Knowledge, attitudes, and practices towards COVID19 pandemic among residents of Jharkhand state, India: An online survey

Background People's adherence to control measures is imperative in the ght against COVID-19. The present study was done to evaluate knowledge, attitudes, and practices towards COVID-19 among residents of Jharkhand and to assist government in deciding further course of action during the COVID-19 outbreak. Methods This study was an online cross sectional survey. The link to the questionnaire was displayed on the ocial website of Rajendra Institute of Medical Sciences, Ranchi, Government of Jharkhand, National Health Mission, Jharkhand, ocial website of all districts under Jharkhand state administration, Integrated Disease Surveillance Programme and Information & Public Relations department. Participation of residents in the survey was also extensively propagated using mass media mainly local television networks, radio channel and newspapers.

Jharkhand. The proposal was approved by Research and Project Committee and Institute Ethics Committee, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand. Participation in the survey was purely voluntary. The survey link mentioned implied consent from the survey participants i.e. those clicking the link and lling up the forms were considered to have given the consent.

Sample size estimation:
It was done using epi-info software (version3.01) [15]. Sample size estimation was based on a similar study done among Chinese residents to assess their knowledge, attitudes, and practices towards COVID-19 [16]. Based on the reported 90% prevalence ofcorrect responses in the study and allowable error of 5%, the required sample size for the study came out to be 139. To compensate for the difference of the awareness levels of the residents in the two regions, a design effect of 1.5 was applied to make the nal sample size to be 208.

Sampling methodology:
It was an online survey with voluntary participation of the state residents. However, the purpose of the study, eligibility criteria and the anonymity and con dentiality clause were clearly highlighted for Relations Department. Survey information with link to questionnaire was also promoted through local television networks, radio channels and newspapers so that maximum number of participations could be achieved.

Survey tool:
A self-structured questionnaire was used to record the responses of the candidates. A thorough review of the various studies already conducted in various parts of the world through structured, semi-structured, or non-structured interview schedule or self-administered questionnaires were taken into account for item selection of this tool [16][17][18][19]. Since data on COVID-19 is scant, we also considered the questionnaires developed for the MERS and H1N1 [20,21]. To generate a comprehensive set of items relevant to Indian scenario we used information available on MyGov #IndiaFightsCorona COVID-19 dashboard of Ministry of Health and Family Welfare, Government of India [6]. The questionnaire consisted of four sections; In the study we have kept the threshold value for calculating correct rates of knowledge and practices at the 50% value of the maximum possible score. Threshold value for classifying knowledge and practices to be adequate were 7 for knowledge and 3 for practice. One question in the practices, "Do you verify news regarding COVID-19 before forwarding on social media" was not used in the calculation of practice score of the participants. This method is commonly used method of determining the threshold values in the absence of any standardized tool. The threshold values thus obtained to classify knowledge and practice scores were also found to be of relevance to epidemiological and public health experts in the state. Content validity of the questionnaire was ensured with the help of ten experts in the eld. Final questionnaire in English was translated into Hindi language.
Hindi to English back translation was carried out to check the quality of translation. A pilot study was carried out on 25 subjects to check the reliability (Cronbach's alpha) and comprehensibility of the questionnaire. It took a participant approximately 3-5 minutes to complete the questionnaire. The knowledge section of the questionnaire was formulated in form of a quiz with highest attainable score of 14. The participants could view their own scores as well as the correct responses at the end of the submission. This was one as a measure to improve respondent's knowledge about COVID-19. Additionally, the participants were given an option to view others responses so that they could update themselves with the current status of responses in relation to this questionnaire. The nal questionnaire version was adapted in the Google Forms and online link for the same was created.

Statistical analysis:
Data obtained was entered in the Microsoft excel and subjected to statistical analysis using SPSS version 18.0 [22]. Descriptive analysis was done to classify demographic details and responses to KAP questions. Correct responses were given a score 1 and incorrect responses were scored as 0 for assessment of knowledge and practice of the participants. Responses were be added up to calculate the correct knowledge and practice scores of the participants. Participants were classi ed to be aware/unaware and following good/bad practices as per the threshold value. Mean correct score for knowledge and practices was also calculated. Chi-square test was used to nd association between study variables; 1) demographic variables and knowledge & practices of participants 2) knowledge and practices of the participants.

