|Year : 2022 | Volume
| Issue : 1 | Page : 3-8
The need of the hour: Understanding the knowledge, attitudes, and practices of general public and at-risk groups in the COVID-19 pandemic management
Hemant Kumar Singh1, Pavithra Balakrishna2, Ganne Chaitanya3, Naresh Kumar Panneerselvam2, Rajeev Aravindakshan4, Pratyusha Ganne5
1 Department of Surgical Oncology, All India Institute of Medical Sciences, Mangalagiri, Guntur, Andhra Pradesh, India
2 Department of General Surgery, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India
3 Department of Neurology, Epilepsy and Cognitive Neurophysiology Lab, University of Alabama at Birmingham, AL, USA
4 Department of Community and Family Medicine, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India
5 Department of Ophthalmology, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India
|Date of Submission||27-Jul-2020|
|Date of Decision||09-Feb-2021|
|Date of Acceptance||09-Aug-2021|
|Date of Web Publication||28-Apr-2022|
Dr. Pratyusha Ganne
Department of Ophthalmology, All India Institute of Medical Sciences, Mangalagiri, Guntur - 522 503, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Understanding the public awareness, attitudes, and practices is needed to successfully control the COVID-19 pandemic. With the second wave of the pandemic spreading and reinstatement of lockdown in many countries, there is an urgent need to understand the knowledge, attitudes, and practices (KAP) of the people (especially the high-risk groups) to control mortality and morbidity. Aims: To explore the KAP of the general population of India and in particular, the at-risk groups, i.e., aged >55 years and those with comorbidities (diabetes, hypertension, chronic kidney disease, ischemic heart disease, and chronic obstructive pulmonary disease) who are at a high risk for developing severe COVID-19 infection and death. Patients and Methods: In this cross-sectional study, the questionnaires were administered through online survey links. The questionnaire had four sections, one for demographics and three each for KAP. The KAP scores were compared for a priori defined questions using Chi-square test, t-test, or ANOVA appropriately. Bonferroni corrected P < 0.05 was considered statistically significant. Results: Of the1259 responses, 83 (6.6%) were above 55 years and 193 (15.3%) had comorbidities. Higher education and income groups were more informed about COVID-19 disease (F > 18.5, P < 0.002). Participants in the at-risk groups had the same level of KAP scores as the general public. While a seemingly higher proportion of the at-risk group followed use-of-mask (n = 206, 94%) and 20 seconds of handwashing (n = 142, 65%), it was not significantly higher compared to the general population (P's > 0.4). Of the 1259 participants, 7%–10% of them did not practice social distancing at all times and 5%–7% were not wearing a mask at all times. Only 538 (42.7%) participants believed that this COVID-19 pandemic will be successfully controlled. Conclusions: This study highlights that at-risk groups are not better prepared compared to the general public, which is the need of the hour to prevent over-crowding of health systems and possibly mitigating COVID-19-related mortality.
Keywords: At-risk, attitude, co-morbidities, COVID-19, elderly, knowledge, practices
|How to cite this article:|
Singh HK, Balakrishna P, Chaitanya G, Panneerselvam NK, Aravindakshan R, Ganne P. The need of the hour: Understanding the knowledge, attitudes, and practices of general public and at-risk groups in the COVID-19 pandemic management. J Med Evid 2022;3:3-8
|How to cite this URL:|
Singh HK, Balakrishna P, Chaitanya G, Panneerselvam NK, Aravindakshan R, Ganne P. The need of the hour: Understanding the knowledge, attitudes, and practices of general public and at-risk groups in the COVID-19 pandemic management. J Med Evid [serial online] 2022 [cited 2022 Nov 30];3:3-8. Available from: http://www.journaljme.org/text.asp?2022/3/1/3/344282
| Introduction|| |
The coronavirus disease (COVID-19) started in early December 2019 in Wuhan, China and rapidly spread across the world achieving a “pandemic” status on March 11, 2020 (declared by the Director-General of the World Health Organization-WHO). As of 10th February 2021, 106,555,206 confirmed cases of COVID-19 had been reported in the world. The first case of COVID-19 in India was reported on 30th January 2020 and India now has the largest number of cases in Asia and the second largest number of cases in the world (total number of confirmed cases as of 10th February 2021: 10,703,119; total deaths: 155,252). The Ministry of Health and Family Welfare introduced several measures to contain the spread of the virus including imposing a nation-wide lockdown, improving testing and quarantine facilities and most importantly raising awareness about the pandemic.
