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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 37  |  Issue : 1  |  Page : 48-56

Indian community's knowledge, attitude, and practice toward COVID-19


1 Department of Pediatric Gastroenterology, Institute of Gastroenterology, Hepatology and Transplant, Nims University, Jaipur, Rajasthan, India
2 Department of Pharmacy Practice, Institute of Pharmacy, Nims University, Jaipur, Rajasthan, India
3 Department of Biochemistry, Intitute of Advance Sciences, Nims University, Jaipur, Rajasthan, India
4 Institute of Advance Sciences, Nims University, Jaipur, Rajasthan, India

Date of Submission25-May-2020
Date of Acceptance03-Oct-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Pratima Singh
Institute of Pharmacy, Nims University, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_133_20

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  Abstract 


Background: The COVID-19 pandemic has caused unprecedented human health consequences. It is imperative to understand the society's awareness toward knowledge, attitude, and practice (KAP) level and the extent of measures required by health authorities. Aims and Objective: The aim of the study was to assess the KAP of the general public of India on COVID-19. In this study, a web-based cross-sectional survey was conducted between March 10 and April 18, 2020. Materials and Method: A 19-item questionnaire was generated using Google Forms and distributed through social media networks via snowball sampling technique. The Chi-square test was used to compare categorical data, and multiple linear regression was used to identify factors influencing KAP. Result: Among 7978 participants, the overall KAP score was 80.64%, 97.33%, and 93.8%, respectively. In multiple linear regression analysis, male gender (β = 0.036: P < 0.001), urban population (β = 0.006: P < 0.002), higher education (β = 0.029: P < 0.001), and higher occupation (β = 0.002: P = 0.05) were associated significantly with high knowledge score. There was a positive significant correlation between knowledge and attitude, knowledge and practice, and attitude and practice. Conclusion: The KAP level among the general public was adequate, however there is a necessity to target specific category population with tailored health education program to ameliorate the level of knowledge and attitude. knowledge and attitude.

Keywords: Attitude, COVID-19, India, knowledge, pandemic, practice


How to cite this article:
Tomar BS, Singh P, Nathiya D, Suman S, Raj P, Tripathi S, Chauhan DS. Indian community's knowledge, attitude, and practice toward COVID-19. Indian J Soc Psychiatry 2021;37:48-56

How to cite this URL:
Tomar BS, Singh P, Nathiya D, Suman S, Raj P, Tripathi S, Chauhan DS. Indian community's knowledge, attitude, and practice toward COVID-19. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Sep 21];37:48-56. Available from: https://www.indjsp.org/text.asp?2021/37/1/48/312878




  Introduction Top


The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) which was initially diagnosed from Wuhan, Hubei Province (Mainland China), has already taken on pandemic proportions, affecting the whole world in the minuscule of time.[1] As of April 30, 2020, >3.3 million cases of COVID-19 cases had been confirmed, resulting in 234,139 deaths worldwide.[2] In reciprocation to the outbreak, the World Health Organization (WHO) declared it as a public health emergency of international concern and called global imperative efforts to prevent the escalation.[3] SARS-CoV-2 is an enveloped RNA β-coronavirus with an outer fringe of envelope proteins resembling like a crown, which has a phylogenetic genome similarity with other known highly pathogenic and transmissible coronaviruses, that is, SARS-CoV-1 (2003) and MERS-CoV (2012).[4] Studies suggest the basic reproduction number (R0) of SARS-CoV-2 to be around 2.2 or more up to 6,[5] making the virus propagate at an alarming rate and proving to be very expeditious and erratic.[6]

India is a country of vast sociocultural diversity; health inequalities and economic disparity present with challenges and threat by the growing pandemic of COVID-19. Enforcement of an immediate lockdown, which was praised by the WHO as “tough and timely,” and cluster containment to break the chain transmission are effective approaches.[7] India is the second-largest internet user in the world with >560 million from 1.39 billion gross population.[8] One threat to the COVID-19 response in India is the ubiquitous spread of misinformation by raising falsehoods such as rinsing the nose with saline, spraying of alcohol and chlorine, or 5G mobile networks inhibiting the spread of the virus, during the crisis, which is dangerous because it can mislead and confuse the public.[9] Over 3 billion posts and 100 billion interactions are present on COVID-19, making infodemic spread faster than a pandemic.[10] The most important factor in preventing the spread of the virus locally is the empowered citizens with the right information and taking advisories being issued by the Ministry of Health and Family Welfare, Government of India, regularly.

