Community Section DOI : 10.7860/JCDR/2021/47016.14614
Year : 2021 | Month : Mar | Volume : 15 | Issue : 03 Page : LC06 - LC12

From Knowledge to Practice: Are we Prepared to Handle COVID-19 Pandemic? A Health Centre Based Cross-sectional Study

Surinderpal Singh1, Anurag Chaudhary2, Mahesh Satija3, Pranjl Sharma4

1 Associate Professor, Department of Community Medicine, Dayanand Medical College and Hospital (DMCH), Ludhiana, Punjab, India.
2 Professor and Head, Department of Community Medicine, Dayanand Medical College and Hospital (DMCH), Ludhiana, Punjab, India.
3 Professor, Department of Community Medicine, Dayanand Medical College and Hospital (DMCH), Ludhiana, Punjab, India.
4 Assistant Professor, Department of Community Medicine, Dayanand Medical College and Hospital (DMCH), Ludhiana, Punjab, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Pranjl Sharma, Assistant Professor, Department of Community Medicine, Dayanand Medical College and Hospital (DMCH), Civil Lines, Ludhiana, Punjab, India.
E-mail: pranjlsharma@gmail.com
Abstract

Introduction

Knowledge is the beginning of prevention, and transformation of knowledge into preventive practices. Knowledge, attitude and practice surveys among populations provide useful information about community behaviour in prevention and control of infectious diseases like Coronavirus Disease 2019 (COVID-19).

Aim

To assess the knowledge, perceptions and practices of patients about COVID-19 visiting Outpatient Department (OPD) of a health training centre during lockdown period.

Materials and Methods

A health centre based cross-divtional study was conducted from 1st to 15th May 2020 for 15 days in Rural Health Training Centre (RHTC) of Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. All patients (18 years and above) who visited the healthcare facility for the first time (visit) during the study period were included in the study. A total of 485 participants recruited through condivutive sampling were interviewed using adapted World Health Organisation (WHO) and previously published questionnaire on knowledge (15 questions), perceptions (2 questions) and practices (3 questions). Knowledge score ranged from 0 to maximum 15. Analysis was performed using SPSS 20.0 statistical software. Descriptive statistics, t-test, one-way analysis of variance (ANOVA) and Chi-square test were used to determine the difference between the groups for different variables at 0.05 level of significance.

Results

Mean knowledge score of the participants was 10.6±2.1. Out of 485 participants (mean age 48.8±16.2 years), majority 425 (87.6%) knew about main clinical symptoms and 448 (92.4%) knew isolation and treatment of COVID-19 infected persons as an effective way of prevention and control of COVID-19. However, 284 (58.6%) and 276 (56.9%) participants knew about transmission through respiratory droplets and by touching contaminated surfaces, respectively. Educational status showed an independent association with higher knowledge. Total 190 (39.2%) of the participants agreed on stigma against specific individuals. Regularly washing of hands (77.7%), three layered masks (29.9%) and physical distancing (33.2%) were commonly followed practices. Higher knowledge score was significantly associated with regular handwashing practices (p<0.001) and wearing of three layered masks (p<0.001).

Conclusion

Results highlighted good knowledge about COVID-19 of study participants. However, continued efforts over time are required to increase the COVID appropriate behavior regarding usage of face mask and physical distancing.

Introduction

In the current scenario of COVID-19 pandemic, ‘prevention’ is the key word in wake of non-availability of treatment and wait for an effective vaccine. During this unprecedented time of medical crisis, various preventive strategies have been adopted. Lockdown was valued as one of the important preventive strategies to contain COVID-19 by Government of India [1,2]. Punjab reported its first case on March 8, 2020 [3] and went a step further by imposing statewide curfew for strict implementation of lockdown [4].

The efforts of medical community are focused towards prevention of COVID-19 infection by adopting measures of protecting human host from disease agent. During lockdown, the masses were exposed to intense information regarding prevention from COVID-19 infection. The general population was repeatedly made aware of symptoms, routes of transmission and preventive measures like using masks, frequent hand washing and physical distancing [5]. Various methods including routine mass media like television, radio and newspaper and some innovative aids like giving message through caller tunes of telephones [6] and billboards was utilised for dissemination of information to public with an objective to change individual and community behavior towards prevention of disease in larger populations.

Knowledge, Attitude and Practices (KAP) surveys during Ebola outbreak provided vital information regarding health education [7] and also about the need to prevent stigma related to infectious diseases [8]. Therefore, similar strategy can be utilised in the context of COVID-19 pandemic. Thus, in the absence of effective cure, implementation of robust preventive strategy becomes essential to contain the pandemic. KAP surveys on COVID-19 in India have observed good knowledge and right practices towards COVID-19 pandemic among respondents and also identified a gap in perception towards COVID-19 myths and facts [9,10]. However, most of these were online surveys targeting that particular strata of population. Therefore, this study was planned with an objective of assessing knowledge, perceptions and practices of patients about COVID-19 visiting OPD of a health training centre during lockdown period in a rural area of Ludhiana, Punjab. The observations of this study may help public health authorities in timely containment of COVID-19 outbreak in India.

Materials and Methods

A health centre based cross-sectional study was carried out from 1st May 2020 to 15th May 2020 for 15 days in RHTC of Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. Ethics approval for the study was duly obtained from the Institutional Ethics Committee. Dayanand Medical College and Hospital Ludhiana (DMCH/R&D/2020-67).

