Knowledge, attitude, and practice regarding COVID-19 infection among chronic disease patients visiting tertiary hospitals of Nepal: a cross-sectional study

doi:10.21203/rs.3.rs-1615003/v1

Aim: To access the knowledge, attitude, and practice (KAP) towards COVID-19 disease among chronic diseases patients visiting tertiary hospitals of Kathmandu.

Methods: A cross-sectional study was conducted among chronic disease patients who visited Tribhuvan University Teaching Hospital and Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu. Semi-structured questionnaire was used to collect patients’ socio-demographic data and perspectives on COVID-19.

Results: Four hundred chronic disease patients participated in the study, with 53.2% female and 46.8% male, and 56.8% of age ≥50 years. Overall, 55.5% of the participants had good knowledge, 56.2% had good practice, and 30.7% had positive attitude towards COVID-19. Younger patients, 18-34 years, were found to have higher odds of having good knowledge compared to other age groups (aOR: 2.5; 95% CI: 1.3-6.0). The patients with less than average family income and those unable to read and write had lower odds of having positive attitude towards COVID-19 (aOR: 0.6; 95% CI: 0.4-0.9 and aOR: 0.4; 95%CI: 0.2-0.9, respectively). A statistically significant correlation was found between the patients’ knowledge and practice, knowledge and attitude, and attitude and practice (p <0.001).

Conclusion: Nearly half of the chronic disease patients in Nepal had poor knowledge and practice whereas more than two-third had negative attitude towards COVID-19 disease. Older age of the patient was significantly associated with poor knowledge and poor practice. These study findings could be helpful for the government and non-government stakeholders while planning COVID-19 awareness campaigns to the targeted patient groups.

Chronic disease

COVID-19

knowledge

attitude and practice

COVID-19 awareness

Nepal

COVID-19 is a communicable disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Genome and protein analysis have suggested that SARS-CoV-2 is transmitted to humans from animal hosts mainly from bats or pangolin [1]. Several studies have noted that the virus can transmit from humans to domestic and wild animals [2–4]. In humans, the virus causes mild to moderate respiratory illness. However, medical attention is required mostly in the patients who have underlying medical conditions [5]. Studies have reported that patient characteristics such as male gender, obesity, advanced age, and smoking habit, and comorbid conditions such as chronic obstructive pulmonary disease (COPD), hypertension, diabetes, chronic kidney diseases (CKD), coronary heart disease (CHD), chronic liver disease (CLD), malignancy, and shock are more likely to increase clinical severity in COVID-19[6]. A study showed that COPD can increase the severity of COVID-19 by five-folds [7]. These comorbidities are likely to increase the expression of cellular receptors [Angiotensin-converting enzyme 2 (ACE-2), Transmembrane protease, serine 2(TMPRSS2)] that which facilitate SARS-CoV-2 infection in the human body[8, 9].

Poor understanding and social stigma related to the virus and viral transmission increases the spread of infection in communities and escalates COVID-19 associated morbidity and mortality [10]. Although governments impose strict rules and regulations to control the disease, it is public knowledge, attitude and practice (KAP) which determine the speed of virus spread [11]. A longitudinal study from France showed that chronic health conditions (Down syndrome, mental retardation, renal transplant, lung transplant, active lung cancer, and end-stage renal disease) were positively associated with increased risk of COVID-19 mortality [12]. Globally, several studies have assessed COVID-19 KAP among health workers, students, and general public, but only a few studies have looked at the perspectives of individuals suffering from chronic diseases [13].These studies report insufficient knowledge, poor practice, and negative attitude regarding COVID-19 pandemic [14–16]. In Nepal, there is no such evidence, despite a high proportion of population living with chronic disease [17]. This study aimed to determine the level of knowledge, attitude and practice regarding COVID-19 among chronic disease patients who visited tertiary hospitals of Kathmandu, Nepal.