According to evidence, public awareness to the control measures is essential in tackling pandemics.[11] Assessing the KAP related to COVID-19 of the general public will help to understand the public awareness and develop better insights to address gaps and strengthen the ongoing preventive efforts. Thus, this study aims to investigate the knowledge, attitude and practices (KAP) of the Indian community during the rapid COVID-19 outbreak. The result of this study is important to inform future prospects focusing on societal readiness to comply with pandemic control measures.

Objective of study

  • Primary objective – To assess the KAP regarding COVID-19 among the general population of India
  • Secondary objective – To assess the factors associated with the level of KAP regarding the COVID-19 outbreak.


Ethics approval

The study was cleared by the Institutional Ethical Committee, NIMS Medical College, NIMS University Rajasthan, Jaipur, as per the Indian Council of Medical Research guideline. The study was performed under the Declaration of Helsinki revised version in 2013. The study was conducted following the Checklist for Reporting of Internet E-Surveys (CHERRIES) guidelines.[12]


  Materials and Methods Top


Study design

To address the large population, qualitative research was done in order to achieve the objectives.[13] This is a cross-sectional survey conducted via snowball sampling technique from March 10 to April 18, 2020, in India. Data collection was done through Google Forms and forwarded to popular Indian social media platforms.

Data process and collection

As a community-based survey was not feasible due to the nationwide lockdown in India, a 19-item online survey was developed using the information published in literature including publications available on the WHO and the Centers for Disease Control and Prevention (CDC)[14],[15],[16] on COVID-19. The developed questionnaire was disseminated to ten participants to understand the barriers faced, acceptance, and the chronology of the questionnaire. After refinements, the questionnaire was made available to the participants through emails and social networking platforms through an URL link with content in English and Hindi language with standardized general description. Participants with age >18 years who can understand the content of the survey and willing to participate were included.

Questionnaire and scoring

The questionnaire consists of two parts: demographic details and KAP study. The survey contained content in both Hindi and English languages. Translation from English to Hindi was done using backward translation approach, and discrepancies between adaption were ensured after consultation with bilingual researchers. Demographic variables included sex (male, female, or transgender), age (18–30, 30–50, or >50 years), marital status (single or married), education level (<senior secondary, senior secondary, graduate, ≥ postgraduate), occupation (unskilled, skilled, student and unemployed, self-employed [includes homemakers], and professional), geographic location (different states of India), and place of residence (urban or rural).

The knowledge section consisted of two parts – ten questions regarding clinical symptoms, prevention, and control of disease (K1–K10) and three questions regarding myth busters on COVID-19 (K11–K13). Each question has three options (yes/no/don't know). A correct answer was given 1 point and an incorrect answer was given 0 point. The overall knowledge scores ranged from 0 to 13. Individuals scoring 11 or above were categorized as excellent, whereas those scoring below 11 scores were brought under poor knowledge. Cronbach's alpha knowledge for knowledge (13 items) was 0.69, which was considered in the range of adequate and acceptable.

Evaluation of attitude of the general public was done by three questions (A1–A3) comprising questions assessing viewpoint on social distancing, control of COVID-19, and lockdown to prevent the spread of COVID-19. Regarding the assessment of practice, the question was composed of three questions (P1–P3): the idea of grocery stocking, preventive measures during the lockdown, and relationship with family and friends. Both attitude and practice questions follows scoring pattern similar with knowledge section. Cronbach's alpha was used to measure the internal consistency of the questionnaire.

Statistical analysis

The data were analyzed via Statistical Package for the Social Sciences, IBM Corp. (Version 22, Chicago, Illinois, U.S.A). Mean with standard deviation was calculated for descriptive analysis, and number with percentage was calculated for categorical variables. The KAP scores were compared by demographics with Chi-square test as appropriate. Multivariate linear regression analysis was used to establish the relationship between demographic variables as independent variables and KAP as the outcome variable. Pearson's coefficient of correlations and variance of inflation factor (VIF) were used to determine the relationship between KAP. Unstandardized regression coefficient (β) with a 95% confidence interval was used to quantify the relation between variables and KAP. Statistical significance was set at ≤0.05.


