|Year : 2022 | Volume
| Issue : 3 | Page : 83-88
Assessment of knowledge–attitude–practice towards COVID-19 among population visiting the endocrinology department in a tertiary care center in south India: A cross-sectional survey
Himamshu Acharya, Hanumantha R Maddukuri, Pramila Kalra, Mala Dharmalingam
Department of Endocrinology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
|Date of Submission||07-Oct-2021|
|Date of Acceptance||25-Oct-2021|
|Date of Web Publication||21-Feb-2023|
Department of Endocrinology, M S Ramaiah Medical College, Bengaluru 560054, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Novel corona-virus disease (COVID-19) has rapidly spread worldwide since its origin in late 2019 in the Wuhan province of China. Knowledge about the disease or lack thereof determines the success of containment of the virus. Individuals with chronic noncommunicable diseases are at a higher risk of complications of COVID-19. Materials and Methods: This cross-sectional survey was conducted to assess the knowledge, attitude, and practices of patients and the people accompanying the patients visiting the Endocrinology out patient department of a tertiary care hospital in south India. A questionnaire that included questions pertaining to knowledge, attitude, and practices regarding COVID-19 was administered. The COVID-19 knowledge questionnaire had 12 questions: four regarding clinical presentations, three regarding transmission routes, and five regarding the prevention and control of COVID-19. Results: Data of 268 individuals were analyzed. The mean knowledge score was 8.43 out of 12. Education was the significant factor that determined knowledge score. The majority agreed that COVID-19 will be controlled (69%) and were hopeful about India winning the battle against COVID-19 (70.5%), 82.1% were avoiding crowded places, and 77.6% were wearing a mask when leaving the house. Caregivers had better knowledge scores as compared with patients. Conclusions: The majority of the individuals attending the Endocrinology clinic had good knowledge about COVID-19. The level of education played an important role in determining the level of knowledge.
Keywords: Awareness, caregiver, coronavirus, diabetes, India, questionnaire
|How to cite this article:|
Acharya H, Maddukuri HR, Kalra P, Dharmalingam M. Assessment of knowledge–attitude–practice towards COVID-19 among population visiting the endocrinology department in a tertiary care center in south India: A cross-sectional survey. D Y Patil J Health Sci 2022;10:83-8
|How to cite this URL:|
Acharya H, Maddukuri HR, Kalra P, Dharmalingam M. Assessment of knowledge–attitude–practice towards COVID-19 among population visiting the endocrinology department in a tertiary care center in south India: A cross-sectional survey. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Mar 23];10:83-8. Available from: http://www.dypatiljhs.com/text.asp?2022/10/3/83/370123
| Introduction|| |
COVID-19 rapidly expanded worldwide within months since its origin in China’s Wuhan province. COVID-19 is transmitted from human to human through close personal contact via droplets produced by coughing or sneezing or through fomites. The presence of asymptomatic carriers is a significant barrier to disease control. Due to the highly infectious nature of the virus, the virus has spread to 188 countries, affecting more than a hundred million individuals and has led to more than two million deaths.
Human behavior plays a vital role in the spread of the virus. Social gatherings increase the risk of outbreaks. Hand hygiene, personal protection with mask/face shield, and social distancing reduce viral transmission. Public awareness is of utmost importance in preventing the virus’s rapid spread. Governments and the World Health Organization (WHO) have run multiple information campaigns on television and social media to educate people. Many countries had to forcefully indulge in lockdown to limit the spread of the virus. This has led to an economic crisis. This economic burden and lack of knowledge have led to noncompliance with social distancing norms and hand hygiene practices.
The severity of COVID-19 is more among individuals with chronic illnesses, including diabetes, hypertension, and obesity. Nonavailability or limited availability of routine medical care, fear of attending hospital during the pandemic has led to worsening health status among patients with noncommunicable diseases. It is crucial to assess the level of knowledge, attitude, and practices toward COVID-19 among patients with noncommunicable diseases. This study was done to assess the knowledge–attitude–practices among patients with noncommunicable diseases who visited the endocrinology outpatient department.
| Objectives|| |
To assess the knowledge, attitude, and practice toward COVID-19 in patients and attendees visiting the Endocrinology clinic.
| Materials and Methods|| |
This is a cross-sectional questionnaire-based study.
The study was done in the Endocrinology department of M.S. Ramaiah Medical College and Hospital. The study was conducted over a period of eight weeks during the first COVID wave lockdown period.
Patients who visited the Endocrinology clinic and their caregivers who were 18 years old or older were considered for the study. Informed consent was sought from all the participants. Individuals who had severe cognitive, hearing, and visual impairment, which affected their ability to answer questions, were excluded. Individuals who did not give consent were excluded from the survey. A convenient sampling method was used. Participants were interviewed in person, through Google forms, and telephonically.