Research design, setting and study population

A cross-sectional study was conducted in two tertiary care hospitals of Kathmandu: Tribhuvan University Teaching Hospital (TUTH) and Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC). All patients with chronic diseases conditions were involved in the study who attended the outpatient department of different departments of TUTH and MCVTC for their routine treatment and follow-up between the period of 22 August 2021 and 19 December 2021.

Study population, sampling method and sample size

The study enrolled patients age 18 years and above who visited the selected hospitals for treatment and follow-up of chronic disease. Those patients with serious health complications including advanced liver failure, advanced respiratory problems, advanced heart failure, hearing impairment, and advanced dementia or mental disorders were excluded.

Study participants were selected systematically, recruiting every 10^th patient from the patient register. Sample size was assumed at 50% prevalence of KAP, since there was no published data that showed knowledge, attitude, and practice related to COVID-19 among chronic disease patients in Nepal, and calculated using Cochran’s formula, n = Z2pq/d2. The estimated sample size was 384, but after adjusting for possible non-response rate of 10%, the final sample size was 422. Fifteen chronic disease patients were interviewed per day.

Research instrument and pre-testing

The research tool included structured questionnaires related to socio-demographic information of participants, their clinical characteristics, and specific information about KAP on COVID-19. The tool had 13 knowledge related items (clinical presentation, route of transmission, prevention and control of the outbreak) scored as true, false or not sure [18,19]. In attitude-related questions, six statements were adopted from the literature assessing participants’ attitudes toward COVID-19, using a five-point Likert scale, with scores ranging from 1 (Strongly disagree) to 5 (Strongly agree). Total scores ranged from 6 to 30, where high score indicated positive attitude [20]. For practice-related questions, total eight questions were used from a previous study, allowing participants to choose between two options ‘Yes’ and ‘No’[21]. All the tools were developed by the researchers with the help of extensive literature review and consultation with experts. The pre-testing was done in 15 chronic disease patients of Bir Hospital located in Kathmandu. Based on pre-testing, minor changes were made in the wording and sequence of the questions. The questionnaires were developed in both English and Local (Nepali) languages.

Data collection procedure

Informed written consent was taken before initiating the data collection from respondents. Data were collected by face-to-face interviews with participants and the range of duration was12 to 15 minutes. Research assistants (medical undergraduates) were involved in the interview at the study sites. The research assistants were personally briefed and trained by the first author beforehand. Confidentiality was maintained by keeping the response safely and was only used for this research purpose. Anonymity of respondents was maintained by assigning code numbers instead of participants’ names. Considering the COVID- 19 pandemic situation, the patients’ safety was assured by maintaining physical distance (at least 2 meters) and wearing a face mask and gloves.

Data analysis

Data was entered in the EpiData version 3.1, then transported to the Statistical Package for Social Sciences (SPSS IBM) version 21.0 for analysis. At first, we performed a descriptive analysis which included calculation of frequency, percentage, mean and median for presentation of socio-demographic and KAP-related variables. The Chi-square test was used to assess differences in categorical variables. Variables with p value of ≤ 0.2 were retained in the multivariable logistic regression to determine potential factors associated with the outcome variable; thus, adjusted odd ratios were calculated. We also checked multi-collinearity between predictor variables. For final result of logistic regression, p value was set statistically significant at <0.05. Additionally, we examined the effect of several predictor variables (age, sex, occupation, marital status, family income, family support, study site, duration of chronic disease, and health insurance) on COVID-19 knowledge; the effect of occupation, education, family support, study site, and duration of chronic illness on COVID19 attitude; and the effect of age, ethnicity, occupation, marital status, family income, family support, duration of chronic illness, and health insurance on the participant’s practice. The level of significance was considered at 5% with p< 0.05 and 95% confidence interval to determine the strength of association between independent variables and outcome variables.

Socio-demographic characteristics

Out of 400 participants who completed the questionnaires, 36.0% (144) had heart disease, 21.7% (87) had lung disease, 15.2% (61) had kidney disease, 9.7% (39) had cancer, and 20.0% (80) had other chronic illness. More than half of the participants (56.8%) were in the age group of 50 and above, and 53.3% were females. Majority (65.3%) of the participants had a history of chronic disease less than 5 years. At the time of study, 61.8% of the participants were immunized with 2 doses of COVID-19 vaccine. Detail information related to the socio-demographic characteristics of study participants are shown in Table 1.