All patients (18 years and above) visiting healthcare facility at RHTC, Pohir during their first-hospital visit from 1st May 2020 to 15th May 2020 were eligible to participate in the study. This was the period when lockdown was in operation across Punjab, but health centres were allowed to function to provide the healthcare services. Therefore, the opportunity was utilised to assess knowledge, perceptions and practices of subjects visiting health centre about COVID-19.

Inclusion criteria: As patient attendance was thin, all patients (18 years and above) willing to participate were included in the study.

Exclusion criteria: Patients who visited the health centre for the second time or more for follow-up, not in a condition to participate due to poor health and not willing to participate were excluded from the study. A total of 486 eligible patients visited during this period. However, one patient did not complete the questionnaire and hence, was excluded from the study. Thus, a total of 485 subjects were finally included.

Data was collected on a pre-tested pre-designed interviewer administered questionnaire after obtaining informed consent in local language. Questionnaire was finalised after seeking opinion of expert faculty members. Health workers (providing regular home-based health promotion and preventive care service to the communities in this rural field practice area for over two decades) who were trained and familiar with the terminology used in the questionnaire, well-versed in local language interviewed the participants in Punjabi under supervision. The first part of the questionnaire had information about socio-demographic characteristics such as age, gender, educational, occupational and marital status of the subjects followed by questionnaire on knowledge (15 questions), perception (2 questions) and practices (3 questions). Questionnaire was adapted from WHO resource [11] and a study conducted in China [12]. Knowledge section had 15 questions about symptoms (questions 1-2), prognosis (question no 3), modes of transmission (questions 4-8) and prevention and control (questions 9-15). All questions had correct/incorrect/not sure options. A correct answer to the question by the participant was given one mark, while all incorrect or not sure responses were assigned zero mark. The total knowledge score ranged from 0-15. Cronbach’s alpha coefficient for knowledge part of the questionnaire was 0.670.

For assessment of perceptions, participants were asked to respond to two questions whether they agree/disagree/not sure to presence of stigma against specific people (COVID-19 infected persons, their contacts and those returned from COVID affected areas) and yes/no/not sure to whether feeling low due to COVID-19/restrictions. Practices were measured using three questions and yes/no response by participants to handwashing with soap/water or sanitiser, wearing of facemasks and whether followed physical distancing after leaving home.

Statistical Analysis

Analysis was performed using Statistical Package for Social Sciences (SPSS), version 20.0 (IBM SPSS statistics 20.0.0, 2011). Descriptive statistics were presented in frequencies, percentages and mean±Standard Deviation (SD). Student’s t-test (independent samples), one-way analysis of variance (ANOVA) and Pearson’s chi-square test wherever applicable was used to determine the difference between the groups for different variables. All tests were two-tailed and p<0.05 was considered statistically significant. Multiple linear regression analysis using stepwise method was performed to identify socio-demographic factors independently associated with the knowledge score. All socio-demographic variables significantly associated with knowledge score (p<0.05) in the univariate analysis were included in multiple linear regression model with knowledge score as the outcome variable. Unstandardised regression coefficients (β), along with 95% Confidence Intervals (CIs) were used to quantify the adjusted associations between exploratory and outcome variables.

Results

The baseline socio-demographic characteristics showed that out of 485 participants, maximum number of the participants 181 (37.3%) belonged to age group of 40-60 years followed by 60 years and above 157 (32.3%). Mean age of the participants was 48.8±16.2 years with a range of 18-88 years. Male participants 248 (51.1%) were marginally higher than females 237 (48.9%). Half of the subjects were educated till 10th grade, while 115 (23.7%) of the subjects had no formal education. A total of 192 (39.6%) participants were homemakers, 51 (10.5%) were shopkeepers or engaged in small business and 47 (9.7%) were farmers. Majority of the participants were married 381 (78.6%) [Table/Fig-1].

Socio-demographic characteristics of the participants (N=485).

CharacteristicsFrequency (%)
Age (years)
<2011 (2.3)
20-2959 (12.2)
30-3977 (15.9)
40-4988 (18.1)
50-5993 (19.2)
60-69104 (21.4)
≥7053 (10.9)
Gender
Male248 (51.1)
Female237 (48.9)
Educational status
No formal education115 (23.7)
Primary (1st-5th grade)140 (28.9)
Matric (6th-10th grade)126 (26.0)
Senior secondary (11th-12th)62 (12.8)
Graduate and above42 (8.7)
Occupational status
Home maker192 (39.6)
Service66 (13.6)
Business51 (10.5)
Farmer47 (9.7)
Skilled/Unskilled Worker52 (10.7)
Student12 (2.5)
Unemployed65 (13.4)
Marital status
Married381 (78.6)
Never married56 (11.5)
Widow/widower46 (9.5)
Divorced02 (0.4)

A total of 15 questions were used to assess knowledge of the participants about COVID-19. Mean knowledge score was 10.6±2.1 with a range between 3-15. The overall correct score rate came out to be 70.7% (10.6 out of 15) and 357 (73.6%) of them scored 10 or higher marks. Majority of the participants knew about the main clinical symptoms 425 (87.6%), while only 284 (58.6 %) and 276 (56.9%) knew that COVID-19 transmits through respiratory droplets of infected patients and by touching contaminated surfaces. Participants mostly knew about regular handwashing with soap/water or sanitiser (77.7%), isolation and treatment of infected individuals (92.4%), isolation of contacts (95.9%) and wearing face masks (97.3%) as the effective ways to prevention and control. However, only half of them answered correctly that one should avoid crowded places [Table/Fig-2].

Knowledge of participants about COVID-19 (N=485).

