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ORIGINAL ARTICLE: COVID-19 SERIES
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Year : 2020  |  Volume : 38  |  Issue : 2  |  Page : 144--151

Gender and occupation predict Coronavirus Disease 2019 knowledge, attitude and practices of a cohort of a South Indian state population

Sridhar Amalakanti1, Kesava Venkata Raman Arepalli1, Ravi Kiran Koppolu2,  
1 Department of General Medicine, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India
2 Department of Microbiology, Nimra Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India

Correspondence Address:
Dr. Sridhar Amalakanti
Department of General Medicine, Great Eastern Medical School and Hospital, Ragolu, Srikakulam, Andhra Pradesh
India

Abstract

Context: Coronavirus disease 2019 (CoViD 19) pandemic has induced the government to initiate strict control measures. Improvements to these measures and shortcomings could be gleaned with the understanding of the knowledge, attitude and practices (KAP) of the public. Aims: The aim of this study the CoViD 19 KAP of a south Indian state population. Settings and Design: This was a Cross-sectional observational study. Subjects and Methods: We conducted an online survey to elicit this information. Statistical Analysis Used: Mean, Standard deviation, Binomial and Multinomial logistic regression. Results: Of the 1837 subjects who answered the survey, 70% were youth (16–29 years), 54% were postgraduates and 47.8% were desk jobholders. The mean knowledge score was 9.92 ± 2.37/14 and 94.44% secured at least above-average score. The subjects had a positive (70%) attitude towards the CoViD 19 situation and 77% of subjects followed good preventive practices. However, we found that women, people with low education and nonmedical background were associated with poor knowledge and practices. The attitude was poor in subjects occupant in physical works. Conclusions: The health policy would better serve the purpose of the groups with poor scores are targeted.

How to cite this article:
Amalakanti S, Raman Arepalli KV, Koppolu RK. Gender and occupation predict Coronavirus Disease 2019 knowledge, attitude and practices of a cohort of a South Indian state population.Indian J Med Microbiol 2020;38:144-151

How to cite this URL:
Amalakanti S, Raman Arepalli KV, Koppolu RK. Gender and occupation predict Coronavirus Disease 2019 knowledge, attitude and practices of a cohort of a South Indian state population. Indian J Med Microbiol [serial online] 2020 [cited 2020 Sep 28 ];38:144-151
Available from: http://www.ijmm.org/text.asp?2020/38/2/144/293905

Full Text



 Introduction



Coronavirus disease 2019 (CoViD 19), a respiratory disease caused by SARS COV 2[1] has been reported in 4,006,257 people worldwide. Moreover, it has killed 278,892 patients by 11 May 2020.[2] As of the 1st week of May 2020, there is no drug/vaccine against the virus.[3] Prevention, therefore, remains the key defence against the disease. To prevent the spread of the infection, countries worldwide have put their states into lockdown with restrictions of all travel and movement of people out of their homes except for emergency purposes.[4] India, the second most populated country in the world, announced lockdown very early in the epidemic.[5] It has recorded 67,152 cases, with 2206 deaths by 11 May 2020.[6] It has also launched public awareness campaigns through the media apart from the curfew to sensitise and update the citizens about CoViD 19.

The effectiveness of all these measures depends on the people's adherence to the government directives and measures. This, in turn, is based on the knowledge, attitude and practices (KAP) regarding the virus in the general public. The pandemic is a totally unprecedented situation to the people, and thus, the response of the public to the unique circumstances needs to be understood for any effective disease control planning. The people's knowledge about the disease, its mode of spread, symptoms and preventive measures form their attitudes and drive their actions. The sources through which most of the general public seek information about the situation can only be understood by a survey from the people directly. An understanding of the attitude of the public towards CoViD19 can help predict the response to government measures. Since CoViD19 is contagious, the practices of the public towards transmission prevention need to be studied to plan strategies matching the deficiencies. This data of the KAP will provide light on the weakest links in disease prevention.[7] This information can improve efficient health policy planning. We studied the KAP aspects in a group of the Indian population of Andhra Pradesh state wherein the disease is on the rise in May 2020.