The ubiquity of social media and information technology is playing a huge role in information dissemination during this pandemic. The WHO (World Health Organization) has identified that the COVID-19 outbreak has been accompanied by a massive 'infodemic' – an overabundance of information, some accurate and some not.
A pandemic brings about a lot of changes in the way people think and act. Anxiety, fear and confusion prevailing in the minds of the public, more so, in those who are at risk (elderly citizens and other health comorbidities such as diabetes, hypertension, chronic kidney disease, ischemic heart disease and chronic obstructive pulmonary disease)., Human reactions can have a positive or negative impact on reducing the extent of the outbreak.,,
With the second wave of the pandemic spreading and reinstatement of lockdown in many countries, there is an urgent need to understand the knowledge, attitudes and practices (KAP) of the people (especially the high-risk groups) to control mortality and morbidity. The success of controlling the pandemic will depend on the ability to predict people's behaviours and responses and identify the target groups who are either susceptible to the disease or are wrongly educated.
To facilitate an efficient management of the pandemic, there is an urgent need to understand the public's awareness about the pandemic. This study aimed to understand the KAP of the people during this pandemic. More importantly, we evaluated the KAPs in the susceptible group of individuals i.e., age > 55 years and people with comorbidities.
| Methods|| |
This cross-sectional survey was conducted between 1st April 2020 and 30th May 2020 (1 week before to the phased reopening of the nation) with the approval from the Institutional Ethics Committee and in accordance with the Declaration of Helsinki. The data were collected online in a completely anonymous manner with no identifiers recorded from the participating individuals. An informed online consent was taken from the participants.
The study questionnaire was administered to the general public of India aged more than 18 years. Snowball sampling technique was used to recruit participants wherein the link for the questionnaire was shared through e-mails, text messages and recirculated thereof.
Considering that 50% of the participants will correctly answer 9 or more out of 17 (>50%) knowledge questions with a 5% margin of error at 90% confidence level, a minimum sample size of 270 was calculated.
Design of the questionnaire
The online questionnaire was a modification of the previously published study, with additional questions to accommodate for the evolving understanding of the disease and to address the needs of the nation. The knowledge questions were adapted from Zhong et al. Additional questions to assess the attitudes and practices were included in view of the reopening of the nation. All questions were closed-ended questions, with participants required to only choose from a pre-existing set of answers.
A pilot study was intended to recruit a maximum of 100 participants, but an unexpectedly exceeding number of replies (n = 625) was obtained and reviewed. Following this, the questionnaire was refined based on the feedback from the participants.
The final questionnaire consisted of four parts. Part A had 8 questions to capture the demographic details of the participants. Part B had 17 questions to test the level of knowledge among the participants. Part C had five attitude-related questions and Part D had three questions to note the practices of the people during the pandemic.
The questionnaire was translated into two regional languages (Hindi and Telugu). Cities were classified as Tier 1, 2 and 3.
Quarantine Included all those people who were isolated either because they were tested positive/had signs and symptoms of the disease/were in contact with a person positive for COVID-19.
At-risk groups: groups that had not only a high risk of development of severe COVID-19 infection but also a high risk of death if they become ill.