Knowledge assessmentFrequency (%)
CorrectIncorrectNot sure
The main symptoms of COVID-19 are fever, cough, fatigue and muscle pain425 (87.6)60 (12.4)-
Shortness of breath is another important clinical symptom194 (40.0)253 (52.2)38 (7.8)
Presently, there is no effective cure for COVID-19216 (44.5)153 (31.5)116 (23.9)
The COVID-19 virus spreads through respiratory droplets of infected individuals.284 (58.6)192 (39.6)09 (1.8)
The COVID-19 virus spreads through direct contact with infected individuals.236 (48.7)203 (41.8)46 (9.5)
Touching contaminated objects/surfaces would result in the infection by the COVID-19 virus.276 (56.9)203 (41.9)06 (1.2)
Eating or contacting with infected animals would result in COVID-19 infection480 (99.0)04 (0.8)01 (0.2)
The COVID-19 virus infection spreads through airborne479 (98.8)06 (1.2)-
Regularly washing hands with hand rub or soap and water is one of the methods of preventing COVID-19377 (77.7)108 (22.3)-
One can prevent COVID-19 by not touching the eye/nose and regular covering the nose when coughing/sneezing321 (66.2)153 (31.5)11 (2.3)
To prevent the infection by COVID-19, individuals should avoid visiting crowded places264 (54.4)212 (43.7)09 (1.8)
By avoiding close contact with anyone who has a fever and cough is another method to prevent COVID-19216 (44.5)227 (46.8)42 (8.7)
One should wear face masks to prevent the infection by the COVID-19 virus.472 (97.3)02 (0.4)11 (2.3)
Isolation and treatment of COVID-19 infected people are effective ways to reduce the spread to others448 (92.4)34 (7.0)03 (0.6)
People having contact with someone infected with the COVID-19 virus should be immediately isolated.465 (95.9)17 (3.5)03 (0.6)

[Table/Fig-3] revealed that knowledge score differed significantly as per age, educational, occupational and marital status of the participants. Knowledge score increased significantly with the decrease in age (p<0.001) and increase in educational status of the participants (p<0.001).

Socio-demographic characteristics and knowledge score of the participants.

CharacteristicsNo. of participants (%)Knowledge score (SD)F/t value††p-value
Age (years)
<2011 (2.3)11.7 (1.8)5.558 (F)<0.001*
20-39136 (28.0)11.1 (1.9)
40-59181 (37.3)10.7 (2.1)
≥60157 (32.4)10.1 (2.5)
Gender
Male248 (51.1)10.7 (2.3)0.082 (t)††0.935
Female237 (48.9)10.6 (2.2)
Educational status
No formal education115 (23.7)9.5 (2.5)15.259 (F)<0.001**
Primary (1-5 grade)140 (28.9)10.6 (2.0)
Matric (6-10 grade)126 (26.0)11.1 (1.7)
Senior secondary (11-12)62 (12.8)11.1 (2.3)
Graduate and above42 (8.7)11.9 (1.6)
Occupational status
Home maker192 (39.6)10.5 (2.2)5.015 (F)<0.001**
Service66 (13.6)11.4 (1.9)
Business51 (10.5)10.6 (1.9)
Farmer47 (9.7)11.1 (2.3)
Skilled/Unskilled Worker52 (10.7)10.2 (2.0)
Student12 (2.5)12.3 (1.4)
Unemployed65 (13.4)9.8 (2.4)
Marital status
Married381 (78.6)10.7 (2.1)6.885 (F)<0.001*
Never married56 (11.5)11.2 (2.4)
Widow/Widower/Divorced48 (9.9)9.7 (2.4)
Total48510.6 (2.1)

SD: Standard deviation; †One-way ANOVA test(F); ††Independent sample t-test (t); p<0.05* statistically significant; p<0.001** statistically highly significant


Multiple regression analysis revealed that knowledge score was primarily predicted by educational status. Those participants with education from primary to graduation and above versus no formal education were significantly associated with higher knowledge score (Primary: β=1.054, p<0.001, Graduates and above: β=2.349, p<0.001). Unemployed had significantly lower knowledge score than homemakers (β=-0.581, p=0.041) [Table/Fig-4].

Multiple linear regression depicting factors independently associated with knowledge score of the participants.

VariableCoefficient (95% CI)Standard errortp-value
Constant9.611 (9.206, 10.02)0.20646.67<0.001**
Primary vs. No formal education1.054 (0.536, 1.572)0.2643.996<0.001**
Matric vs. No formal education1.548 (1.014, 2.081)0.2725.698<0.001**
Senior secondary vs. No formal education1.521 (0.866, 2.176)0.3334.563<0.001**
Graduate and above vs. No formal education2.349 (1.607, 3.091)0.3776.223<0.001**
Unemployed vs. Homemakers-0.581 (-1.137, -0.024)0.2832.0510.041*

Multiple linear regression test using stepwise method; CI: Confidence interval p<0.05* statistically significant; p<0.001** statistically highly significant


Television was the main source of information (79.8%), followed by social media (23.7%), family (27.4%) and friends (15.5%) about COVID-19 [Table/Fig-5].

Channels of information about COVID-19.

When asked about perceptions, 190 (39.2%) of the participants agreed that COVID-19 generates stigma against specific people, another 98 (20.2%) were not sure and this differed significantly as per their age (p=0.038), education (p<0.001) and occupational (p=0.013) status. Participants who disagreed on stigma had significantly higher knowledge score than their counterparts (p<0.001). Restrictions due to COVID-19 caused low feeling in 283 (58.4%) of the participants, while 34 (7.0%) were unsure about it. Perception of feeling low differed significantly across age groups (p=0.018) and education levels (p=0.033) [Table/Fig-6].

