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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 224-230

An appraisal of knowledge, attitude and practices of anganwadi workers under integrated child development services scheme on infection prevention and control in the initial months of COVID-19 pandemic in District Lucknow, UP, India


1 Associate Professor, Department of Community Medicine, Dr. RMLIMS, Lucknow, Uttar Pradesh, India
2 Assistant Director, NIPCCD, Lucknow, Uttar Pradesh, India
3 Research Fellow, GRID Council, Noida, Uttar Pradesh, India
4 Director, GRID Council, Noida, Uttar Pradesh, India

Date of Submission14-Apr-2022
Date of Decision08-Jun-2022
Date of Acceptance01-Jul-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Dr. Manish Kumar Singh
Flat 901, Faculty Residential Apartment, Dr. RMLIMS, Vibhuti Khand, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_34_22

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  Abstract 


Background: During the COVID-19 pandemic, Anganwadi workers (AWWs) were repositioned for community support, community surveillance, community awareness on infection prevention and mitigating stigma/discrimination entailing infection, going door to door. The job entailed good knowledge, attitude and practices (KAP) with regard to infection prevention and control (IPC). Aims: To assess the KAP of AWW with regard to IPC in context of COVID-19 in Lucknow district. Methods: A cross-sectional survey was conducted using Google form between 30 June and 28 July 2020. AWWs were recruited from Lucknow district irrespective of their training status; data analysis was done on 137 participants. The mean KAP score was calculated and student t-test was applied. Chi-square test was performed between categorical variables and KAP. Univariate and multivariate logistic regression was applied between independent and dependent variables. Results: The mean score of knowledge was 7.22 ± 2.64, attitude was 4.34 ± 1.14 and practice was 4.44 ± 1.11. There was a significant difference between good and poor score for KAP. Participants with older age, good knowledge and attitude scores were more likely to have good practices. Conclusion: AWWs had good attitude and practices, but lacked adequate knowledge on IPC measures. Ensuring training for AWW on IPC is important.

Keywords: Anganwadi workers, coronavirus, Integrated Child Development Services, infection prevention and control, knowledge, attitude and practices


How to cite this article:
Singh MK, Maurya M, Yoosuf AS, Nargotra S, Pawar PJ, Mukherjee R, Mahapatro A. An appraisal of knowledge, attitude and practices of anganwadi workers under integrated child development services scheme on infection prevention and control in the initial months of COVID-19 pandemic in District Lucknow, UP, India. J Med Evid 2022;3:224-30

How to cite this URL:
Singh MK, Maurya M, Yoosuf AS, Nargotra S, Pawar PJ, Mukherjee R, Mahapatro A. An appraisal of knowledge, attitude and practices of anganwadi workers under integrated child development services scheme on infection prevention and control in the initial months of COVID-19 pandemic in District Lucknow, UP, India. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:224-30. Available from: http://www.journaljme.org/text.asp?2022/3/3/224/365878




  Introduction Top


The Integrated Child Development Services (ICDS) Scheme launched in 1975 is the most extensive government led program for provision of early childhood development, education and maternal health.[1] It is manned with a network of 1.4 million Anganwadis who play a key role in improving the health of rural poor. Despite the ICDS scheme being a flagship initiative, implementation of its projects has been no exception from the disruptions caused by the on-going COVID-19 pandemic.[2]

Understanding the socioeconomic impact of the pandemic and inherent shortage of trained healthcare professionals, the Indian government repurposed the Anganwadi ecosystem to mitigate the crises that ensued the pandemic. Online interactive training sessions were conducted by the Ministry of Women and Child Development for capacity building and dissemination of information regarding COVID-19.[3] Anganwadi workers (AWWs) were repositioned to create community support by going from door-to-door, screening people for flu symptoms for community surveillance, conducting community education on hand, respiratory hygiene and social distancing, sensitising the community to mitigate the stigma and discrimination entailing infection and creating community support.[2],[4] In the course of providing these services, strict adherence to infection prevention and control (IPC) measures for the prevention of COVID-19 infection is of importance to protect self as well as others.

IPC is an evidence-based approach which involves epidemiology, infectious diseases, social science and strengthening of health system and is a functional solution that prevents harm caused by infection.[5] A global analysis of COVID-19–IPC measures revealed, most guidelines included administrative controls such as risk assessment, early diagnosis and suspected case isolation etc., environmental control measures such as routine cleaning and disinfection of surfaces, waste management etc., and use of personal protective equipment (PPE) such as face shields and surgical masks, handwashing, gloves etc.[6] Appreciating the importance of IPC in terms of patient safety and quality of health service delivery, Ministry of Health and Family Welfare released its broad guidelines and a facilitators guide for training in COVID-19 management.[2],[7] However, there has been limited available literature on training needs and understanding of AWW on IPC measures during the very initial days of the pandemic.

