting bored was observed in around 14% participants [Figure 2]. This risky behaviour is detrimental as it can effectuate into silent community transmission. Hand hygiene and social distancing was positively associated with better knowledge score. Though more than 95% respondents practiced frequent hand washing, only 77.89% followed recommended guidelines of washing hands for >20 secs, thus reflecting the discordance between information and implementation. A surveillance done in Hong Kong in early February 2020 revealed that non-pharmaceutical interventions like quarantine and isolation, social distancing, border restrictions, and behavioral changes in public were associated with reduced transmission of COVID-19. It warrants educational and promotional road map to augment cognizance and compliance of the population during pandemic crisis.
The information about HCQ as a potential prophylaxis for COVID-19 which circulated among the masses translated into accelerated sale of HCQs from local pharmacy shops, even without prescription. But in our survey, almost more than 85% didn't purchase HCQ and among those who purchased, 50% were HCWs. The facts and reports of adverse effects related to HCQ medication may be the reason of lower rate of HCQ purchase among respondents.
Protection of healthcare capacity and vulnerable groups at risk is of paramount importance during pandemic. As increasing number of infected cases would challenge IPC measures, periodic surveillance of implemented measures shall offer insight towards facilitators, barriers, human factors and ergonomics influencing compliance.,, Proactive formulation and implementation of disease control campaigns complemented with timely and relevant communication can mitigate the transmission path and reduce the social, economic and emotional burden associated with COVID-19 pandemic.
Our study has few limitations. As virtual snowball sampling method was used, the survey was respondent driven; hence it cannot be taken as a representation for general population. The KAP among population of lower class and with lower educational qualification was not obtained due to online English questionnaire and restricted access to community during national lockdown. Better sampling techniques and large sample size of the population would help in analysing the risk perception of population which can be instrumental for comprehensive national disease control policy
| Conclusion|| |
In our study, more the 90% were optimistic about pandemic control. But accuracy for knowledge was around 75% and less than 50% respondents had 80% knowledge score, thus reflecting inadequate information about COVID-19. The knowledge score had significant association with optimism, adherence to preventive and control measures. Around 75% followed the recommended guidelines of hand hygiene and a few (5%) didn't follow lockdown restrictions. Existing lapses and barriers can be addressed by dissemination of accurate information, education and communication (IEC) materials optimized to literacy level, cultural appropriateness, age and geographical distribution. Reinforcement of strong and appealing health messages into community would promote behavioural changes, compliance and solidarity to conquer the COVID-19 contagion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Coronaviridae Study Group of the International Committee on Taxonomy of Viruses: The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020;5:536-44.
Ministry of Home Affairs, Government of India. Government of India issues Orders prescribing lockdown for Containment of COVID-19 epidemic in the Country. Press Information Bureau. Order dated 24 March 2020. Available from: https://pib.gov.in/newsite/PrintRelease.aspx?relid=200655
. [Last accessed on 2020 Apr 03].
Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: Pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Trav Med 2020;27:taaa020. doi: 10.1093/jtm/taaa020.
Kong Q, Jin H, Sun Z, Kao Q, Chen J. Non-pharmaceutical intervention strategies for the outbreak of COVID-19 in Hangzhou, China. Public Health 2020;182:185-6.
Xingchen P, David MO, Tianyue G, Zhongsheng L, Chunhua P, Chungen P. Lessons learned from the 2019-nCoV epidemic on prevention of future infectious diseases. Microbes Infect 22. 2020:86-91.
Wani RT. Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh's scale updated for 2019. J Family Med Prim Care 2019;8:1864-9.
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.
Frieden TR, Lee CT. Identifying and interrupting superspreading events- implications for control of severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis 2020;26:1059-66.
Cowling BJ, Ali ST, Ng TWY, Tsang TK, Li JCM, Fong MW, et al
. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: An observational study. Lancet Public Health 2020;5:e279-88.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]