Table 1

Socio-demographic characteristics of the participants (N = 400)
Characteristics		Frequency	Percentage
Age (years)	18–34	55	13.8
	35–49	118	29.5
	50 and above	227	56.8
Sex	Male	187	46.8
Sex	Female	213	53.2
Ethnicity	Dalit	38	9.5
	Aadibashi/Janajati	139	34.8
	Brahmin/Chhetri	185	46.3
	Others	38	9.5
Marital status	Married	315	78.8
	Marital dislocation	56	14.0
	Never married	29	7.2
Education	Illiterate	64	16.0
	literate	83	20.8
	up to SLC	148	37.0
	Plus two and higher	105	26.3
Occupation	Employee	142	35.5
	Agriculture	99	24.8
	Housewife	77	19.3
	Currently not working	64	16.0
	Labor	18	4.5
Family income (per month in Nepalese rupees)	≥ 30,000	225	56.3
Family income (per month in Nepalese rupees)	< 30,000	175	43.8
Duration of chronic disease (years)	< 5 years	261	65.3
	5 to 10 years	84	21.0
	> 10 years	55	13.8
National health insurance	Insured	142	35.5
National health insurance	Not insured	258	64.5
COVID-19 vaccination	No	89	22.3
	Single dose	64	16
	Full dose	247	61.8

Knowledge variables

Table 2 shows that the higher proportion of participants (62–91%) had good knowledge about COVID-19 symptoms, treatment, severity, transmission, use of face-mask, social distancing, role of isolation, and differences between common cold and COVID-19. However, some participants (10–25%) were doubtful about the transmission of COVID-19 via contact with wild animals and protection measures for children and young adults.

Table 2

Knowledge of chronic disease patients on COVID-19 infection
Knowledge	True, n (%)	False, n (%)	I am not sure, n (%)
The main symptoms of COVID-19 are fever, fatigue, dry cough, and body aches.(True)	363 (90.8)	12 (3)	25 (6.3)
Unlike the common cold, stuffy nose, and sneezing are less common in person infected with the COVID-19 virus.(True)	251 (62.7)	67 (16.8)	82 (20.5)
Currently, there is no effective cure for COVID-19, but early symptomatic and supportive treatment can help most patients recover from the infection. (True)	335 (83.8)	18 (4.5)	47 (11.8)
Not all persons with COVID-19 will develop to severe cases. Only those who are elderly and have chronic Illnesses are more likely to be severe cases.(True)	350 (87.5)	20 (5.0)	30 (7.5)
Eating or touching wild animals is the primary cause COVID-19 infection.(False)	95 (23.8)	165 (41.3)	140 (35.0)
Persons with COVID-19 cannot infect the virus to others if they do not have a fever. (False)	72 (18.0)	250 (62.5)	78 (19.5)
The COVID-19 virus spreads via respiratory droplets of infected individuals.(True)	348 (87.0)	12 (3.0)	40 (10.0)
The COVID-19 virus is airborne.(True)	273 (68.3)	52 (13.0)	75 (18.8)
Ordinary residents can wear face masks to prevent the infection by the COVID-19 virus.(True)	366 (91.5)	9 (2.3)	25 (6.3)
It is not necessary for children and young adults to take measures to prevent the infection by the COVID-19 virus. (False)	40 (10)	333 (83.3)	27 (6.8)
To prevent the infection by COVID-19, individuals should avoid going to crowded places and avoid taking public transportation. (True)	350 (87.5)	26 (6.5)	24 (6.0)
Isolation and treatment of people who are infected with COVID-19 virus are effective ways to reduce the spread of the virus.(True)	347 (86.8)	13 (3.3)	40 (10)
People who have contact with someone infected with the COVID-19 virus should be immediately isolated in a proper place. In general, the isolation period is 14 days. (True)	306 (76.5)	28 (7.0)	66 (16.5)

Attitude variables

More than half of the participants (55–56%) agreed with the importance of precaution measures (social distancing and hand washing) which need to be taken during the pandemic. A quarter of the participants strongly agreed that compliance with the government rules would prevent the spread of COVID-19. Other findings regarding attitude towards COVID-19 are given in Table 3.