Data were recorded online, and responses were parsed into data spread sheets. Demographic details were presented as counts and percentages. For assessment of the knowledge, each correct response was given a score of 1 and an aggregated knowledge score was calculated which was represented as mean ± standard deviation. Comparison of nominal and ordinal data was performed using Chi-square tests. Comparison of continuous quantitative variables was performed using t-test and ANOVA. Multiple comparisons were corrected for using the Bonferroni test where applicable (PBonferroni <0.05 was considered significant). Statistical analyses were performed using SPSS software version 23.0 (IBM, Armonk, NY, USA).
| Results|| |
A total of 2952 questionnaires were distributed, and we received 1259 completed responses [Figure 1]. The overall response rate was 42.5%.
|Figure 1: Mapping of the geographical location of the study participants. It can be seen that participants were recruited from all over India|
Click here to view
The demographic profile of the participants is as shown in [Table 1]. The mean age of the participants was 34 ± 12 years (range: 18–80 years). There were 786 (64.3%) men and 1061 (84.2%) who had a bachelor's degree or more. There were 344 (27.3%), 446 (35.4%) and 469 (37.3%) participants from Tier 1, 2 and 3 cities, respectively. In the at-risk groups, we had 83 (6.6%) who were aged above 55 years and 193 (15.3%) who had comorbidities.
Knowledge level of the participants
The average knowledge score of the participants was 14.73 ± 1.99 (range: 5–17). Education level influenced the mean knowledge score, which was highest amongst those with a master's degree and reduced as the education level decreased (F = 18.5, P < 0.002) [Figure 2]. A similar pattern was seen with the annual income level, where participants of the higher income group had higher knowledge scores (F = 23.5, P < 0.001) [Figure 3]. Women scored more than the men (t = −2.51, P = 0.01). However, the score did not depend on the age (Spearman ρ =0.03, P = 0.27), the quarantine status (t = −1.92, P = 0.06) or the geographical location (F = 1.62, P = 0.19). Targeting the susceptible age group (>55 years), we found that people aged <55 years had better mean knowledge scores than those aged >55 years (t = 2.08, P = 0.037). However, individuals with and without comorbidities had similar knowledge scores (t = 0.78, P = 0.43).
|Figure 2: The relationship between the mean knowledge score and the education level (F = 18.5, P < 0.002)|
Click here to view
|Figure 3: The relationship between the mean knowledge score and the annual income level (F = 23.5, P < 0.001)|
Click here to view
A total of 538 (42.7%) participants agreed that this COVID-19 pandemic will be successfully controlled. Education level allowed participants to perceive the pandemic in a more realistic sense, where lesser proportion of participants with an education higher than a bachelor's degree (177, [37.7%]) believed that the pandemic may not be easily controlled compared to those with high school graduation or lower (43, [55.8%)] (χ2 = 18.78, P = 0.005). Participants with a relatively younger age were more unsure, while relatively older participants were more optimistic that this pandemic will be controlled (χ2 = 3.51, P = 0.026).
The majority of the participants (1100 [87.3%]) agreed that social distancing should be followed. This attitude co-occurred with higher knowledge scores amongst these participants (F = 56.39, P < 0.001). Willingness to getting tested is crucial in the containment of the disease and 1136 (90.2%) participants were willing to get tested if necessary. Again, higher knowledge scores were noted amongst the participants who were willing to get themselves tested (F = 20.17, P < 0.001). Only 680 (54%) participants felt that the information available on mass media was true. Of these, 625 (91.9%) were willing to get themselves tested. There was no statistically significant difference in the willingness to get tested between people who felt that the information on mass media was true and those who did not (χ2 = 8.86, P = 0.06). The majority of the participants (1007 [80%]) were worried that the cases will rise after lockdown will be lifted in India.