Socio-demographic variables and COVID-19 perceived perceptions of the participants (N=485).

VariableCOVID-19 generates stigma against specific peopleFeeling low due to lockdown or COVID-19
I. Socio-demographicAgree (%)Disagree (%)Not sure (%)Yes (%)No (%)Not sure (%)
Age (years)/Total190 (39.2)197 (40.6)98 (20.2)283 (58.4)168 (34.6)34 (7.0)
<203 (27.3)7 (63.6)1 (9.1)8 (72.7)3 (27.3)-
20-3959 (43.4)58 (42.6)19 (14.0)72 (52.9)56 (41.2)8 (5.9)
40-5977 (42.5)70 (38.7)34 (18.8)121 (66.9)52 (28.7)8 (4.4)
≥6051 (32.5)62 (39.5)44 (28.0)82 (52.2)57 (36.3)18 (11.5)
p-value (Chi-Square)0.038* (13.34)0.018* (15.32)
Gender
Male104 (41.9)101 (40.7)43 (17.3)141 (56.9)87 (35.1)20 (8.1)
Female86 (36.3)96 (40.5)55 (23.2)142 (59.9)81 (34.2)14 (5.9)
p-value (Chi-Square)0.217 (3.05)0.598 (1.03)
Educational status
No formal education27 (23.5)46 (40.0)42 (36.5)60 (52.2)41 (35.7)14 (12.2)
Primary52 (37.1)58 (41.4)30 (21.4)89 (63.6)39 (27.9)12 (8.6)
Matric63 (50.0)47 (37.3)16 (12.7)80 (63.5)42 (33.3)4 (3.2)
Senior secondary24 (38.7)29 (46.8)9 (14.5)31 (50.0)28 (45.2)3 (4.8)
Graduate and above24 (57.1)17 (40.5)1 (2.4)23 (54.8)18 (42.9)1 (2.4)
p-value (Chi-Square)<0.001** (41.93)0.033* (16.77)
Occupational status
Home maker68 (35.4)76 (39.6)48 (25.0)111 (57.8)70 (36.5)11 (5.7)
Service33 (50.0)26 (39.4)7 (10.6)36 (54.5)27 (40.9)3 (4.5)
Business19 (37.3)23 (45.1)9 (17.6)28 (54.9)20 (39.2)3 (5.9)
Farmer19 (40.4)23 (48.9)5 (10.6)31 (66.0)12 (25.5)4 (8.5)
Skilled/Unskilled Worker17 (32.7)26 (50.0)9 (17.3)36 (69.2)14 (26.9)2 (3.8)
Student9 (75.0)3 (25.0)-8 (66.7)4 (33.3)-
Unemployed25 (38.5)20 (30.8)20 (30.8)33 (50.8)21 (32.3)11 (16.9)
p-value (Chi-Square)0.013* (25.48)0.118 (17.91)
Marital status
Married144 (37.8)159 (41.7)78 (20.5)217 (57.0)137 (36.0)27 (7.1)
Never married30 (53.6)20 (35.7)6 (10.7)40 (71.4)13 (23.2)3 (5.4)
Widow/Widower/Divorced16 (33.3)18 (37.5)14 (29.2)26 (54.2)18 (37.5)4 (8.3)
p-value (Chi-Square)0.073 (8.55)0.323 (4.67)
II. Knowledge Score (SD)10.9 (1.8)11.3 (1.9)8.6 (2.3)10.9 (2.1)10.6 (2.2)8.7 (2.4)
p-value (F)<0.001** (64.692)<0.001** (15.121)

SD: Standard deviation; One-way ANOVA test: F; p<0.05* statistically significant; p<0.001** statistically highly significant


As far as practices were concerned, 360 (three-fourth) participants were regularly washing hands with soap/water or sanitiser and had significantly higher knowledge score than those who practiced no handwashing (10.9 vs. 9.7, p<0.001). On further analysis, it was observed that as age advanced, handwashing practices significantly decreased (p=0.008) and increased with increase in education status of the participants (p<0.001). There was a significant difference (p=0.013) according to the marital status of the participants. No significant difference was observed between occupation and handwashing practices (p=0.240). Only 145 (29.9%) participants wore three layered cotton/surgical mask when leaving home and another 331 (68.2%) wore a simple cloth face-cover as a mask. Wearing of masks differed significantly across gender (p=0.045*) and marital status of the subjects (p=0.042). Participants wearing three layered masks had significantly higher knowledge score than their counterparts (p<0.001). Only 161 (33.2%) participants followed physical distancing with males (40.3%) following more than females (25.7%) (p<0.001). However, knowledge score had no significant association with physical distancing (p=0.916) [Table/Fig-7].

Socio-demographic variables and preventive practices followed by the participants (N=485).