Table 3

Attitude of chronic disease patients towards COVID-19 infection
Attitudes	Strongly disagree n(%)	Disagree n(%)	Neutral n(%)	Agree n(%)	Strongly agree n(%)
It is important to keep my distance from others, to avoid spreading SARS-CoV-2	5 (1.3)	6 (1.5)	8 (2.0)	154 (38.5)	227 (56.8)
Washing hands is essential to protect myself from COVID-19	3 (0.8)	3 (0.8)	13 (3.3)	159 (39.8)	222 (55.5)
To protect myself from COVID-19 exposure, I should stay home if I am sick, unless I am receiving medical care.	3 (0.8)	9 (2.3)	29 (7.2)	204 (51)	155 (38.8)
COVID-19 will eventually be successfully controlled.	30 (7.5)	70 (17.5)	106 (26.5)	155 (38.8)	39 (9.8)
Nepal’s measures can help win the battle against COVID-19	35 (8.8)	78 (19.5)	88 (22.0)	159 (39.8)	40 (10)
Compliance with Ministry of Health precautions will prevent the spread of COVID-19	15 (3.8)	29 (7.2)	39 (9.8)	217 (54.3)	100 (25.0)

Practices variables

Furthermore, analysis of participants’ compliance toward COVID-19 prevention showed that the majority (63–92%) followed a good practice to reduce transmission and prevent the infection. However, only one-third of the participants had noted helpline numbers in their mobile device or phone diary for emergency contact, in case they or someone they know needed COVID-19 advice (see Table 4 for details).

Table 4

Practices related variables of chronic disease patients regarding COVID-19 infection
Practices	Yes n(%)	No n(%)
Did the outbreak of the COVID-19 make you increase the frequency of washing hands?	369 (92.3)	31 (7.8)
Did the outbreak of the COVID-19 make you use hand sanitizer more frequently?	348 (87.0)	52 (13.0)
Did the outbreak of the COVID-19 make you use personal protective equipment (e.g. mask) more frequently?	357 (89.3)	43 (10.8)
Did you carry hand sanitizer with you during the outbreak in Nepal?	253 (63.2)	147 (36.8)
Did you write down or store in your phone any helpline number to contact in case you suspected that you or someone you know had the COVID-19 virus?	137 (34.3)	263 (65.8)
Did you maintain social distance during the outbreak?	364 (91)	36 (9)
Did you cover cough and sneeze with a tissue, handkerchief, etc. during the outbreak?	339 (84.8)	61 (15.3)
Did you avoid unnecessary travel or outing during the outbreak?	343 (85.8)	57 (14.2)

Factors associated with knowledge, attitude, and practice

Overall, 55.5% of the study participants had good knowledge, 56.2% had good practice, and 30.7% had positive attitude towards COVID-19 disease. People aged 18–34 years had higher odds of having good knowledge (aOR:2.5, 95% CI: 1.3-6.0) compared to those aged 50 years and above. Likewise, people with family income below average had lower odds (aOR: 0.6; 95% CI: 0.4–0.9) of having good knowledge compared to those with above-average income. Participants who were unable to read and write had lower odds of having positive attitude (aOR: 0.4, 95%CI: 0.2–0.9) compared to those pursing secondary and above education. In our multivariable analysis, age, family income, family support, and enrolment into national health insurance were found to be associated with good COVID-1i related practices. All the variables whose p value was < 0.2 were adjusted, except education which showed interaction with knowledge variables (see Table 5 for details).