In early 2020, Uttar Pradesh (UP) had 187997 Anganwadi/Mini Anganwadi Centres and more than 897 operational ICDS projects.[8] In view of the COVID-19 pandemic, training on IPC was given to AWWs for combating it in Lucknow district. The present study was conducted to assess the knowledge, attitude and practices (KAP) of AWWs with regard to IPC in the context of COVID-19 and understanding their training needs in Lucknow district.


  Methods Top


Study design and setting

A cross-sectional survey was conducted among the AWWs of Lucknow district. Lucknow district has six ICDS projects, with around 600 AWWs. The study was conducted online from 30 June to 28 July 2020.

Participants

We targeted to include all AWWs in-position in Lucknow district in the study. Any AWW who declined consent to participate or was non-responsive to our request to participate was excluded. Recruitment of participants was done first during an online training program on IPC in context of COVID-19 in July 2020, organised under the aegis of National Institute of Public Cooperation and Child Development (NIPCCD) Regional Centre, Lucknow, Ministry of Women and Child Development. Participants were further recruited on field at the various ICDS project sites via the trained Child Development Project Officer/Mukhya Sevika who participated in the online training. A soft copy of information on important Do's and Don'ts developed by the authors was shared with the AWWs who responded to the questionnaire. Any subsequent queries were also addressed by the authors on one-to-one interaction telephonically.

Data sources/measurement and variables

A structured questionnaire was designed on Google forms (both in English and Hindi) for the collection of data. It contained a section to indicate informed consent and questions regarding participant profile, KAP. The form was designed with the help of IPC trainers and piloted on seven AWWs in another district of Uttar Pradesh.

The participant profile included demographic data such as age, education (intermediate/high school/graduate/post-graduate), place of residence (urban/rural) and years of experience. Participants were also asked if they had any training regarding COVID-19 for IPC. [Supplementary Table 1] shows the variables of KAP.



To assess the KAP, a total 30 questions were asked (including 16 for knowledge, 6 for attitude and 8 for practices). The survey questions were based on the training material for the online training program for COVID-19 management and published literature regarding infection, prevention and control and COVID-19. The initial draft of the questionnaire was validated by three experts of the field. The final questionnaire was drafted after the inclusion of all suggestions and upon the consensus of all experts.

Study size

Applying the finite correction factor for sample size calculation for cross sectional study, assuming the prevalence of KAP as 50% at 95% confidence interval (CI) and 7.5% absolute precision, the desired sample size came out to be 134. The total study size was 137.

Quantitative variables and statistical methods

Statistical analysis was done using STATA 16 (StataCorp LLC, Texas, USA). Descriptive analysis on demographic characteristics and training related information was presented as numbers and percentages. Frequencies and percentage of KAP were individually analysed after excluding missing data. In further analysis, each individual question was assigned one mark which gave a total score of 16, 6 and 8 for KAP, respectively. The mean scores were calculated for KAP with assumption that any missing data or 'can't say' option in question denotes that the participant does not know the correct response. The total score was then calculated into categorical variable with 50% cut-off for each category. This cut-off was pragmatically decided through consensus of the authors since we were apprehensive that the population median scores would be too low given that COVID-19 was 'too new' at that point of time and hence, could lead to artefactual interpretations. A cut-off level of >8 and 8 or below 8 was set for good knowledge and poor knowledge, respectively. In attitude component, a cut-off level of >3 was set for the good attitude and 3 or below 3 was set for poor attitude. Similarly, a cut-off level of >4 was set for good practices and 4 or below 4 was set for bad attitude. Bivariate logistic regression was performed using 95% CI to determine significant association between independent variables and categorical dependent variables. P < 0.05 was considered statistically significant.

Ethical consideration

The study was undertaken as an evaluation of AWWs and permission of NIPCCD, Lucknow was taken prior to the evaluation. To uphold participant autonomy, privacy and confidentiality, personal details and potential identifiers were removed or coded from the data. The study was approved by the Institutional Ethics Committee of Dr. Ram Manohar Lohia Institute of Medical Sciences.