Consented subjects were surveyed with a questionnaire, which consisted of two parts: demographics and the knowledge–attitude–practice questionnaire. Demographic variables included age, gender, marital status, disease status, education, occupation, and current place of residence. The COVID-19 knowledge questionnaire had 12 questions: four regarding clinical presentations, three regarding transmission routes, and five regarding the prevention and control of COVID-19. These questions were answered on a true/false basis with an additional “I don’t know” option. The questionnaire had two questions about attitude and three questions about practices toward COVID-19. A question about problems faced by the subjects during lockdown was also included. The questionnaire was made available in English, Kannada, and Telugu languages. The interview was done face to face, on the phone, and online among patients who were well versed with Google forms. During data analysis, educational classes were subdivided into four groups: no formal education, school (formal education up to 12 years), bachelors/graduates, and postgraduates/PhDs/postdoctoral fellows. For regression analysis, these four classes were combined to form two groups: Subjects without a bachelor’s degree, that is, individuals with no formal education, education up to secondary school were considered in a single group and subjects with at least a bachelor’s degree were classified in another group.
Frequencies of correct answers to knowledge questions and various attitudes and practices were analyzed. Descriptive analysis was carried out by mean and standard deviation for quantitative variables; frequency and proportion for categorical variables. The association between categorical explanatory variables and the quantitative outcome was assessed by comparing the mean values. According to demographic characteristics, knowledge scores and attitudes and practices of different subjects were compared with independent-samples t-test, one-way analysis of variance (ANOVA), or Chi-square test as appropriate. Multiple regression analysis was used to assess the association between quantitative variable and categorical variables.
| Results|| |
A total of 268 participants completed the survey questionnaire. Among this final sample, the mean age was 43.64 years (standard deviation [SD]: ±15.28, range: 18–85), 103 (38.4%) were women, 154 (57.5%) held a bachelor’s degree or a higher qualification, 105 (39.2%) were employed, and 176 (65.7%) were urban residents. Other demographic characteristics are shown in [Table 1].
|Table 1: Demographic characteristics of the study population and their mean knowledge score|
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The majority of the patients had type 2 diabetes (35.44%), with hypothyroidism (17.16%) and hypertension (9.32%) being the second and third most common conditions, respectively. Out of 268 respondents, 111 (41.41%) were caregivers [Table 2].
The correct answer rates of the 12 questions on the COVID-19 knowledge questionnaire were 24.6%–93.7% [Table 1]. The mean COVID-19 knowledge score was 8.43 (SD: 2.56, range: 0–12), suggesting an overall 70.2% (8.43/12*100) correct rate on this knowledge test. The 75th percentile of the knowledge score corresponded to a score of 10 out of 12. One hundred and four (38.8%) participants had a knowledge score of ≥10. This was taken as a cutoff for a good knowledge score. Knowledge scores significantly differed across genders, categories of education levels, and occupations [Table 1]. The questions assessing the level of knowledge are enlisted in [Table 3].
Sixty-nine percent of the participants were optimistic that COVID-19 will come under control. The proportions of neutral and pessimistic participants were 23.5% and 7.5%, respectively. We also asked our participants whether India will win the battle against COVID-19, to which 70.5% answered yes. Almost all participants (94.4%) said that they follow preventive practices. The majority of participants (82.1%) were avoiding crowded places, and 77.6% of the participants were always wearing masks while going out [Table 4].
Regression analysis was generated through SPSS version 18 for the prediction of knowledge level. The adjusted R² of the model was 0.088 with R² = 0.330. Linear regression explains 33% of the variance in the data. The Durbin-Watson d +1.7, which is between the two critical values 1.5 < d < 2.5. Therefore, we assumed that there is no first-order linear auto-correlation in our multiple linear regression data.
The F-ratio in the ANOVA test was used to predict whether the overall regression model was a good fit for the data. The independent variables statistically significantly predicted the dependent variable, F (6, 261) = 5.316, P (0.001) < 0.05. (i.e., the regression model is a good fit of the data).
Estimated model coefficients
The general form of the equation to predict knowledge level from gender, age, occupation, place of residence, and marital status is:
Predicted knowledge level = 6.263 + (1.128 × marital status) + (0.112 × occupation) + (1.108 × education) + (0.547 × sex) + (0.325 × place)−(0.180 × age).
Multiple regression was run to predict knowledge level from gender, age, occupation, place of residence, and marital status. These variables statistically significantly predicted knowledge level, F (4, 95) = 32.393, P < 0.0005, R2= 0.577. All four variables added statistically significantly to the prediction, P < 0.05. The highest contributing predictor variable is education (0.214), and the next is marital status (0.156) [Table 5].
Source of information about COVID-19
Sixty-four percent of participants obtained information about COVID-19 through television. Print (12.3%) and social media (14.9%) were also sources of knowledge about COVID-19 [Table 6].
Awareness of comorbidities affecting COVID-19 outcome
Among 157 patients, 61 (38.9%) felt that COVID-19 is going to affect their preexisting disease condition. Overall, 45 (28.7%) were unsure whether COVID-19 would affect their disease, whereas the remaining 51 (32.5%) patients were of the impression that COVID-19 would not affect them.