Table 5

Factors associated with knowledge of COVID-19 among chronic disease patients
Variables	Category	Knowledge n(%)		aOR (95% CI)	Practice n(%)		aOR (95% CI)	Attitude n(%)		aOR (95% CI)
Variables	Category	Good (n = 222)	Poor (n = 178)	aOR (95% CI)	Good (n = 225)	Poor (n = 175)		Good (n = 123)	Poor (n = 277)
Age	18–34 years	41 (74.5)	14 (25.5)	2.5 (1.3-6.0)*	43 (78.2)	12 (21.8)	2.6 (1.1–6.5)*	20 (36.4)	35 (63.6)	-
	35–49 years	75 (63.6)	43 (36.4)	1.7 (1.1–2.8)*	72 (61)	46 (39)	1.7 (1-2.8)*	36 (30.5)	82 (69.5)	-
	50 and above	106 (46.7)	121 (53.3)	Ref	110 (48.5)	117 (51.5)	Ref	67 (29.5)	160 (70.5)	-
Sex	Male	110 (58.8)	77 (41.2)	1.4 (0.8–2.4)	-	-	-	58 (31)	129 (69)	-
Sex	Female	112 (52.6)	101 (47.4)	Ref	-	-	-	65 (30.5)	148 (69.5)	-
Occupation	Employee	93 (65.5)	49 (34.5)	0.9 (0.3–2.9)	93 (65.5)	49 (34.5)	2.2 (0.6–7.7)	44 (31)	98 (69)	1.5 (0.4–6.2)
	Agriculture	52 (52.5)	47 (47.5)	0.8 (0.2–2.4)	46 (46.5)	53 (53.5)	1.5 (0.4–5.4)	24 (24.2)	75 (75.8)	1.5 (0.4–6.1)
	Housewife	42 (54.5)	35 (45.5)	1.3 (0.4–4.3)	41 (53.2)	36 (46.8)	1.9 (0.5–6.9)	33 (42.9)	44 (57.1)	3 (0.8–12.0)
	Unemployed	25 (39.1)	39 (60.9)	0.5 (0.1–1.9)	40 (62.5)	24 (37.5)	3.9 (1.1–14.8)	19 (29.7)	45 (70.3)	1.9 (0.5–8.1)
	Labor	10 (55.6)	8 (44.4)	Ref	5 (27.8)	13 (72.2)	Ref	3 (16.7)	15 (83.3)	Ref
Education	Illiterate	18 (28.1)	46 (71.9)	-	-	-	-	11 (17.2)	53 (82.8)	0.4 (0.2–0.9)*
	literate	34 (41.0)	49 (59.0)	-	-	-	-	31 (37.3)	52 (62.7)	1 (0.5-2)
	up to SLC	81 (54.7)	67 (45.3)	-	-	-	-	44 (29.7)	104 (70.3)	0.8 (0.4–1.4)
	≥Plus two	89 (84.8)	16 (15.2)	-	-	-	-	37 (35.2)	68 (64.8)	Ref
Marital status	Never	23 (79.3)	6 (20.7)	2.6 (0.6–10.2)	23 (79.3)	6 (20.7)	1.5 (0.4–6.1)	-	-	-
	Married	178 (56.5)	137 (43.5)	1.8 (0.9–3.7)	182 (57.8)	133 (42.2)	1.7 (0.9–3.4)	-	-	-
	Marital dislocation	21 (37.5)	35 (62.5)	Ref	20 (35.7)	36 (64.3)	Ref	-	-	-
Family income	Up to 30,000	113 (50.2)	112 (49.8)	0.6 (0.4–0.9)*	108 (48)	117 (52)	0.5 (0.3–0.8)*	62 (27.6)	163 (72.4)	0.7 (0.4–1.2)
Family income	> 30,000	109 (62.3)	66 (37.7)	Ref	117 (66.9)	58 (33.1)	Ref	61 (34.9)	114 (65.1)	Ref
Family support	No support	7 (41.2)	10 (58.8)	0.6 (0.2–2.2)	8 (47.1)	9 (52.9)	0.9 (0.3-3.0)	4 (23.5)	13 (76.5)	1.1 (0.3-4.0)
	Full support	163 (59.1)	113 (40.9)	1.4 (0.8–2.4)	179 (64.9)	97 (35.1)	2.4 (1.5–4.1)**	96 (34.8)	180 (65.2)	1.5 (0.9–2.7)
	Neutral	52 (48.6)	55 (51.4)	Ref	108 (48)	117 (52)	Ref	23 (21.5)	84 (78.5)	Ref
Study site	MCVTC	107 (69.5)	47 (30.5)	3 (1.9–4.9)***				29 (18.8)	125 (81.2)	0.4 (0.2–0.6)***
Study site	TUTH	115 (46.7)	131 (53.3)	Ref				94 (38.2)	152 (61.8)	Ref
Duration of chronic disease	< 5 years	160 (61.3)	101 (38.7)	1.6 (0.8–3.1)	162 (62.1)	99 (37.9)	1.6 (0.8–3.1)	90 (34.5)	171 (65.5)	1.7 (0.8–3.3)
	5 to 10 years	40 (47.6)	44 (52.4)	1.2 (0.6–2.5)	37 (44)	47 (56)	0.8 (0.3–1.8)	18 (21.4)	66 (78.6)	0.9 (0.3–2.1)
	> 10 years	22 (40)	33 (60)	Ref	26 (47.3)	29 (52.7)	Ref	15 (27.3)	40 (72.7)	Ref
Health insurance	Insured	90 (63.4)	52 (36.6)	Ref	93 (65.5)	49 (34.5)	Ref	-	-	-
Health insurance	Not insured	132 (51.2)	126 (48.8)	0.7 (0.4–1.08)	132 (51.2)	126 (48.8)	0.6 (0.3–0.9)*	-	-	-
Notes: p value less than 0.05; p value less than 0.01 ; ** p value less than 0.001