 Subjects and Methods



In the South Indian state of Andhra Pradesh, we conducted a KAP study concerning the CoViD19 epidemic. A 55-point questionnaire [Supplement 1] was answered online by the subjects (age >15 years) who were recruited through Whatsapp/Facebook/Twitter or other social media. This online mode was chosen because of the strict lockdown. The response was limited to one per device. The questionnaire [Supplement 1] was opened to responses from 29th April 2020, to 2nd May 2020 on Google forms platform. Questions included demographic data, knowledge about CoViD 19, attitude towards CoViD 19 situation and infection preventive practices domains. Questions on knowledge carried one mark for the correct answer and zero for wrong/don't know response. The questionnaire was initially tested for validity and reliability. Two experts in public health, one news personnel and a microbiologist assessed and commented on the questionnaire. Modifications were made accordingly. Pretesting of the questionnaire was done on 20 subjects. They answered the questionnaire twice 2 weeks apart. Cronbach's alpha was 0.73 and the intraclass correlation coefficient was 0.96. The study was approved by the institutional ethical committee at the Great Eastern Medical School, Ragolu.(10/IEC/GEMS and H/2020). As participation was voluntary, it was considered as consent for the study. The data were extracted to the Microsoft excel sheet and analysed. The sample size was calculated based on a previous study.[8] The sample size obtained was 1632. Measures of central tendency and frequencies were described. Parametric quantitative data were described by the mean and standard deviation. Qualitative data were described by frequencies and analysed by binary logistic regression and multinomial logistic regression. Subgroup analysis was performed on similar lines. Statistical significance was set at P < 0.05. Missing data were excluded from analysis. Data analysis was performed with SPSS software-version 20.0 (SPSS Inc. Chicago, IL, USA). Responses were graded into three categories of knowledge. Score <5/14 = Poor knowledge. 6–10 = Average score. More than 10 = Very good score.

Responses to attitude questions were added, and responses with score <7 were considered as poor attitude. Responses to practice questions were added, and responses with a score <7 were equated to poor practices.

 Results



A total of 1837 people answered the questionnaire. The demographic details are presented in [Table 1].{Table 1}

Of the participants, 70.6% were youth with elderly people forming only 4.8%. Both the male and female gender were almost equal in number (Males-56.5%, Females-43.1%). Participants were predominantly educated, with 44.8% constituting the 10th standard to degree level and 54% more than degree level. Desk workers, including people working in offices, shops, clinics (47.8%) and students (39.4%), were also represented in the study. About 55% were related to the medical profession. Four CoViD-positive patients also responded.

Knowledge

The mean knowledge score of the subjects was 9.92 ± 2.37. Significantly 94.44% people had at least average knowledge (score >5) [Figure 1]. [Figure 2] shows that most of the participants obtained knowledge regarding CoViD 19 from television and google search. [Table 2] shows that age 35–50, female gender, intermediate education and non-medical background were the factors associated with poor knowledge of COVID-19. In our study, 15.6% of participants did not have accurate knowledge of CoViD 19 symptoms. And 13.4% of subjects did not recognise the higher risk for elderly people.{Figure 1}{Figure 2}{Table 2}

Attitude

Most of our participants (70%) had a positive attitude towards CoViD 19 situation [Figure 3].{Figure 3}

[Table 3] shows that people engaged in physical work when compared to desk work are associated with poor attitude towards CoViD-19. To the question of whether we could control the virus completely, 74.6% responded positively, 2.2% responded negatively and 23.2% were ambivalent. Multinomial logistic regression shows the negative responses to this question were associated with male gender (P = 0.002, odd's ratio = 4.82,95% confidence interval [CI] 1.76–13.24) and housework occupation (P = 0.04, odd's ratio = 8.03,95% CI 1.10–58.55).{Table 3}

In this study, 18% of subjects constantly worried about contracting the disease. Moreover, 29.9% of participants did not worry. The rest 52.1% worried sometimes but not all the time.