  Results Top


Study population characteristics

A total of 8075 survey forms were retrieved, of which 97 questionnaires were excluded as the participants declined to give consent [Supplementary Table 1]. The remaining 7978 questionnaires were completed and consented to participate with an overall rate of 98.79%. The details of demographic characteristics are presented in [Table 1]. A large proportion of male respondents (52.4%) were found. The leading age group was 18–30 years, accounting approximately 54.2% of both the genders. In addition, a total of 5588 (70.04%) respondents hold a degree of graduate or above, 3232 (40.5%) pursue as a student or unemployed, and 5108 (64%) were single.

Table 1: Characteristics of the study participants (n=7978)

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Knowledge score related to COVID-19

As to knowledge, the mean was 11.36 ± 1.2 (range 0–13), suggesting an overall 80.64% correct rate of knowledge. Univariate analysis with knowledge level significantly varied across age, gender, education, and occupation. Nearly 89.4% of the respondents agreed that isolation and quarantine are important steps to stop the spread of the novel coronavirus, and only 83.19% of the respondents were aware of the fact that pregnant women are more at risk toward COVID-19. Whereas, only 37% believed that eating citrus fruit and gargling with salt water cannot help in preventing infection with the novel coronavirus [Table 2]. On multiple linear regression analysis, male gender (β = 0.036: P < 0.001), urban population (β = 0.006: P < 0.002), higher education (β = 0.029: P < 0.001), and higher occupation (β = 0.002: P = 0.05) were associated significantly with a high knowledge score. There was no evidence of multicollinearity between independent variables (range of VIF = 1.102 and 1.287) [Table 3].
Table 2: Knowledge score of coronavirus disease 2019 by demographic variables

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Table 3: Participants' characteristics with knowledge score regarding coronavirus disease 2019 based on multiple linear regression

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Attitude score related to COVID-19

The overall correct rate in attitude was 97.33%. Majority of the population (97.6%) had not visited any populated place. Nearly 98.33% of the respondents believed that COVID-19 can be successfully controlled. Moreover, 96.01% agreed with the idea of lockdown to prevent the spread of COVID-19. On multiple linear regression analysis, female gender (β = −0.006: P = 0.008), middle age (β = −0.011: P < 0.001), higher education (β = 0.025: P < 0.001), and higher occupation (β = 0.020: P < 0.001) were associated significantly with good attitude score [Table 4]. There was no evidence of multicollinearity between marital status, geographical area, and attitude (range of VIF = 1.102 and 1.052, P > 0.05) [Table 5].
Table 4: Attitude score of coronavirus disease 2019 by demographic variables

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Table 5: Participants' characteristics with attitude score regarding coronavirus disease 2019 based on multiple linear regression

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Practice score related to COVID-19

Based on the results, the overall response rate was 83.8%. In the present study, most males (72.7%) denied the idea of grocery stocking; in contrast, 55.2% of the females agree with this idea of grocery stocking. Both genders, 90.7% of males and 97.1% of females, were taking proper preventive measures while leaving home [Table 6]. On multiple regression analysis, male gender (β = 0.093: P < 0.001), old age (β = 0.030: P < 0.001), single status and other (β = 0.113: P < 0.001), and lower education (β = −0.007: P = 0.007) were associated significantly with good practice. However, there was no evidence of multicollinearity of geographical area and occupation with practice score (range of VIF = 1.052 and 1.310, respectively, P < 0.05) [Table 7].
Table 6: Practice score of coronavirus disease 2019 by demographic variables

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Table 7: Participants' characteristics with practice score regarding coronavirus disease 2019 based on multiple linear regression

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  Discussion Top


Since the outbreak, coronavirus had brought chaos to lives and economics around the world. As of now, India is facing the biggest health emergency because the country has gained independence. Encouragement of public to adopt precautionary behaviors for containment strategies as KAP is foreground for public cooperation and backbone for implementing any health policy. Countries have reported community response to COVID-19 from China and Middle East.[14],[17] From the aspect of attention, this is the unique paper from India including 7978 individuals analyzed toward COVID-19.