Attitudes of susceptible group compared to general public: People aged > 55 years (57 (61.3%]) were more positive that the COVID-19 pandemic will be controlled than those < 55 years (480 [41.2%]) (χ2 = 14.6, P = 0.001). Similarly, people with comorbidities were more positive than those without (χ2 = 6.24, P = 0.04). Majority of the participants in both age groups disagreed that social distancing is unethical and there was no difference between the groups (χ2 = 4.89, P = 0.08). Similarly, there was no difference between those with comorbidities and those without (χ2 = 5.46, P = 0.065). There was a strong willingness to get tested in both people aged >55 years (85 [91.4%]) and those with comorbidities (179 [92.7%]) which was not different from the general population (χ2 > 2.4, P > 0.29).
Overall, hand washing for an adequate duration of at least 20 s was followed by only 816 (64.8%) participants. It is most essential to understand the practices followed by the susceptible groups compared to the general public. Only 757 (63.4%) of those aged >55 years and 59 (64.9%) of those <55 years practiced adequate duration of handwashing (χ2 = 1.903, P = 0.59). Of the people with comorbidities, 121 (62.7%) practiced handwashing for at least 20 s, which was not different from the general public (χ2 = 5.23, P = 0.15). Overall, a strict social distancing at all times was being followed by only 1128 (89.6%) of participants. Of those < 55 years, 124 (10.6%) and of those aged > 55 years, 7 (7.5%) was not practicing social distancing at all times (χ2 = 1.59, P = 0.45). Similarly, 21 (10.9%) of those with comorbidities and 110 (10.3%) of the general public were not practicing social distancing at all times (χ2 = 1.2, P = 0.55). A small number (5 [5.4%]) of those aged > 55 years, 69 (5.9%) of those < 55 years, and 14 (7.2%) of those with comorbidities were not wearing a mask at all times. A small proportion (70 [5.6%]) of the participants who knew that COVID-19 spreads through respiratory droplets and that wearing a mask can prevent COVID-19 spread did not practice wearing a mask at all times. On the brighter side, more than 75% of those who did not know these facts also practiced wearing a mask always. Social distancing was not practiced at all times by 128 (10.2%) of those who knew that social distancing can prevent the spread of COVID-19. Of the people who knew that frequent washing of hands can prevent the spread of COVID-19 1252 (99.4%), only 813 (64.9%) of them were practicing adequate duration of handwashing for at least 20 s. Neither the education level nor the income level influenced the pattern of responses in the practice questions (χ2 > 2.6, P > 0.2) [Table 2].
| Discussion|| |
In this study, we found that all groups of participants had adequate knowledge about this pandemic with the more educated and the people with higher income being slightly better aware than the rest of the participants. But, only 42.7% had faith that this pandemic will be successfully controlled. A significant lapse in the practices was observed with nearly 35% of the participants not practicing handwashing for a minimum of 20 s, 10.5% not practicing social distancing at all times, and 5.8% never or only sometimes wearing a mask. The at-risk group has no heightened preparedness compared to the general public.
Pandemics such as COVID-19 can have complex medical, social, political and economic consequences. This pandemic has raised significant panic and anxiety in the world. The lack of a definitive cure, the rapid increase in the number of new cases, the rapid spread of misleading information and various restrictions imposed in the name of lockdown has created confusion and raised significant concerns in the minds of the people. In the current study, only 42.7% were hopeful that this pandemic will be successfully controlled. This is in contrast to the studies conducted in Malaysia and China where the majority of the public had a positive attitude towards overcoming COVID-19., Winning the trust of the people that this pandemic can be controlled successfully is very crucial to persuade them to follow public health recommendations. In this regard, effective risk communication is the need of the hour. Risk communication has been defined by the WHO as the 'exchange of real-time information, advice and opinions between experts and people facing threats to their health, economic or social well-being'. The principles of empathy and caring, competence and expertise, honesty and openness and dedication and commitment should be inculcated in the messages spread by the authorities to win the confidence of the people. Providing the latest, accurate information and at the same time acknowledging the deficiencies in the system will help not only to maintain but also even build trust in this time of crisis.