Practices

[Figure 4] shows that a high proportion (77%) of people followed good practices to prevent CoViD 19 infection. Also, 9% of subjects had good practicing habits before CoViD 19 pandemic.{Figure 4}

[Table 4] shows that female gender, house working occupation and lower knowledge score are associated with poor practices. People who started wearing face masks after CoViD 19 epidemic were 81.7%, those who wore masks inconsistently were 9.3% and those who still did not wear masks were 4%. Moreover, 4.9% wore masks even before CoViD 19 epidemic. Multinomial logistic regression showed that intermediate education (10th standard to degree) was associated with not wearing a mask (P = 0.01, odd's ratio = 0.41, 95% CI 0.20–0.84).{Table 4}

After the epidemic, 85% of subjects avoided crowds. However, 9.5% of them opined that it is not always possible to avoid crowds. Moreover, 1.2% did not make any active attempt to avoid crowds. Interestingly, 4.3% of subjects had always avoided crowds long before the pandemic. Multinomial logistic regression showed that housework occupation (P = 0.01, odd's ratio = 38.63, 95% CI 2.16–689.80) and currently married status (P = 0.02, odd's ratio = 0.05, 95% CI 0.004–0.56) were associated with not avoiding crowd behaviour.

In this study, 77% of subjects used sanitiser/soap when they washed their hands. But 11.7% did not use it. Among the subjects, 11.3% had always had this practice.

 Discussion



Our online survey to understand the KAP of a group of subjects in Andhra Pradesh, a state with rising CoViD 19 cases in India (May 2020), showed that >90% of subjects had above-average knowledge. The subjects acquired information of CoViD 19 from television and Google search (Internet). Predictors of poor knowledge were middle age, female gender, intermediate education and lack of medical background. In our study, 70% of subjects had a positive attitude towards the control of CoViD 19. The subjects occupied in physical work had a poor attitude. Importantly, 77% of participants followed good practices against CoViD 19 infection. And, 9% even practiced them before the epidemic. Female gender, low knowledge and housework occupation were associated with poor practices.

The presence of a high proportion of youth, educated people and desk job workers in our study may be due to the nature of the recruitment of subjects. As we recruited subjects through social media linked to smartphones, which are mostly used by these groups, our study was represented by them. Other online studies also showed a similar profile of responders. A study performed in China had a similar demographic profile.[7] A large United States (US) and United Kingdom (UK) study with 6000 participants was constituted by a high proportion of youth.[9] An Egyptian CoViD 19 KAP study reported 48% of youth and 52.2% university graduates.[10] Young subjects were the predominant responders in two other different locations.[11],[12] Two other studies [11],[13] reported subjects constituting 75%–85.58% of responders who had university-level education.

The high proportion (94.44%) of participants with at least average knowledge of CoViD 19 shows that the subjects were well informed. This result was in line with a large study in China with 90% correct responses. This was 69% in a Ugandan study [12] and 62% in a study from Paraguay.[11] Television and Google (Internet search) were the predominant sources of information in our study, mirrored in a Thailand study.[8] The use of television and social media by the Indian central and state governments to disseminate CoViD 19 news and education has thus been utilised by the public. Our study supports the continuation of this usage policy. In the Egyptian study, social media (66.9%), the Internet (58.3%) and television (52.6%) were the main sources of CoViD 19 information.[10] A study from the United Arab Emirates showed that 61% participants accessed CoViD 19 information through social media.[14] It was as high as 83.5% in a study from Kuwait.[13] While social media (74%), television and radio (72%), were a significant source of knowledge for Ugandan health workers,[12] the government website (79%) and the World Health Organisation (WHO) (88%) were more accessed sources of information.

The middle age group (30–49), females, and the people educated up to 10° were associated with poor knowledge in our study. This may be due to preoccupation with day to day work/worry. Women busy with household work may have less access to information and factual knowledge.[15],[16] The undereducated by way of social communication via phone, etc., and the highest educated by continuous news and digital media updates [17] may be abreast with CoViD 19 knowledge. Nonmedical background with poor knowledge is understandable and is seen in other studies also.[18] The comparative predictors of poor knowledge in four studies are shown in [Table 5].{Table 5}

In our study, 15.6% of subjects did not know the signs and symptoms of CoViD 19. In the Thailand study,[8] this was up to 56.7%. In the US,[9] it was 21.2%, in the UK [11] it was 16.4%, and in Kuwait, it was 12.4%–26.9%.[13] It may mean that either the subjects had not had a strong sensitization to the clinical signs and symptoms or are not confident to answer affirmatively regarding this aspect. As this is an important factor to identify or suspect a CoViD 19 victim, more penetrant knowledge providing measures on this aspect may be planned by the knowledge providers.