Correlation between knowledge, attitude, and practice

There was a significant difference (p-value < 0.01) regarding knowledge, attitude, and practice of chronic disease patients towards COVID-19 (Table 6).

Table 6

Correlation between knowledge, attitude and practice of chronic disease patients toward COVID-19 infection
Variable	Correlation coefficient (rs)	p-value
Knowledge-Attitude	0.2**	0.001
Knowledge-Practice	0.4**	< 0.001
Attitude-Practice	0.2*	0.003
Notes: rs, Spearman’s correlation coefficient; * correlation is significant at the 0.05 level (2-tailed); ** Correlation is significant at the level of 0.01 level (2-tailed).

In our study, 65.3% participants had a history of at least one chronic disease, with the majority aged 50 years and above. The study participants suffered from a variety of chronic diseases such as cardiovascular disease, lung disease, kidney disease, and cancer, among 36.0%, 21.7%, 15.2%, and 9.7% respectively. Studies have shown that these chronic conditions, one or multiple, attribute to disease severity and worsen clinical outcomes in COVID-19 patients [22, 23, 24, 25, 26].

Nepal is a lower-middle-income country with fragile health systems including chronic inadequacy of human resource [27]. People’s knowledge, attitude, and practice with regards to COVID-19 could have played an important role in breaking the chain of transmission in the communities, hence, minimizing the impact. But, this study found that only 55.5% of the participating patients (requiring long-term care) had good knowledge, 56.2% had good practice, and 30.7% had positive attitude towards COVID-19. In a study conducted among cancer patients in Nepal, 79.4% of the participants gave correct response to knowledge related questions, 89.7% had positive attitude towards isolation need for infected individuals, and 95.5% reported good practices such as avoiding crowded place [13].In our study, 90.8% of the participants were aware about COVID-19 symptoms, 91.5% had knowledge about the role of face masks in preventing spread of virus, 87.5% avoided crowded places, and 83.8% knew that no specific antiviral treatment was available for COVID-19. A similar community based study conducted among the general public of province 2 showed that the participants had adequate knowledge about COVID-19 [11].

