Public Knowledge, Attitudes, Practices towards COVID-19 and assessment of risks of infection: An online cross-sectional survey in India


 The global debacle, ushered in by the coronavirus disease 2019 (COVID-19) needs no elaboration. India has documented 10.5 million cases, of which 10.1 million have recovered while more than 151 thousand people have succumbed to the pandemic as of January 10, 2021. Of late, the second wave of the infection and new variants of the virus have also surfaced across various latitudes and longitudes of the globe. Various control measures have been adopted globally, however, the success and effectiveness of the control measures are affected by people’s knowledge, attitudes, and practices (KAP) towards the pandemic. Therefore, the aim of this study was to determine the level of KAP toward COVID-19 among the Indian public. A cross-sectional online survey of Indian public was conducted between 18th May 2020 and 24th June 2020. The survey questionnaire consisted of demographic characteristics, pertaining to knowledge (15 items), attitude (10 items), and practices (7 items), modified from a previously published questionnaire on COVID-19. A total of 566 persons completed the survey. The overall correct rate and the average score of the knowledge questionnaire were 75.8 % and 13.6 ± 2.7 respectively. Attitude and practice scores were respectively 3.55 ± 0.45/5 and 2.75 ± 0.43/3 towards COVID-19, respectively. Maximum respondents demonstrated moderate level of knowledge (67.6 %) and attitude (96 %) while 81.9 % were found to follow good practices towards the pandemic. A positive correlation was observed between knowledge towards practice and attitude towards practices. Despite the good practice skills, a considerable percentage (6 %) of respondents never wore nose masks, washed hands, and maintained social distance during the outbreak. By the same token, 3.2 %, and 14.9 % of the public were in high and in the medium risk of infection, respectively. Due to the limited sample, we must be cautious when generalizing these findings to whole populations. Nevertheless, the study highlighted the indispensability of befitting health education programs aimed at improving KAP among the mass.


Introduction
With ~90 million cases and nearly 1.9 million mortality as on January 10, 2021, Coronavirus Disease 2019 (COVID-19) has spelled a global fiasco of unprecedented nature since December 2019. It includes ~10.5 million cases and 151 K deaths against 10 million recoveries from India alone since the first case of COVID-19, reported on January 30, 2020, in the state of Kerala, South India . The number started escalating in late March 2020 and has been steadily increasing to date, however, the peak (97,894 cases/day) was reached in mid-September (16 th September 2020) while 16,311 new cases were documented on 10th January 2021. Global health experts and South Asian governments had expressed concern about the spread of COVID-19 and the plausibility of more than 7.6 million deaths in South Asia alone in case of inaction (Walker et al, 2020). Thus, it becomes imperative that the people of India must be completely aware of the strategies to address the spread of COVID-19 and must adopt necessary measures.
Specifically, in the Indian context, the Prime Minister enforced a nation-wide lockdown on 25th March 2020 for 3-weeks initially while subsequent phases of lockdown were extended till May-end. Besides ensuring timely execution of the viral detection tests and endeavoring to develop effective vaccines, India has been beavering away to combat the debacle through various suggestive measures to reduce community spread and the overburdening of the country's health system. During the lockdown, Indians were only permitted to leave the house for basic activities such as buying groceries and seeking medical treatment. The lockdown also restricted Indians from leaving the country and all foreigners from entry. Non-essential sectors were ordered to close or allow employees to work from home. In India, circa 80 % of the workers are employed in the informal sector, and about a third are employed as day-laborers. In this milieu, triggered rapid migration from the cities to rural areas in some parts of the country raised fears of the rapid spread of infections and exacerbation of existing health and economic inequalities (LGH, 2020).
Most European nations and Italy had reported a resurgence in the coronavirus infections, leading to a second wave of the deadly virus during the month of July, August, and September attributed to premature relaxation of strict interventions (Bontempi, 2020).
Importantly, the infections during the second-wave have been considered to be far worse than the first due to the new variant SARS-CoV-2 (CNBC, 2020; Pedro et al, 2020. Xu and Li 2020). This had obviously posed further challenges to the already distressed population and in ensuring strict compliance with practice guidelines, such as social distancing, washing hands, and wearing masks. Albeit, various interventions to control the spread of SARS-CoV-2 are in place, howbeit, the path to return to normalcy seems to be an arduous one for various countries; thus, knowledge of the effect of each intervention is urgently required. Much seems to be highly cryptic as far as this novel virus is concerned; this further projects the indispensability of the strict compliance to the various precautionary guidelines to curb the spread of the virus. Most While this immediate reaction to the lockdown was envisaged, these actions provided grounds to raise questions regarding the status of understanding and attitude toward COVID-19 among Indians. However, on a positive note, the timely lockdown was reported to reduce the spread by >60% in the month of May 2020 (Rampal, 2020). By April 2020, the Indian government had identified several hotspots of COVID-19 infections in the country. With the objective of successful 'flattening of the curve' in India, widespread and effective mitigation endeavors were undertaken.
The Indian Ministry of Health and Family Welfare (MOHFW) along with state-level health departments have been providing information on COVID-19 through various communication channels and through a mobile application, Aarogya-Setu. However, as a matter of concern, with the ushering of the 2 nd wave (Pedro et al., 2020), a highly infectious new variant of SARS-CoV-2 has been identified in UK (BBC, 2020), leading to the suspension of all flights to and from the KAP and risk assessment towards the COVID-19 outbreak. We hope that the outcome of the survey will identify key variables to make informed decisions in the further control of COVID-19 by the relevant authorities.