Compared to 3.7% of subjects in the US [9] and 1.7% subjects in the UK,[9] 13.4% of our study subjects did not know that the elderly are more severely affected by CoViD 19. This may be due to differences in the knowledge between the Western and Eastern world.[20]

In our study, 70% of subjects had a positive attitude towards CoViD 19 prevention and course. It was over 90% in the Chinese population.[9] This confidence may be due to the strict lockdown control measures by the government [5] the success of these measures in Chinese [21] and also due to the low case fatality rate in the Indian peoples.[22] The poor attitude in subjects occupied in physical labour may be due to loss of work, potential layoffs [23] and also the low educational status (associated with poor attitude). This is also seen in the Thailand study data [8] [Table 6].{Table 6}

[Table 7] shows the attitude predictors across studies regarding the control of the epidemic.{Table 7}

An earlier small Indian study focusing on mental issues reported that 72% of participants worried about the risk for infection.[24] The Egyptian study reported that 86.9% of participants are worried of contracting the infection.[10] In Thailand,[8] 57.9% of participants reported that they worry about CoViD 19. In our study, 18% participants felt so. This comparatively lower value may be due to the early severe lock down [5] measures by the government and the slow spread of the disease compared to other countries.[22]

In our study, 77% of participants followed good practices, while 9% of them had these habits before the epidemic. These good preventive practices were reported to be 47.37% in Thailand,[8] 97.2% in China,[19] and 89.7% in a Chinese healthcare worker study [25] and 74% in a Ugandan health worker study.[12] These suggest that a good number of people practice preventive measures against CoViD 19, and the proportion is understandably high in health care-associated people. As half of our participants had a medical background, we recorded a high percentage of good practices. The predictors for poor CoViD 19 infection preventive practice across studies included are shown in [Table 8].{Table 8}

Poor practices were associated with females, house workers and low knowledge in our study. Poor knowledge in the females who generally do the housework in India [15],[16] may be an important factor. This group then should be a target for better sensitization against CoViD 19.

In our study, 4% of subjects did not wear masks. It was 37% in the earlier Indian mental health study [24] and 65% in the Egyptian study.[12] This behaviour is as high as 83% in the Thailand study.[8] This may be due to the rural background and lower education status of the Thailand study [8] participants. A Paraguayan study reported 25.69% of participants not wearing a mask.[11] Interestingly, a study done in an earlier phase of the pandemic reported that 46% of health-care workers did not wear a mask in duty.[12] Conflicting guidelines from the Center for disease control [26] and the WHO [27] may be one reason. Across studies, the factors associated with not wearing masks are shown in [Table 9].{Table 9}

In our study, 11.7% did not wash their hands with sanitizer soap. Among the Ugandan health workers, it was only 4%.[12] In Thailand,[8] 54.8% did not. Probably, due to lower education and rural residence of Thailand [8] study participants.

Our study showed that 85% of the subjects avoided crowds to prevent infection. This is similar to 90% reported in the previous indian study.[24] A study from Paraguay reported 88.35% crowd avoidance practice.[11] This may be due to the awareness and intention of the public or due to the government imposed curfew. Across the different studied there were different predictors of avoiding crowds [Table 10].{Table 10}

The responders of our study were mostly educated and young. Uneducated and elderly were not overtly represented in the study. The study is also subject to the honesty and recall bias of the subjects. Other limitations of the study were access to smartphone and knowledge of english language. Overall, the subjects had good knowledge of CoViD 19. Their information sources were television and the internet. Our study shows the need to improve the CoViD 19 knowledge in women, people with low education and no medical background and in the adult age group. There is a need to address the attitudes amongst physical workers.

Conclusion

Across the discussed CoViD 19 KAP studies, it is reflected that poor knowledge is associated with lower education, poor attitude with manual work and poor practices with house workers. These aspects should be considered under any global interventions against CoViD 19.

Acknowledgement

We thank Dr Srikanth Guttikonda and Mr. Madhusudhana Rao Korada for questionnaire assessment. Mr. Teja Jallepalli for his help with Ms. Excel. We thank Dr. Abhiram Chadalawada for helping with hardware.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 Supplement 1: Questionnaire



General Questions

My age is

16-29

30-49

50 and above

Other:

I am a

Male

Female

Other:

I am

Never married

Married

Other:

I have studied

<5th std

6–10th std

10°/diploma

More than degree

My daily work before Covid19.