VariableWashed hands with soap/water or hand rubConsistently wore face-mask when leaving homeFollowed physical distancing
I. Socio-demographicYes (%)No (%)Cloth face cover (%)3 layered cotton/Surgical mask (%)No (%)Yes (%)No (%)
Age (years)/Total360 (74.2)125 (25.8)331 (68.2)145 (29.9)9 (1.9)161 (33.2)324 (66.8)
<2010 (90.9)1 (9.1)9 (81.8)2 (18.2)-7 (63.6)4 (36.4)
20-39113 (83.1)23 (16.9)88 (64.7)47 (34.6)1 (0.7)41 (30.1)95 (69.9)
40-59132 (72.9)49 (27.1)120 (66.3)57 (31.5)4 (2.2)56 (30.9)125 (69.1)
≥60105 (66.9)52 (33.1)114 (72.6)39 (24.8)4 (2.5)57 (36.3)100 (63.7)
p-value (Chi-Square)0.008* (11.77)0.454 (5.72)0.099 (6.27)
Gender
Male186 (75.0)62 (25.0)169 (68.1)78 (31.5)1 (0.4)100 (40.3)148 (59.7)
Female174 (73.4)63 (26.6)162 (68.4)67 (28.3)8 (3.4)61 (25.7)176 (74.3)
p-value (Chi-Square)0.690 (0.16)0.045* (6.18)0.001* (11.62)
Educational status
No formal education69 (60.0)46 (40.0)86 (74.8)26 (22.6)3 (2.6)36 (31.3)79 (68.7)
Primary104 (74.3)36 (25.7)99 (70.7)38 (27.1)3 (2.1)47 (33.6)93 (66.4)
Matric100 (79.4)26 (20.6)86 (68.3)38 (30.2)2 (1.6)40 (31.7)86 (68.3)
Senior secondary52 (83.9)10 (16.1)40 (64.5)21 (33.9)1 (1.6)22 (35.5)40 (64.5)
Graduate and above35 (83.3)7 (16.7)20 (47.6)22 (52.4)-16 (38.1)26 (61.9)
p-value (Chi-Square)<0.001* (18.74)0.066 (14.68)0.922 (0.91)
Occupational status
Home maker141 (73.4)51 (26.6)134 (69.8)52 (27.1)6 (3.1)50 (26.0)142 (74.0)
Service52 (78.8)14 (21.2)37 (56.1)28 (42.4)1 (1.5)23 (34.8)43 (65.2)
Business43 (84.3)8 (15.7)32 (62.7)18 (35.3)1 (2.0)18 (35.3)33 (64.7)
Farmer31 (66.0)16 (34.0)34 (72.3)13 (27.7)-17 (36.2)30 (63.8)
Skilled/Unskilled worker41 (78.8)11 (21.2)39 (75.0)12 (23.1)1 (1.9)23 (44.2)29 (55.8)
Student9 (75.0)3 (25.0)6 (50.0)6 (50.0)-7 (58.3)5 (41.7)
Unemployed43 (66.2)22 (33.8)49 (75.4)16 (24.6)-23 (35.4)42 (64.6)
p-value (Chi-Square)0.240 (7.97)0.249 (14.86)0.082 (11.22)
Marital status
Married281 (73.8)100 (26.2)262 (68.8)112 (29.4)7 (1.8)124 (32.5)257 (67.5)
Never married49 (87.5)7 (12.5)30 (53.6)25 (44.6)1 (1.8)19 (33.9)37 (66.1)
Widow/Widower/Divorced30 (62.5)18 (37.5)39 (81.2)8 (16.7)1 (2.1)18 (37.5)30 (62.5)
p-value (Chi-Square)0.013* (8.65)0.042* (9.90)0.784 (0.49)
II. Knowledge score (SD)10.9 (1.9)9.7 (2.6)10.4 (2.2)11.2 (1.9)8.4 (2.2)10.710.6
p-value (F/t value)<0.001** (4.786)††<0.001** (11.448)0.916 (0.106)††

SD: Standard deviation; †One-way ANOVA test: ‘F; ††Independent sampled t test: “t; p<0.05* statistically significant; p<0.001** statistically highly significant


Discussion

This health centre based study offered insights into earlier days of COVID-19 pandemic in the rural Punjab, India and assessed knowledge, perceptions and practices of the patients. In the present study mean knowledge score was observed to be 10.6±2.1. The score rate was observed to be 70.7% during the initial phase of COVID-19 pandemic. Similarly, Narayana G et al., in a study conducted among general public in India also observed that 74.7% participants had correct knowledge about COVID-19 [9]. Other studies conducted by Zhong B et al., in China (90.0%), Azlan AA et al., in Malaysia (80.5%) and Olum R et al., in Uganda (82.4%) observed higher knowledge of participants about COVID-19 [12-14]. Some of the variation could be due to the difference in study settings, participants, data collection methods and knowledge measurement. Regular dissemination of public information by health authorities started very early in India and this effort could have contributed to the knowledge of the study participants.

Regarding knowledge about symptoms, majority of the participants (87.6%) knew about main clinical symptoms in the present study, however shortness of breath was known to only 40% of the participants. Similar observation was reported by Narayana G et al., Dkhar SA et al., and Tandon T et al., in India wherein majority of the participants knew about main clinical symptoms of COVID-19 [9,10,15]. Austrian K et al., in Nairobi, Kenya observed that awareness about difficulty in breathing was known to 42% of respondents [16]. In the present study, 284 (58.6%) participants knew respiratory droplets as the route of transmission. However, other studies from Narayanan G et al., (90.8%) and Tandon T et al., (95%) in India [9,15] and Zhong B et al., in China (97.8%), Azlan AA et al., in Malaysia (81.9%) and Kebede Y et al., in Ethiopia (95.1%) reported higher level of knowledge regarding transmission through respiratory droplets [12,13,17]. As seen in previous studies by Narayana G et al., and Tandon T et al., in India [9,15] and Zhong B et al., in China, Azlan AA et al., in Malaysia, Olum R et al., in Uganda and Austrian K et al., in Nairobi, Kenya [12-14,16], majority of the participants in the present study were well aware about consistent use of facemasks (97.3%) and isolation and treatment of infected individuals (92.4%) as the effective ways to reduce the infection. Regular education of residents regarding wearing of mask was the important practice adopted by health authorities and moreover, wearing of masks was made compulsory by Government [18], which indeed helped to raise the awareness.