Survey Plan and Participants
A quantitative survey-based approach was utilized keeping in view the appropriateness of a survey in assessing large populations with relative ease ( (Table 3) was prepared and rated on the 5-point Likert scale ranging from strongly disagree (1), disagree (2), neutral (3), agree (4), and strongly agree (5) for positive attitude questions. As far as the negative-attitude questions were concerned, a score of 1 was awarded for the response-strongly agree, with the score increasing to 5 against the response-strongly disagree. People who scored <35 were classified as having a 'poor' attitude, those who scored 36-60 were classified as having a 'moderate' attitude and those who scored >61 were classified as having a 'good' attitude. A total of 8 practice questionnaires (Table   4) were prepared and rated on the 3-point Likert scale format ranging from never (1), sometimes (2), and always (3). In case of negative practice questions, the scores were reversed, e.g., 'always' was assigned a score of 1 and likewise. Scores of <12 indicated a 'poor' level of practices, scores of 13-20 indicated a 'moderate', and scores of >21 indicated a 'good' level of practices while responding to the outbreak of COVID-19. The assessment of the risk of infection was analyzed based on the practice skills.

Statistical analysis
The data collected from the survey were collated, followed by deletion of incomplete and duplicate responses. The first completed responses were counted as accurate. The descriptive statistics and one-way analysis of variance (ANOVA) or Chi-square test, as appropriate, were performed using Microsoft Excel to determine the differences between groups for selected demographic variables and their KAP toward COVID-19. Regression tests were applied to find any correlation between knowledge, attitude, and practice scores. The statistical significance level was set at p<0.05.

Demographic characteristics
A total of 625 participants attempted the survey questionnaire. Amongst these, 23 and 36 responses were incomplete and repetition of the attempts respectively. The first complete attempt was counted as a valid response and the repeated attempts and incomplete responses were excluded (59). The final data-sample consisted of 566 participants and the correct response rate was 90.6 %.
Among these final respondents, almost equal representation of either gender was documented while the majority of the respondents were within the age group of 15-29 years (72 %), and unmarried (74.6 %) ( Table 1). The majority of the respondents either held or pursued college-level education (95.2 %) against 27 participants with school education (<12 th grade). In terms of occupation, more than half of the respondents (55.7 %) were students, followed by people in private jobs (26.7 %), government jobs (8 %), and the healthcare sector (3 %). The participants belonged to 25 states of the country out of 36 states and union territories with maximum representation from Assam (230), followed by Tamil Nadu (228), and rest from other 23 states.
Pertinently, in seven states, only one participant answered ( Figure 1). The various other demographic characteristics are shown in Table 1.