Problems faced due to COVID-19
We asked our subjects about the significant problems faced by them during the lockdown. Unavailability of routine medical care due to the shutdown of outpatient clinics, financial crisis were the most common problems faced. A few subjects also complained about the nonavailability of essential medicines. Three individuals also reported domestic violence [Table 7].
| Discussion|| |
This study was conducted in the city of Bangalore, amid a nationwide lockdown. This assessment of knowledge among patients attending the Endocrinology clinic was done to find lacunae in knowledge among patients at high risk of complications of COVID-19. In this study, we assessed knowledge using a 12-point questionnaire. We considered the 75th percentile of the score as the cutoff for an individual to have a good score.
This study’s uniqueness is that we have assessed the knowledge of caregivers who have accompanied the patient. This is important, as many of the patients who attend the Endocrinology clinic are dependent on caregivers who influence the knowledge, attitude, and practices of the entire family. In our study, caregivers had relatively better knowledge than patients themselves, which was statistically significant (8.71 ± 2.70 vs. 8.24 ± 2.45, P = 0.015).
The majority of the participants were well educated, with approximately half of them having a bachelor’s degree. Education was the most important determinant of good knowledge toward COVID-19. There was a significant difference in knowledge scores between various groups. Participants with a postgraduate/postdoctoral degree had the highest knowledge score (9.42 ± 2.04, n = 69), whereas participants with a bachelor’s degree had the second-best mean knowledge score (8.71 ± 2.81, n = 85). Individuals who did not receive any formal education had the lowest knowledge score. A similar study was conducted in China by Zhong et al. This highlights the importance of education in public health.
We used online, telephonic, and face-to-face surveys in the outpatient department to avoid education bias. We assumed that individuals having Internet access would be better educated and this can lead to bias. This bias was also seen in an online study conducted by Pal et al. in patients with type 1 diabetes about the knowledge, attitudes, and practice toward COVID-19, where 73% of participants had a graduate or higher degree. Many studies previously conducted by Mahmood et al., Yue et al., and Mohamed et al. were all online-based surveys using social media. We tried to avoid this bias by interviewing the patients who could not use online surveys. Our study population had 35.4% participants who had less education than the 12th grade, and 7.1% did not have any formal education. This gave a more realistic representation of the community.
Approximately 56% of the participants belonged to the age group of 18–40. This younger subgroup of participants had better knowledge scores than the middle-aged and the elderly population. Although 56% were of the younger age group, compared with other studies conducted by Reuben et al., Dkhar et al., and Ning et al., our study had a better representation of people older than 40 years. Better access to information through the Internet and social media might be the possible reason for this difference in knowledge among different age groups.
Knowledge is a prerequisite for establishing prevention beliefs, forming positive attitudes, and promoting positive behaviors toward disease. So, the availability of information plays a significant impact in controlling the pandemic. The greater the participant’s knowledge, the more confident they were in defeating the virus. A good knowledge among participants was expected because of widespread news and information through television, print media, social media, and messaging application WhatsApp.
Most of the participants also held an optimistic attitude towards the COVID-19 pandemic: 69% believed that COVID-19 would finally be successfully controlled, and 70.5% had confidence that India can control the spread of the virus. The participants were cautious and followed safe practices: Many avoided crowded places (82.1%) and wore masks when going out (77.6%) during the initial rise of the COVID-19 outbreak and amid lockdown in India. Here, we analyzed a gap between what participants thought about safe practices and what they were practising. Public health authorities need to address these lacunae and recognize the target populations for health education and prevention of COVID-19.
As the survey was done amid nationwide lockdown, we also asked our respondents about their problems due to lockdown. About 30% of individuals complained about the difficulty in consulting doctors (n = 79), and 7.5% complained about drugs’ nonavailability. Three participants also complained about domestic violence, which was reported to have increased during the lockdown.
The majority of the study participants were well educated, with 57.4% of the participants having a graduate degree or above. The overall literacy rate was 92.9%. This contrasts with India’s literacy rate of 74%, with the graduate rate being 8.15%. As the study was done during the early stages of COVID-19 in India, the majority had knowledge about the disease and were having good practices. Our study was not designed to demonstrate burnout fatigue, which was evident with noncompliance with mask use, social distancing during the latter part of the pandemic.
| Conclusion|| |
The majority of the individuals attending the Endocrinology clinic had good knowledge about COVID-19. The level of education was the most significant factor determining the level of knowledge. The majority of the individuals were optimistic about the control of the disease. Preventive practices were followed by the greater part of the study subjects. Caregivers had better knowledge scores as compared with patients. As the number of cases soar all over the world with vaccination lagging, this study assessing the knowledge, attitude, and practice toward COVID-19 highlights the importance of health education in preventing the spread of the virus.
We sincerely thank Mr. Shivaraj N. S., Assistant Professor, Department of Community Medicine, M. S. Ramaiah Medical College and Mrs. Anjana George, Biostatistician, Ramaiah International Centre for Public Health and innovations, for their valuable input on statistical analysis.
Ethical policy and Institutional Review board statement
The study protocol was approved by ethics committee of Ramaiah Medical College (Reg. no. ECR/215/Inst/KA/2013/RR-19) on June 29, 2020 (Approval no.: MSRMC/EC/AP-18/06-2020).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]