  Results Top


[Table 1] provides demographic characteristics and training related information of the participants. A total of 137 survey responses were received. The mean age of the participants was 44.3 ± 9.2 years ranging from 28 to 72 years. Majority of the participants were from rural areas (89%). Across the participants, around 49% of the participants had education status at intermediate level and below while 51% had completed graduation or post-graduate qualification. Approximately 57% of the participants had already received training on COVID-19 management. The mean years of experience in ICDS program was 18.4 ± 9.8 years ranging from 1 to 39 years.
Table 1: Demographic and training related information

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Knowledge of Anganwadi workers regarding COVID-19

In the knowledge component, [Supplementary Table 2] depicts the distribution of responses for individual questions. The mean knowledge score was 7.2 ± 2.64 with the highest score at 14.4 out of 16. Less than half (39.4%, 95% CI = 31.2%–48.1%) of the participants had accurate knowledge. The remaining 83 participants (60.6%, 95% CI = 51.9%–68.8%) were not knowledgeable. An independent sample t-test conducted to compare the good scores (M = 9.4, standard deviation [SD] = 1.61) and poor scores (M = 5.4, SD = 1.75) in the knowledge category demonstrated that there was a significant difference in the scores, t(135) = −14.20, P < 0.001.



Attitude of Anganwadi workers regarding COVID-19 and infection prevention and control

The distribution of responses for each question of attitude is presented in [Supplementary Table 3]. The mean score of attitudes for the respondents was 4.3 ± 1.14 with the highest score at 6 out of 6. Majority of the respondents had positive attitudes (85.4%, 95% CI = 78.4%–90.8% vs. 14.6%, 95% CI = 9.2%–21.6%). An independent sample t-test conducted to compare the good scores (M = 4.7, SD = 0.6) and poor scores (M = 2.3, SD = 1.21) in the attitude category demonstrated that there was a significance difference in scores, t(135) = −13.57, P < 0.001.



Practices of Anganwadi workers regarding COVID-19 and infection prevention and control

The assessment of practices of AWWs regarding COVID-19 and IPC was done using 8 questions. The distribution for good practices is presented in [Supplementary Table 4]. The mean score of practices for the respondents was 4.44 ± 1.38 with the highest score at 8 out of 8. Majority of the respondents had positive practices (70.1%, 95% CI = 61.7%–77.6% vs. 29.9%, 95% CI = 22.4%–38.3%). An independent samples t-test conducted to compare the good scores (M = 5.13, SD = 0.75) and poor scores (M = 2.85, SD = 1.20) in the practices demonstrated that there was a significant difference in scores, t(135) = −13.45, P < 0.001.



Factors influencing the knowledge, attitude and practices of Anganwadi workers

[Table 2], [Table 3], [Table 4] represent the association between influence factors and KAP with regard to COVID-19 among the AWWs. In multivariate logistic regression analysis, respondents with good practices scores were more likely to have good scores in knowledge component (adjusted odds ratio [AOR]: 3.39, 95% CI: 1.40–8.22, P < 0.01). It was also seen that with increasing age of respondents (AOR: 1.07, 95% CI: 1.02–1.13, P = 0.01) and those with good knowledge scores (AOR: 2.99, 95% CI: 1.20–7.43, P = 0.02) were more likely to score good scores in practice component. Multivariate logistic regression analysis was further conducted using median score of KAP component as cut-off for good and poor scores. Respondents who had training in COVID-19 (AOR: 2.23, 95% CI: 1.05–4.75, P = 0.04) and those with good practices component scores (AOR: 2.22, 95% CI: 1.05–4.68, P = 0.01) were more likely to score good scores in the knowledge component. In addition, those with good scores in practices component (AOR: 2.22, 95% CI: 1.05–4.68, P < 0.01) were more likely to have good scores in the attitude component. However, with increasing age of the respondents (AOR: 0.84, 95% CI: 1.05–4.68, P = 0.01), they were less likely to have good scores in attitude component. Furthermore, with increasing age of the respondents (AOR: 1.07, 95% CI: 1.03–1.12, P < 0.01), those with good scores in knowledge component (AOR: 2.23, 95% CI: 1.04–4.78, P = 0.04) and those with good scores in attitude component (AOR: 7.84, 95% CI: 1.42–43.14, P = 0.02) were more likely to score good scores in practices component.
Table 2: Predictors of knowledge of Anganwadi workers on COVID-19 and Infection Prevention Control measures

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Table 3: Predictors of attitude of Anganwadi workers on COVID-19 and Infection Prevention Control measures

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Table 4: Predictors of practices of Anganwadi workers on COVID-19 and Infection Prevention Control measures

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  Discussion Top


Frontline health workers such as AWWs are integral to the public health response towards COVID-19. It is, therefore, of paramount importance that they have adequate knowledge about clinical manifestation, diagnosis, proposed treatment and established prevention strategies for the disease. Extensive search of literature did not yield any study on KAP of AWW for IPC in the context of COVID-19.