Results: Study participants characteristics
A total of 4683 responses were received from all the 24 districts of Jharkhand state. Majority of the participants were males (81.4%) below 30 years of age. Most of the participants were of the level of graduate or above (81.7%). A mix of responses was received from different work categories and more than 30 percent of total participants had a monthly income of up to 132 USD. (Table I). Mean correct knowledge score was 10.73+2.2. More than 70% correct response rate was observed for most of the question except regarding usage of appropriate type of sanitizer. Approximately 4% of the participants confused the symptoms of common u and gastro-intestinal ailments clinical symptoms of COVID-19 infection. Approximately 29% respondents were not aware of the ways of spread of COVID-19, more importantly regarding spread from asymptomatic patients. (Table II). Approximately 90% of the participants were in the view that COVID-19 will nally be controlled in India. However, 27.2% believed that the virus is going to stay for at least 6 months time period and 21.1% of them were unsure about the time duration required to contain the virus (Table III). An analysis of the type of fear among those who are worried about COVID-19 revealed that fear of death was the single most common fear among the participants across all the age groups. (Image I). Mean practice score for the participants was 4.5+0.69 (Table IV). More than 92% of the participants followed the lockdown as per the government guidelines and did not go outside of their homes without any compelling reason. Around 98% of the participants did wear mask while going out and but around one third of the participants did not made efforts to avoid touching the eyes, nose, and mouth with their hands (Table IV). A very signi cant nding from this study is that majority of participants were updating themselves through the authentic information provided by central and state government (57.2%) or by using dedicated COVID-19 dashboard #IndiaFightsCorona by MyGov.in (49.5%) (Image II). Female participants and those of the higher age groups were more aware regarding COVID-19 (p<0.05). Education status was signi cantly associated with the knowledge and practices in relation to COVID-19 (p<0.05). Similarly those falling in the higher economic classes were more aware about COVID-19 (p<0.05) however practices were similar across the all economic strata ( Table V). Knowledge of the participants was signi cantly translated into the practices of the participants. Individuals who were aware in the present scenario also performed good practices in relation to COVID-19 (Table VI).