Assessment of knowledge
A total of 18 questions were used to gauge knowledge-status of the participants on COVID-19. The average knowledge score for the participants was 13.6 ± 2.7, (range: 2-18). The overall correct answer rate of the knowledge questionnaire was 75.8 % (13.6/18*100) while the correct answer rates for all the participants ranged from 11 % to 100 %. As shown in  Unexpectedly, attitude score showed a reverse trend with the education level, for example, the participants with school education recorded 3.61/5, while those with Ph.D. registered a score of 3.46/5 (Table 5). In the case of attitude level towards COVID-19, generally speaking, the majority of the participants (96 %) had a moderate attitude, while only 2% 'poor' and 2% 'good' attitude towards different items of the inquiry were documented. There was no significant difference in the attitude level of any demographic variables (Table 6). Regression tests revealed that there was no statistically significant correlation between knowledge and attitude ( Table 7). Table 4 represents the responses obtained for practice items of the questionnaire towards COVID-19. Around 6 % (n=35) of participants reported that they were 'never' following good practices towards COVID-19 such as wearing a nose mask, maintaining social distance, washing hands, and avoiding crowded places during the pandemic. However, around nine out of ten participants affirmed with an 'always' response, following the afore-stated good practices. Around 11 % and 9 % of participants respectively said that they were willing to attend functions and shake hands with friends during the outbreak. Almost, eight out of ten people supported lockdown imposed in the country to control COVID-19 spread and 6 % voiced against it. All responses to the practice questions were significant at p<0.001. Practice score increased with increase in education level, for example, participants holding school education exhibited 2.69/3, while 2.79/5 was recorded for the doctoral level education (Table 5). In the case of occupation category, healthcare workers showed more practice skills score (2.88) than others such as students (2.72), people in government jobs (2.85) and private jobs (2.77), and unemployed individuals (2.70). The practice score was significantly associated with age group (p<0.05), and the state of the respondents (p<0.001) ( Table 5). In the case of practice level towards COVID-19, generally speaking, eight out of ten had a 'good' practice level, while 15 % showed 'moderate' and 3.2 % registered 'poor' practice skills towards different items of the inquiry ( Table 6). Comparison of practice skills of different characteristics revealed that age (p<0.01), and state of participants (p<0.001) had significant differences during the survey period. There was no significant difference (p>0.05) in the practice skills with respect to gender, marital status, education status, and occupation category. Regression tests revealed a statistically significant positive linear correlation between knowledge and practices (r = 0.116, p<0.01) and attitude and practice scores (r = 0.164, p<0.001) ( Table 7).

Assessment of Risk of infection
Assessment of risks of infection was analyzed among all the respondents based on the eight practice questions (Table 4). According to the risk-categories, among all respondents, 3.2 % (n=18) did belong to high-risk category, 14.9 % (n=84) were in the medium-risk category, and most of the participants (81.9 %, n=464) were in the low-risk category (Table 6). High-risk category people were those who responded with a 'never' remark for wearing a mask, washing hands, maintaining social distance, avoiding crowded places and an 'always', preferring handshake while meeting friends in this disease outbreak. The medium-risk category people were those who said 'some time' for the above practices, while the classification of the low-risk category people was based on their response as 'always' for the above practices. Comparatively, greater high-risk people belonged to male (4.5 %) compared to female (3.9 %), low aged (4.9 % for 15-29 years) in contrast to people in the age group, 30-49 years (1.3%), unmarried (4.7 %) than married (2.8 %), and low educated (7.4 % for school education category) than higher educated (2.6 % for Ph.D. degree) categories ( Figure 2).  Most importantly, a significant percentage of participants (~6 %) did not follow the above precautions and ~7 % responded with 'sometimes' only. This is a very serious problem in the country at the moment, suggestive of the need for strict regulations immediately. Indeed, it appears that in the Indian context, the use of face masks is not a norm in society. It is uncommon for the typical Indian to wear a face mask when ill. These dangerous practices were more related to the male participants, particularly those in the young age-group (15-29), low education status, and more specifically, the students. Previous studies also suggested that such risks-taking behaviors are more linkable to the younger age, males, and poorly educated public (Zhong et al.,

Conclusion
India is facing a stiff challenge to control the spread of COVID 19 among its population during the relaxation of preventive measures against COVID-19. Findings of this study show that the Indians have moderate knowledge, attitude, and good practice skills towards COVID-19, which is important to limit the spread of the disease. However, the KAP score significantly differed among demographic variables of age, education, and the state with respect to the knowledge, while age and state of the residents seemed to exert a profound dictate on the practices. Although the government has taken major steps to limit the spread of the disease, more effort is needed particularly during the 2 nd wave. The demographic variables linked to high risk of infection (18-29 age, less education, and student-category) must be addressed appropriately. A positive correlation was observed between knowledge towards practice and attitudes towards practice skills. The outcomes of the study are envisaged to be of some assistance to public health policymakers and health workers. On a concluding note, we anticipate that health education programs would be augmented soon, particularly aimed at improving KAP towards COVID-19 among the high-risk populations. We are upbeat that with concerted endeavors of the Government and the people of the Indian nation, COVID-19 shall be vanquished.
[editorial] The Lancet 395 (10230)            The option, highlighted in bold is the correct and appropriate answer for the respective question