Our findings demonstrated that, in this all-female cohort of community workers, the mean attitude and practices scores were above 50% cut-off, while the mean knowledge score was below it. Among the participants, 39.4%, 85.4% and 70.1% had good KAP scores, respectively.

In a previous study in Venezuela among healthcare workers (HCWs), good knowledge and appropriate practices was observed in the majority of the HCWs (76.3%); positive attitude was significantly higher in frontline workers (52.8%). However, there was poor knowledge regarding the virus name (62.9% chose the wrong answer) and proper use of PPE in different scenarios.[9] In our study, also, 93.7% of participants responded that COVID-19 is a virus and not SARS COV 2. A recent study among Vietnamese Healthcare worker also revealed that HCWs had good knowledge (91.3%), a positive attitude (71.5%) and appropriate practice (83.1%) regarding COVID-19 prevention.[10] The difference in scores on knowledge component compared to our study is primarily due to the respondents in these studies being medical HCWs including doctors involved in day today care of COVID-19 patients.

A descriptive cross-sectional study in Tripura, Northeast India, among ASHAs observed that only 10% of the ASHAs had adequate knowledge, 30.9% showed positive attitude and 88% adhered to the good practices. ASHA and ICDS workers are frontline community level health worker, recently repositioned for community surveillance and awareness. Lack adequate knowledge in them is a matter of concern and needs to be addressed via on job trainings.[11] A nationwide survey in Nepal, among frontline HCWs, revealed that 76% had adequate knowledge, 54.7% had positive attitude and 79% had appropriate practice.[12]

In our study, majority of the participants correctly identified some of the symptoms of COVID-19, such as breathing difficulty (96.24%), fever (90.23%) and dry cough (85%). Other important symptoms such as loss of taste/smell and diarrhoea were lesser known. The findings are very similar to the study in Mozambique.[13] A KAP study among ASHA worker in NE India also reported that majority (90%) of the participants were aware of the primary symptoms for COVID-19.[11] The reason for increased awareness about major symptoms is a result of nationwide circulation of information, education and communication (IEC) material by central and state governments on different media platforms.

In a previous study by Feldman et al. among HCWs, direct contact with contaminated surfaces and objects was the most mentioned transmission route (91%), followed by direct contact with an infected person (90%) and respiratory droplets (89%).[13] In our study, though the AWW were aware of the preventive measures, they had poor knowledge of route of transmission. This is an important knowledge gap that in turn can have an impact on adopting and maintaining the correct attitude and practices.

Feldman et al. reported, about 39% of participants to have listed the correct combination of appropriate prevention measures (wash hands, wear a mask, avoid touching your face, cover mouth when coughing or sneezing, home isolation if unwell and practice social distancing).[13] In our study, 98% of participants responded that wearing a mask, hand hygiene and physical distancing is important all the time. The reason may be extensive IEC using caller tunes, print and Audio Visual media.

In our study, majority of AWWs knew that hand washing as an important element of standard precautions. However, they lacked accurate knowledge with regard to the recommended steps and duration. The overall poor performance of knowledge scores of AWWs reflects on their present competencies and the effectiveness of prior training. Frontline workers such as AWWs undergo training related to water, sanitation, hygiene and other basic IPC measures.[14] The government of India has sanctioned job training, refresher training and induction training of AWWs as they are recognised to play a crucial role in improving community health.[14] Previously conducted studies on pre- and post-training evaluation among AWWs have shown that their knowledge significantly improved after training and that refresher training programs need to be conducted at intervals to improve the quality of their services.[15]

In our study, only about half of the participants knew that there are three layers in surgical mask and that white side should face inwards. With regard to practice of using mask, 60% of participants were aware of the correct way of using surgical face mask covering Nose, mouth and chin and about 45% knew the recommended maximum duration of wearing it. About three fourth of AWW responded that N95 mask can be reused, however only one fifth were aware of the correct way of reuse. A previous study on use of PPE in COVID-19 found that knowledge, attitude and practice of HCWs regarding the use of face masks were inadequate. Around 43.6% of participants knew about correct method of wearing the masks and about 75.5% knew the recommended maximum duration of wearing it. The HCWs had a positive attitude but moderate-to-poor level of knowledge and practice with regard to use of face mask.[16] Community awareness campaigns on proper use of face mask, social media and other mass communication channels is the need of the hour in this pandemic.