Educational levels had significant positive association with COVID-19 knowledge scores as reported by Narayana G et al., in India and Zhong B et al., in China [9,12]. The current study also identified that education was an important factor independently associated with knowledge score of the participants. Kebede Y et al., in Ethiopia (secondary school and above vs. non-attenders, p<0.01) reported similar association of education with knowledge [17]. Akalu Y et al., in Ethiopia observed that educational status of can’t and write vs. secondary and above were significantly associated with poor knowledge (p<0.05) [19]. Rahman A and Sathi NJ, in Bangladesh (Bachelor and higher vs. higher secondary, p<0.05) also reported association similar to current study in education levels with knowledge [20]. In the current study, television (79.8%) was the main source of COVID-19 information for the participants. Similarly, Narayana G et al., and Tandon T et al., in India reported television (74.5%) and television news channels (61.6%) [9,15] and Austrian K et al., in Nairobi, Kenya reported Government TV advertisements (85.9%) to be the most common and trustworthy source of information [16]. Also, national television channel aired famous popular old and religious serials with health education on COVID-19 in between breaks during lockdown in India.

The present study revealed perceived stigma by nearly 40% of the participants against COVID-19 infected persons, their contacts and those returned from COVID affected areas [21]. Overall, 283 (58.4%) participants were feeling low due to COVID-19 or restrictions. Kebede Y et al., in Southwest Ethiopia also reported presence of perceived stigma [17]. Application of social media and technology during COVID-19 pandemic may spread misinformation and may instead increase stigma and dilute public health gains achieved [22]. Although there was regular dissemination of factual information of COVID-19 to the community on television (79.8%) as it was evident from the present study, still the spread of misinformation through social media might have led to perceived social stigma [22]. As also recommended by WHO, choice of terminology during such times has to be used carefully giving a clear message rather than confusion [23]. Frequent use of term social distancing could also have been interpreted wrongly by some community members as to socially distance from the infected individuals and was later being used with more appropriate word physical distancing.

Knowledge about handwashing as an effective method of prevention was also reflected in the practices being followed by the participants in the present study, wherein 360 (74.2%) of the participants followed handwashing. Other studies conducted by Narayana G et al., (98.2%) Dkhar SA et al., (87.0%) and Tandon T et al., (97.8%) in India [9,10,15] and Azlan AA et al., in Malaysia (87.8%), Olum R et al., in Uganda (74.0%), Kebede Y et al., in Ethiopia (77.3%), Rahman A and Sathi NJ, in Bangladesh (98.6%), Lau LL et al., in Philippines (82.2%) and Muto K et al., in Japan (86.0%) also reported frequent handwashing as the predominant preventive practice carried out by the participants [13,14,17,20,24,25]. Higher knowledge score was significantly associated with regular handwashing practices (p<0.001). As seen in previous studies by Narayana G et al., (97.1%), Dkhar SA et al., (73.0%) and Tandon T et al., (85.0%) in India [9,10,15] and Zhong B et al., in China (98.0%), Rahman A and Sathi NJ, in Bangladesh (91.4%), Reuben RC et al., in Nigeria (82.3%) [12,20,26], majority of participants wore facemask in terms of either cloth face-cover (68.2%) or three layered masks (29.9%). This is also corroborated by the results of Akalu Y et al., in Ethiopia, wherein about 78% of the subjects wore reusable masks [19]. Possible explanation for higher use of cloth face-cover over three layered masks in the present study could be due to the shortage of three layered masks during early days of pandemic [27,28]. Therefore, to ensure that public should wear at least cloth face-cover, rather than not wearing any mask, regular messages were spread on television, radio and social media platforms which were given by politicians and officials to wear cloth face-cover (popularly named ‘Gamchha’ in vernacular language) [5,28].

In the current study, only 161 (33.2%) of the participants followed physical distancing. This is in concordance with the finding by Akalu Y et al., in Ethiopia wherein physical distancing (29.9%) was the least practiced preventive measure [19]. Lau LL et al., in Philippines reported that 65.9% of the respondents maintained a distance from persons with influenza like symptoms [24] and in contrast Narayana G et al., Dkhar SA et al., and Tandon T et al., in India reported that most of the participants (96.9%, 87.0% and 97.5%, respectively) were following physical distancing [9,10,15].

Limitation(s)

Knowledge questionnaire used in the study was adapted from previously tested surveys [11,12], although thorough estimation of its validity and reliability could have led to the development of an improved questionnaire. The assessment of practices was self-reported by participants instead of observing them might have produced biased results, as the participants could have responded more in favour of socially acceptable practices. Also, the study participants had come for OPD consultation and this might have made them more aware of COVID-19 infection.

Conclusion(s)

The present study gives an insight into knowledge, perceptions and practices of rural community regarding COVID-19 infection during early stage of lockdown period. Mean knowledge score of study participants was above average. Young and educated participants had higher knowledge score and followed preventive practices more religiously in comparison to their counterparts. Majority of the participants knew about clinical symptoms and preventive practices. Handwashing was the most common practice followed. Most of the participants agreed that this disease generates social stigma. This study also helps to identify target groups for intervention for increasing knowledge, perception and practices regarding COVID-19 infection.