Internet and social media have the greatest potential to reach out to a large population in the shortest time in the present era. Using these can be an easy and effective way of risk communication and dissemination of information about the disease and practices that can prevent its spread. Another approach could be by involving religious/community heads whom large sectors of people trust and follow. Involving these faith leaders in decision-making can facilitate change in behaviours and practices of a large number of people. Establishing feed-back systems through which at-risk population can communicate their concerns to the authorities are equally important in planning outbreak management strategies and evaluating the success of these strategies from time to time.
We observed that the at-risk population was not better prepared than the general public in this pandemic, which is a matter of concern. Reports have shown that older individuals and those with systemic comorbidities are at a higher risk of severe COVID-19-related illness.,, Hence, greater attention has to be paid to this sector of population by the health planners, executors and all people at large. Some important measures that can be taken to reduce the risk for this group include: restricting the movement of these people by involving voluntary organisations to help in delivering food, groceries and other daily needs at the doorstep of these people and providing teleconsultations for minor health issues to avoid going to hospitals where they could be potentially exposed to COVID-19, providing city-wise helpline numbers for elderly living in old-age homes or living alone and re-assigning at-risk people to behind-the-scene duties at workplaces to limit exposure to potential spreaders of COVID-19. It is also important to support this section of the society emotionally and help them cope with the trauma of being highly vulnerable to COVID-19.
The strength of this study is that the sample included participants from nearly every state of India and both at-risk and the general population were studied and compared [Figure 3]. However, the limitations are being an online survey, the underprivileged groups of people might not have taken part in the survey due to the lack of access to the internet and there is a possibility of the participants giving desirable answers to the attitude and practice questions.
| Conclusions|| |
This study shows that people in India (including the at-risk population) are well informed about the disease and ways of preventing them. However, the preparedness of the people especially the at-risk groups is inadequate to deal with this pandemic. Addressing this will be the need of the hour to prevent over-crowding of health systems and possibly mitigating COVID-19-related mortality.
We acknowledge the efforts of all the participants in diligently answering the questionnaire and also the participants of the pilot study who shared their thoughts and experiences and provided feedback to improve the questionnaire.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Merchant RM, Lurie N. Social media and emergency preparedness in response to novel coronavirus. JAMA 2020;323:2011-2.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety and perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al.
The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Funk S, Gilad E, Watkins C, Jansen VA. The spread of awareness and its impact on epidemic outbreaks. Proc Natl Acad Sci U S A 2009;106:6872-7.
Arafat SM, Kar SK, Marthoenis M, Sharma P, HoqueApu E, Kabir R. Psychological underpinning of panic buying during pandemic (COVID-19). Psychiatry Res 2020;289:113061.
Kretchy IA, Asiedu-Danso M, Kretchy JP. Medication management and adherence during the COVID-19 pandemic: Perspectives and experiences from low-and middle-income countries. Res Social Adm Pharm. 2021;17:2023-6.
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.
Khare A. Location and agglomeration factors predicting retailers' preference for Indian malls. J Mark Anal 2020;15:1-22.
Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. PLoS One 2020;15:e0233668.
Reynolds B, Quinn Crouse S. Effective communication during an influenza pandemic: The value of using a crisis and emergency risk communication framework. Health Promot Pract 2008;9:13S-17S.
Zhao Y, Cheng S, Yu X, Xu H. Chinese public's attention to the COVID-19 epidemic on social media: Observational descriptive study. J Med Internet Res 2020;22:e18825.
Rakotoniana JS, Rakotomanga Jde D, Barennes H. Can churches play a role in combating the HIV/AIDS epidemic? A study of the attitudes of Christian religious leaders in Madagascar. PLoS One 2014;9:e97131.
Liu K, Chen Y, Lin R, Han K. Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. J Infect 2020;80:e14-8.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al.
Comorbidity and its impact on 1590 patients with COVID-19 in China: A nationwide analysis. Eur Respir J 2020;55:2000547.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al.
Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]