Discussion
To the best of our knowledge, this is the rst study in India which was done at state wide level to examine the KAP towards COVID-19 among general residents. The area of study is especially important given the impact of disease on the mankind with world leaders quoting the pandemic an important landmark in history of world, dividing the timelines into pre-corona and post-corona period. The study ndings shall be utilized by the state government to effectively design future course of action in wake of COVID-19.
In the study we found an overall high correct rate in the knowledge questionnaire, indicating that most respondents are knowledgeable about COVID-19. High correct rate of knowledge in relation to COVID-19 among Jharkhand residents was not unexpected. Jharkhand state was 28th state in the country to report COVID positive patient [23]. The state was reportedly corona free till 31st March 2020 when the nationwide coronavirus death toll climbed to 32 while the number of cases had spiked to 1251, which is approximately two months after the reporting of 1st case in the country [24]. The transmission rate of COVID-19 in the state is also low when compared to the national average. As of 17th May 2020, there are only 101 active COVID-19 positive cases in the state. Serious situation of the epidemic and the overwhelming news reports on this public health emergency are also responsible for high correct rate of knowledge and good practices. The high level of awareness among study population regarding COVID-19 has been reported from other studies too [16,19,25]. However, many areas of concern have been identi ed based on the survey ndings. Still 100% of the population is not aware of the symptoms related to COVID-19 and days taken to appear the symptoms. It is empirical for everybody to understand basic symptomatology since shorter the time taken to report to a screening centre the lesser will be the spread and the health effects. It is unknown to many that elderly age groups and those with the co-morbidities are more prone of getting infected. Several studies have shown that patients with older age and comorbidities like hypertension, diabetes, cardiovascular disease and respiratory system disease need careful observation and early intervention to prevent the potential development of severe COVID-19 [26,27]. These groups should especially be reached to make them more responsive towards implementing self-prevention measures. Ways of viral spread and suitable distance to be maintained with other people were not recognized by signi cant number of the participants. R naught value of the disease is higher than one, implying a faster and rapid spread of disease before it ceases down [28]. Addressing issues related to the spreadibility of disease will help prevent its exponential spread given the highly contagious nature of disease. Still one fourth of the participants were unaware of government guidelines on mandatory usage of face masks indicating a gap in framing, implementation and publicizing of the novel laws. Markets are these days oated with various kind of sanitizers with repots coming that many not following speci cations required for prevention against COVID-19 [29, 30, 31] It is imperative for public to understand type of sanitizers to be used so that they do not stay in swag that they are adequately protected after using any sort of sanitizer available in the market.
The majority of the participants also held a hopeful attitude towards the COVID-19 pandemic. Most of them believed that COVID-19 will nally be successfully controlled, and had con dence that India will ultimately get though the situation. This is in synchronization with the results of another study carried out in another region of India where people also held optimistic attitude about the disease [32]. The con dent attitude of the Jharkhand residents could be related to the unprecedented COVID-19 control measures such as country-wide lock down, mandatory wearing of masks and banning of pan masala by the state of Jharkhand, sealing of hotspots, developing dedicated COVID-19 hospitals with isolation, quarantine and management facilities for COVID-19 infected and suspected patients, sanitization drives and rigorous contact tracing of which enhance people's con dence in winning the battle against the virus. [33]. Similar to results of another study carried out in China, in our study also respondents feared of death the most among all age groups [34]. The fear among participants to a certain extent is being answered in newer government campaigns that emphasize upon increasing body's immunity so that even if the disease is encountered one may remain asymptomatic and apparently well. Also, gradually with increased understanding of the disease, we have more treatment options and better recovery rates [35,36,37]. Newer campaigns should de nitely take into the account social stigmas attached to the disease. For example "Hate Disease but not the Diseased" is already been promoted across COVID-19 campaigns [38].
Sound knowledge and optimistic attitude of the participants was also re ected in their practices in this period [16,17,18,19]. But there are concern areas; especially mask hygiene should be emphasized; rstly, wearing a mask for their as well as others safety is important and secondly, that outer surface of mask should never be touched. Also, indigenously developed corona tracker mobile application "AarogyaSetu" is not been used by all. Rigorous emphasis on its utility among masses in terms of daily updates, self-risk assessment and option for applying of e-pass could prove bene cial. Source of information for more than half of participants was government recommendations or state run online dashboards. It con rms that national and state governments are putting efforts to connect and reach to the people.
Age of the participants did have an impact on the knowledge of participants but the practices did not signi cantly improved with increasing age. Since, it can be assumed that people of all groups were sensitized and worried in the present scenario so everyone tried to perform good practices. Females outperformed their male counterparts as far as knowledge regarding COVID-19 was tested [16]. However, male participants performed signi cantly better practices than the females. The possible reason could be that in India, socio-cultural beliefs enable males to go out of home more frequently than females for daily routine chores or employment related work so they keep themselves more equipped and follow healthy hygiene practices more religiously. However, since females get more time to stay at homes and use internet so are more aware than the males.
At present there are generic awareness campaigns being carried out throughout the country and in the state as well. These campaigns are not been designed keeping in mind the felt needs, current knowledge and practice being performed by the residents. The areas identi ed with a knowledge lag could be speci cally targeted using behavioral change communication techniques. The domains where already acceptable knowledge levels have been reached can only be targeted through sensitization and reenforcement strategies. The future campaigns should de nitely take into account the socio-cultural and economic context into account. Key stakeholders like non government organizations which are active in the region can be involved suitably. Many people believe that corona is going to stay for longer. Hence future information education communication/behavioral change communication campaigns should be more than just awareness raising campaigns government [25,39]. They should also teach people on how to live with corona in times to come. Social taboos related to COVID-19 infection among residents should also be addressed so that people do not avoid visiting COVID screening facilities. Development of standard operating procedures for all job sectors shall help in early resumption of services to ease down nancial worries besides preventing spread of corona at the workplaces. [40,41]. Social media was source of information for signi cant proportion of population. Hence, social media platforms like WhatsApp and Facebook should be utilized for dissemination of authentic updates on COVID-19.
The study was a web based survey of the KAP practices among the residents of Jharkhand state, India. Opinion of considerable population which might not have an access to internet might have been left in the survey. However, the large sample size involved in the study validates the ndings to an extent. Responses from all ages, educational & occupational classes and economic strata have been received with varying proportions that corresponds to their population size. There was possibility of hawthorne effect in this study but clause of anonymity and study being an online survey would have limited the bias. The study also touched the areas related to mental health, economic issues but did not take an elaborated opinion. Hence future studies examining impact of COVID-19 on mental health and economic aspects of individuals can be planned to bring a comprehensive policy or guidelines in relation to pandemic. Health impact of COVID-19 on should be assessed to reorient health care delivery system in the current situation demanding limited mobility of people.

Conclusions:
The study identi ed thrust areas for future awareness campaigns. Participants had positive attitude but were also logically worried and uncertain about near future. Adequate knowledge of participants was visible in the practices of residents. There is however a gap across age groups, gender, literacy and income levels which should be addressed in future campaigns Authors' contributions: AR carried out designing and literature review. NN was involved in manuscript writing and statistical analysis. DK was involved in conceptualization and designing. NM developed the de nition of intellectual content and carried overall reviewing. SK provided technical inputs and carried critical revision. LR was involved in designing the survey tool and providing recent updates on COVID-19 in the Jharkhand state which were utilized in manuscript preparation. All authors took part in research meetings concerning data analysis goals, strategies, challenges and visualization.     Figure 1 Major concern among participants who are worried from COVID-19

Figure 2
Source of information regarding COVID-19? (*multiple options could be marked for this question)