SD: Standard deviation; †One-way ANOVA test(F); ††Independent sample t-test (t); p<0.05* statistically significant; p<0.001** statistically highly significantMultiple linear regression test using stepwise method; CI: Confidence interval p<0.05* statistically significant; p<0.001** statistically highly significantSD: Standard deviation; One-way ANOVA test: F; p<0.05* statistically significant; p<0.001** statistically highly significantSD: Standard deviation; †One-way ANOVA test: ‘F; ††Independent sampled t test: “t; p<0.05* statistically significant; p<0.001** statistically highly significant

References

[1]Balsari S, Sange M, Udwadia Z, COVID-19 care in India: The course to self-reliance Lancet Glob Health [Internet] published online 2020 Aug 24. Available from: https://doi.org/10.1016/S2214-109X(20)30384-3. [Last accessed on 2020 Sep 05]  [Google Scholar]

[2]Government of India. Ministry of Information and Broadcasting. PM calls for complete lockdown of entire nation for 21 days. PM addresses the nation on COVID-19. Available from: https://pib.gov.in/PressReleasePage.aspx?PRID=1608009. [Last accessed on 2020 Sep10]10.1016/S2214-109X(20)30384-3  [Google Scholar]  [CrossRef]

[3]Bharti V, 10 days, 9K cases in Punjab, 70% with no signs The Tribune 2020 Aug 11 Available from: https://www.tribuneindia.com/news/punjab/10-days-9k-cases-in-punjab-70-with-no-signs-124907. [Last accessed on 2020 Sep 10]  [Google Scholar]

[4]Mohan V, Punjab extends curfew till May 17, lockdown will be lifted from 7 am to 11 am daily The Times of India 2020 Apr 30 Available from: https://timesofindia.indiatimes.com/city/chandigarh/punjab-to-relax-curfew-for-four-hours-daily/articleshow/75455371.cms. [Last accessed on 2020 Sep 10]  [Google Scholar]

[5]Government of India. Ministry of health and Family Welfare. An illustrative guide on COVID appropriate behaviours. Available from: https://www.mohfw.gov.in/pdf/Illustrativeguidelineupdate.pdf. [Last accessed on 2020 Sep 12]  [Google Scholar]

[6]UNICEF. COVID-19 materials audio spot and caller tune Punjabi. Available from: https://iec.unicef.in/document/covid-19-materials-audio-spot-and-caller-tune-punjabi. [Last accessed on 2020 Sep 12]  [Google Scholar]

[7]Acharya R, Gundi M, Ngo T, Pandey N, Patel SK, Pinchoff J, COVID-19-related knowledge, attitudes, and practices among adolescents and young people in Bihar and Uttar Pradesh, India: Study description 2020 New DelhiPopulation CouncilAvailable from: COVID-19-related knowledge, attitudes, and practices among adolescents and young people in Bihar and Uttar Pradesh, India: Study description (popcouncil.org). [Last accessed on 2020 Dec 16]10.31899/pgy14.1006  [Google Scholar]  [CrossRef]

[8]Jalloh MF, Robinson SJ, Corker J, Li W, Irwin K, Barry AM, Knowledge, attitudes, and practices related to ebola virus disease at the end of a national Epidemic-Guinea, August 2015 MMWR Morb Mortal Wkly Rep 2017 66(41):1109-15.DOI: http://dx.doi.org/10.15585/mmwr.mm6641a4. [Last accessed on 2020 Dec16]10.15585/mmwr.mm6641a429049279  [Google Scholar]  [CrossRef]  [PubMed]

[9]Narayana G, Pradeep Kumar B, Ramaiah JD, Jayasree T, Yadav DL, Kumar BK, Knowledge, perception and practices towards COVID-19 pandemic among general public of India: A cross-sectional online survey Current Medicine Research and Practice 2020 10:153-59.https://doi.org/10.1016/j.cmrp.2020.07.013. [Last accessed on 2020 Dec16]10.1016/j.cmrp.2020.07.01332839725  [Google Scholar]  [CrossRef]  [PubMed]

[10]Dkhar SA, Quansar R, Saleem SM, Khan SM, Knowledge, attitude, and practices related to COVID-19 pandemic among social media users in J&K, India Indian J Public Health 2020 64(2):S205-10.10.4103/ijph.IJPH_469_2032496256  [Google Scholar]  [CrossRef]  [PubMed]

[11]World Health Organization. Risk communication and community engagement (RCCE) action plan guidance COVID-19 preparedness & response. March 16, 2020. Available from: https://www.who.int/publications/i/item/risk-communication-and-community-engagement-(rcce)-action-plan-guidance. [Last accessed on 2020 Sep 12]  [Google Scholar]

[12]Zhong B, Luo W, Li H, Zhang Q, Liu X, Li W, 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(10):1745-52.[Last accessed on 2020 Dec 16]10.7150/ijbs.4522132226294  [Google Scholar]  [CrossRef]  [PubMed]

[13]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(5):e0233668Available from: https://doi.org/10.1371/journal.pone.0233668. [Last accessed on 2020 Sep 12]10.1371/journal.pone.023366832437434  [Google Scholar]  [CrossRef]  [PubMed]

[14]Olum R, Chekwech G, Wekha G, Nassozi DR, Bongomin F, Coronavirus disease-2019: Knowledge, attitude, and practices of health care workers at Makerere university teaching hospitals, Uganda Front. Public Health 2020 8:181Available from: https://doi.org/10.3389/fpubh.2020.00181. [Last accessed on 2020 Sep 12]10.3389/fpubh.2020.0018132426320  [Google Scholar]  [CrossRef]  [PubMed]