Office

Shop/clinic/hospital

Housework

Physical work

Student

Not working

I am a medical person/student

Yes

No

Presently I am living

At home

Locked outside due to curfew in another place

In home quarantine

In govt quarantine place

I am presently living

In Andhra or Telangana

Outside Andhra or Telangana but in India

Outside India

There are children below 15 years of age in our family with us now

Yes

No

There are adults above 50 years age in our family with us now

Yes

No

I have diabetes (blood sugar)

Yes

No

I have kidney disease

Yes

No

I have lung disease

Yes

No

I am a smoker

Yes

No

I am using chemotherapy

Yes

No

I had a liver/kidney/major organ transplant

Yes

No

I have heart disease

Yes

No

I have liver disease

Yes

No

I have a body mass index (BMI)>40

Yes

No

I have HIV infection

Yes

No

I have/had CoViD19

Yes

No

I read/see about CoViD19 from

Newspaper

Television

Google

WhatsApp/Facebook/Twitter/Instagram

Other:

Knowledge Questions

CoViD19 in the body can be killed by taking medication 1 point

Yes

No

Don't know

Elderly people are severely affected by the virus 1 point

Yes

No

Don't know

People with lung problems are severely affected by CoViD19. 1 point

Yes

No

Don't know

The USA has made a successful vaccine against CoViD19 1 point

Yes

No

Don't know

Fever, cough and difficulty in breathing are seen in CoViD19 patients 1 point

No

Not sure

Yes

In India, home quarantine means 1 point

Staying in home + no visitors

Maintaining one meter distance from family members in home

Using face mask at home

Using separate utensils at home

All of the above

Other:

It is scientifically proven that eating wild animals causes CoViD19 infection 1 point

Yes

No

Don't know

Coronavirus positive persons can transmit infection without fever or cough 1 point

True

False

Don't know

Corona virus is spread by droplets from mouth and nose 1 point

True

False

Don't know

Coronavirus 19 infected people will show disease features within 14-28 days 1 point

True

False

Don't know

The country with the highest number of CoVirus positive cases till April 28 was 1 point

USA

Italy

China

In India, CoViD 19 infection is tested (as of April 28th) by 1 point

Throat/nasal swab

Blood test

Both

Don't know

Corona virus can spread through touch 1 point

True

False

Don't know

CoViD19 epidemic started in 1 point

Italy

China

India

Older people should be more careful than younger ones

Yes

No need

Other:

Practice

We started to clean all packets/substances (milk packets, chips, chocolate, packed food, plastics) brought from outside

Yes

No

Most of the time but not every time

I wash all items long before CoViD19 outbreak

I started washing hands with sanitizer/60% spirit

Yes

No

I wash hands with sanitizer long before CoViD19 outbreak

I started washing hands for 20 seconds

Yes

No

Not always

I wash hands for 20 seconds before CoViD19 outbreak

I started washing my hands when I come from outside every time

Yes

No

Not every time but most of the times

I wash my hands long before CoViD19 outbreak

I started maintaining distance from other people when going out

Yes

No

Not possible every time

I maintain distance long before CoViD19 outbreak

I avoid groups of people nowadays

Yes

No

It is not possible every time

I avoid crowds long before CoViD19 outbreak

I started to wear a mask when I go out after CoViD19 outbreak

Yes

No

Most of the time

I am using mask long before CoViD19 outbreak

I have started washing hands frequently

Yes

No

Not frequently but sometimes

I wash my hands frequently long before CoViD19 outbreak

Attitude

I will be happy to isolation/quarantine if I am tested to be positive

Yes

No

Other:

I will test myself for CoViD19 if it is available in private

Yes

No

Not sure

I will go to a govt doctor if I have symptoms

Yes

No

Maybe if symptoms are severe

Food, milk packets and cool drink bottles from outside should be washed with sanitizer

Yes

No

Not always

I would like to check my CoViD 19 status

Yes

No

Not sure

I would like to check my CoViD19 status if it is free

Yes

No

Not sure

I would like to check my CoViD19 status even if fee has to be paid

Yes

No

Not sure

Anyone with the symptoms of the infection should report to the authorities themselves

Yes

No

Depends on the situation

We will definitely control the CoViD19 epidemic spread

Yes

No

Not sure

I worry about getting infected by the present epidemic coronavirus every day

Yes

No

Sometimes, not everyday

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