Based on our findings, the study significantly includes male, single, and well-educated population. The overall 80.64% of knowledge score was higher and unanticipated. The reason behind these findings could be the ubiquitous mass media coverage on the rampant caused toward COVID-19 by the then highly effected countries and also through health communication for preventive measures by the Ministry of Health and Family Welfare, Government of India.[18],[19] Furthermore, sample characteristics consisting participants with higher education hold the predication of knowledge score, which is similar to that of a Chinese study but varied with an Iranian study.[14],[15],[16],[17] Participants were aware regarding clinical symptoms, transmission, prevention, and control of disease, contrast to myth buster questions. More than one-third of the participants believed that eating citrus fruits and gargling with salt water can help prevent infection. According to the WHO, gargling warm or salt water and consuming citrus fruits will not kill the novel corona virus.[20] Fourteen percent out of hundred believe that alcohol drinking can kill novel coronavirus. Alcohol is a highly inflammable substance as well as a strong disinfectant, hence it can be used as a cleansing agent for surfaces.[21] No evidence supports that alcohol consumption can kill the virus, whereas intake of excessive alcohol can cause health-related complications.[22] A robust association between female gender and knowledge score regarding COVID-19 was found in the present study. These findings are inconsistent with that of other Asian studies which have indicated that males had higher levels of knowledge among the general population.[23] Multivariate analysis showed education level and occupation as strong indicators of knowledge domain regarding COVID-19, which postulates that the combination of better access to information and high education level leads to appropriate apprehension and comprehension of information on COVID-19, consequent to better knowledge on COVID-19. Therefore, government and public health policymakers should recognize target populations for COVID-19 prevention and health education.

Our study has strong association of knowledge significantly with positive attitude and practice. In recent, majority of the population (97.6%) have taken optimistic measures by avoiding going to crowded places. This practice is primarily due to strict measures taken by government to prevent an overwhelmed wave of new infection, whereas second due to awareness, acceptance, and action of people with good knowledge. Unfortunately, 3.6% of males are going to crowded place because of two potential reason: first in India men are likely to expose in outwork exposing them to crowded place and second according to studies, men and adolescents have more risk-taking behavior which is deemed a dangerous practice toward COVID-19.[24] Similar findings were obtained in previous studies conducted in China.[14] Massive agreement was found toward the idea of lockdown in India, which has helped to prevent potential rise in cases. According to the Indian Medical Council of Research, the reproduction factor (Ro) of SARS-CoV-2 is 2.5. One person can infect 406 peoples in 30 days; if the lockdown and social distancing are practiced properly, one sick person can only infect 2.5 persons. Successful containment of pandemic cab ne made through social distancing, which is already proven by millennial example in the pandemic of influenza.[25]

Lack of information, imprecise information, and deception can lead to hysteric and fuel behavioral outcomes; for example – panic buying.[26] According to recent studies, panic buying is having a detrimental impact on health supply chains, leading to shortage of essentials such as sanitizers, masks, and pain relievers.[27] In our study, 55% of females and 27.3% of males agrees with the idea of grocery and medicine stocking. As panic buying disturbs the balance of demand and supply in a good supply chain system,[28] no research was found to establish a relation between the association of marital status and gender in grocery and medicine stocking. Mental health is another major issue that is becoming critical in managing the COVID-19 pandemic. Social chaos and arbitrary relationship are destroyed due to panic and fear, thus superseding evidence and psychologically, change in environment makes us feel unsafe, scared, and anxious.[28] Family and friends act as a major source of positive coping by improvising our psychological wellbeing and providing sense of reassurance.[29] In our study, majority of population were connected with family and friends.

Limitations of the study

Though the sample size was huge, longitudinal study designs are essential for future research for more generalized findings. Educational attainment and occupation are frequently considered as proxy measures of socioeconomic data due to the self-reported format of questionnaire or it may rely on the honesty of individual thus, we may call it as a bias in study. Possible selection bias, due to limited participants with assess of the internet can be reached which excludes vulnerable population, hence, call for a special research targeting population with low education and economic background. Lastly, due to limited questions to assess the level of KAP, in-detail information was not achieved, which requires in-depth interviews with multidimensional measures. Despite these limitations, our study provides valuable information on a huge sample size of 7978 Indian population during the critical period of nationwide lockdown and COVID-19 outbreak.


  Conclusion Top


Majority of the Indian population demonstrated good knowledge, positive attitude, and good practice regarding the COVID-19 pandemic. Furthermore, due to systemic approach and health communication strategies, significant awareness and apprehension in knowledge, preventive strategies, and optimistic attitude was assimilated in the general population. In addition, government policymakers have worked well in targeting grass-root population having low level of education and nonprofessional workers through health promotion activities. Noteworthily, awareness toward panic buying and beliefs in myths require to be addressed through health educational programs.

Acknowledgment

We thank all the participants for their voluntary participation in the survey.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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