[15]Tandon T, Dubey AK, Dubey S, Manocha S, Arora E, Hasan MN, Knowledge, attitude, and perception of Indian population toward coronavirus disease (COVID-19) J Family Med Prim Care 2020 9(8):4265-69.10.4103/jfmpc.jfmpc_818_2033110843  [Google Scholar]  [CrossRef]  [PubMed]

[16]Austrian K, Pinchoff J, Tidwell JB, White C, Abuya T, Kangwana B, COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya. [Preprint] Bull World Health Organ [Internet] E-pub: 2020 April 6. Available from: http://dx.doi.org/10.2471/BLT.20.260281. [Last accessed on 2020 Sep 12]10.2471/BLT.20.260281  [Google Scholar]  [CrossRef]

[17]Kebede Y, Yitayih Y, Birhanu Z, Mekonen S, Ambelu A, Knowledge, perceptions and preventive practices towards COVID-19 early in the outbreak among Jimma university medical center visitors, Southwest Ethiopia PLoS ONE 2020 15(5):e0233744Available from: https://doi.org/10.1371/journal. pone.0233744. [Last accessed on 2020 Sep 12]10.1371/journal.pone.023374432437432  [Google Scholar]  [CrossRef]  [PubMed]

[18]PTI. Wearing face masks compulsory in Punjab now: CM Amarinder. The Tribune [Internet]. 2020 Aug 9. Available from: https://www.tribuneindia.com/news/punjab/wearing-face-masks-compulsory-in-punjab-now-cm-amarinder-68907. [Last accessed on 2020 Sep 12]  [Google Scholar]

[19]Akalu Y, Ayelign B, Molla MD, Knowledge, attitude and practice towards COVID-19 among chronic disease patients at Addis Zemen hospital, Northwest Ethiopia Infection and Drug Resistance 2020 13:1949-60.10.2147/IDR.S25873632612371  [Google Scholar]  [CrossRef]  [PubMed]

[20]Rahman A, Sathi NJ, Knowledge, attitude, and preventive practices toward COVID-19 among Bangladeshi internet users Electron J Gen Med [Internet] 2020 17(5):em245Available from: https://doi.org/10.29333/ejgm/8223. [Last accessed on 2020 Sep 12]10.29333/ejgm/8223  [Google Scholar]  [CrossRef]

[21]World Health Organization. Gender and COVID-19: Advocacy brief, 14 May 2020. World Health Organization. Available from: https://apps.who.int/iris/handle/10665/332080. [Last accessed on 2020 Sep 10]  [Google Scholar]

[22]World Health Organization. Managing the COVID-19 infodemic: Promoting healthy behaviours and mitigating the harm from misinformation and disinformation Joint statement by WHO, UN, UNICEF, UNDP, UNESCO, UNAIDS, ITU, UN Global Pulse, and IFRC. September 23, 2020. Available from: Managing the COVID-19 infodemic: Promoting healthy behaviours and mitigating the harm from misinformation and disinformation (who.int). [Last accessed on 2020 Dec 16]  [Google Scholar]

[23]World Health Organization. A guide to preventing and addressing social stigma associated with COVID-19. February 24, 2020. Available from: https://www.who.int/publications/m/item/a-guide-to-preventing-and-addressing-social-stigma-associated-with-covid-19. [Last accessed on 2020 Sep 10]  [Google Scholar]

[24]Lau LL, Hung N, Go DJ, Ferma J, Choi M, Dodd W, Knowledge, attitudes and practices of COVID-19 among income-poor households in the Philippines: A cross-sectional study J Glob Health 2020 10(1):011007Available from: http://www.jogh.org/documents/issue202001/jogh-10-011007.htm. [Last accessed on 2020 Sep 10]10.7189/jogh.10.01100732566169  [Google Scholar]  [CrossRef]  [PubMed]

[25]Muto K, Yamamoto I, Nagasu M, Tanaka M, Wada K, Japanese citizens’ behavioral changes and preparedness against COVID-19: An online survey during the early phase of the pandemic PLoS ONE 2020 15(6):e0234292Available from: https://doi.org/10.1371/journal.pone.0234292. [Last accessed on 2020 Sep 12]10.1371/journal.pone.023429232525881  [Google Scholar]  [CrossRef]  [PubMed]

[26]Reuben RC, Donladi MMA, Saleh DA, Ejembi PE, Knowledge, attitudes and practices towards COVID-19: An epidemiological study in North-Central Nigeria J Community Health [Internet] 2020 published online Jul 07. Available from: https://doi.org/10.1007/s10900-020-00881-1. [Last accessed on 2020 Sep 12]10.1007/s10900-020-00881-132638198  [Google Scholar]  [CrossRef]  [PubMed]

[27]Sharma V, Make masks at home to overcome the shortage, government tells how The Tribune 2020 April 02 Available from: Make masks at home to overcome the shortage, government tells how: The Tribune India. [Last accessed on 2020 Dec 25]  [Google Scholar]

[28]India Today Web Desk. PM Modi’s address to the nation: Everything he has said in previous Covid-19 messages. India Today. 2020 May 12. Available from: PM Modi’s address to the nation: Everything he has said in previous Covid-19 messages - India News (indiatoday.in). [Last accessed on 2020 Dec 25]  [Google Scholar]