The findings of our study on association between demographic characteristics and KAP revealed that there is a crucial connection between knowledge and practices scores. It also showed that training on COVID-19 can lead to good knowledge scores. Most importantly, increase in age of the worker, good knowledge and good attitude led to good practices. This result implies that although it is difficult to estimate how much knowledge and attitude may lead to good practices, a desirable change can be brought about by improving and increasing the capacity of training for AWWs. A previous study among HCW in Vietnam also had similar finding, with senior HCWs (aged 40 and higher) and those who had good knowledge of COVID prevention being more likely to practice all measures of prevention.[10] Previous studies Venezuela and Nepal among HCWs had reported older age as an appropriate predictor for good practices.[12],[17]

With the emergence of COVID-19 pandemic, the Anganwadi ecosystem across India was rapidly repositioned to provide essential services to the communities. However, the limitation of knowledge and training were quite evident at the initial stages of the pandemic. It is crucial that frontline workers such and AWWs are trained and provided refresher courses to improve their knowledge and understanding of COVID-19. The Ministry of Women and Child Development conducted capacity building sessions for AWWs on online platforms regarding COVID-19 and its precautionary measures.[2] However, the effectiveness and impact this training need to be evaluated in order to safeguard these frontline human resources.

Our study has some limitations. First, it was a cross-sectional design in a single district of Uttar Pradesh and cannot be generalised to AWWs in other districts or states across the nation. Second, the convenience sampling technique used in the study may have led to a selection bias as participants who required the training may have been present for the online training thus giving poor scores. A robust study design such as pre- and post-training evaluation across all the districts of Uttar Pradesh can be used in order to assess the overall KAP of AWWs in the state.


  Conclusion Top


We identified that the KAP related to IPC in context of COVID-19 among the AWWs in Lucknow, Uttar Pradesh, were modest to protect themselves from the pandemic. However, there is alarmingly poor knowledge among these frontline workers and urgent training is required to ensure improvement of their knowledge which would ultimately affect their attitude and practices during these difficult times. Finally, this study provides critical insights in to how to improve the practices of precautionary measures among the AWWs, who are frontline workers, working in proximity with the community.

Acknowledgement

ICDS supervisors, Lucknow District.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The Women and Child Development Department Government of Maharashtra. Anganwadi Functions: Women and Child Development Department, Government of Maharashtra, India. Women and Child Development Department, Government of Maharastra. Available from: https://womenchild.maharashtra.gov.in/content/innerpage/anganwadi-functions.php. [Last accessed on 2021 Feb 21].  Back to cited text no. 1
    
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Poddar P, Mukherjee K. Response to COVID-19 by the Anganwadi Ecosystem in India. Report No.: 020_THL0620_DGR; February, 2021. Available from: https://assets.kpmg/content/dam/kpmg/in/pdf/2020/06/anganwadi-report-2020.pdf. [Last accessed on 2021 Feb 10].  Back to cited text no. 2
    
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India: The Dual Battle against Undernutrition and COVID-19 (Coronavirus). World Bank. Available from: https://www.worldbank.org/en/news/feature/2020/04/27/covid19-coronavirus-india -response-health-undernutrition-anganwadi-workers-healthcare. [Last accessed on 2020 Sep 21].  Back to cited text no. 3
    
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National Health Mission. COVID-19 Facilitator Guide: Response and Containment Measures Training Toolkit for ANM, ASHA, AWW. Ministry of Health and Family Welfare. Available from: https://www.mohfw.gov.in/pdf/FacilitatorGuideCOVID19_27%20March.pdf. [Last accessed on 2021 Feb 15].  Back to cited text no. 7
    
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Tien TQ, Tuyet-Hanh TT, Linh TN, Hai Phuc H, Van Nhu H. Knowledge, attitudes, and practices regarding COVID-19 prevention among Vietnamese Healthcare Workers in 2020. Health Serv Insights 2021;14:1-7.  Back to cited text no. 10
    
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Chowdhury P, Baidya S, Paul D, Debbarma P, Kalita B, Karmakar S. Assessment of knowledge, attitude and practices among Accredited Social Health Activists (ASHAs) towards COVID-19: A descriptive cross-sectional study in Tripura, India. medRxiv 2021.  Back to cited text no. 11
    
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Feldman M, Lacey Krylova V, Farrow P, Donovan L, Zandamela E, Rebelo J, et al. Community health worker knowledge, attitudes and practices towards COVID-19: Learnings from an online cross-sectional survey using a digital health platform, UpSCALE, in Mozambique. PLoS One 2021;16:e0244924.  Back to cited text no. 13
    
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Chughtai AA, Seale H, Chi Dung T, Maher L, Nga PT, MacIntyre CR. Current practices and barriers to the use of facemasks and respirators among hospital-based health care workers in Vietnam. Am J Infect Control 2015;43:72-7.  Back to cited text no. 17
    



 
 
    Tables

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



 

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