More than half of the study participants in Nepal having a good knowledge and practice regarding COVID-19 might be a satisfactory finding for relevant stakeholders, and it could be due to the national and international efforts for public awareness through different means of communication. The Government of Nepal had urged the public through audio-visual channels, social media platforms, and telecommunication services to adopt social distancing, use mask at public places, and periodically use sanitizer or hand washing measures. Moreover, this study found that most of the participants agreed about the importance of strictly following the government’s public health message. In contrast, 19.5% and 8.8% of the participants disagreed and strongly disagreed that the government’s public health measures would help curb the pandemic. This may be due to the public dissatisfaction towards politicians and government officials as they kept on violating government’s public health rules by organizing mass gatherings and rallies during the pandemic [28].

Regarding COVID-19 related practice, most of the chronic disease patients in this study (92.3%) were found to have increased the frequency of hand washing during the pandemic than before. More than 80.0% of the participants frequently used hand sanitizer, wore personal protective equipment, maintained social distance, maintained cough and sneeze etiquettes, and avoided unnecessary travel. A similar study from Vietnam revealed that knowledge was significantly associated with participants’ practice, i.e. those having good knowledge about COVID-19 had a higher probability of following good practices [29].

Younger adult patients (18–34 years) with chronic disease had two folds of good knowledge compared to older adults aged 50 and above. Similarly, participants’ education, family income, family support, and health insurance status were found to be associated with COVID-19 related practices. In Nepal, the chronic disease patients with no registration with social health insurance were less likely to have good practice regarding COVID-19. This finding suggests that increasing the coverage of health insurance would help in improving the pandemic related practices in individuals or households requiring long-term care. It is important that all people, regardless of health status, are aware of and strictly follow the general public health advice issued by the CDC or the WHO [30, 31].

The study has few limitations. It captured the patient population of Kathmandu valley only, so the KAP of chronic disease patients living in other areas of the country could not be explored. Further, the study did not ask ‘quality of life’ related questions, which would have helped us understand the status of people who require long-term care and the findings would have a policy and programmatic impact regarding the improvement of healthcare services for the most needy group of patients.

Nearly the half of chronic disease patients had poor knowledge and practice, whereas more than two-third had a negative attitude, regarding COVID-19. Increasing age was significantly associated with poor knowledge and poor practice. Chronic disease patients who were not enrolled into the national social health insurance program were not found to have a good practice either. Based on these findings, effective health education and awareness programs might be urgently needed that are aimed at mobilizing and improving COVID-19 related KAP, especially for chronic disease patients from low family income, with older age, and those not covered by the health insurance. Collaborative efforts between the Ministry of Health and Population, health service providers, development partners, and the media are urgently needed to implement more effective tools that increase the knowledge, attitude, and practice of individuals and households requiring long-term care.

COVID-19: Coronavirus disease 19

SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2

KAP: Knowledge, Attitude, and Practice

CDC: Centers for Disease Control and Prevention

WHO: World Health Organization

TUTH: Tribhuvan University Teaching Hospital

MCVTC: Manmohan Cardiothoracic Vascular and Transplant Center

Ethics approval and consent to participate: Before data collection, ethical approval was obtained from the Ethical Review Board of the Nepal Health Research Council (NHRC), Kathmandu Nepal (Reference number: 639/2021 P), and administrative approval was taken from the study sites. Prior written informed consent was obtained from all study participants or their primary relatives, whichever applicable.

Consent for publication: not applicable

Availability of data and materials: The data that support the findings of this study are available on request from the corresponding author.

Competing interests: None

Funding: This study was partially supported by Nepal Health Research Council under the Provincial Research Grant-2021, award number was113.

Authors' contributions:

KR: Conceptualized, drafted manuscript

AB: Conceptualized and drafted manuscript

BS, SB: Drafted manuscript

ST, NB, SS, KP: Data collected and cleaned and entered and analyzed the data

SB, SD, SKD, DKA: Commented on manuscript

Acknowledgments: We would like to express our gratitude to Nepal Health Research Council for funding support. We also thank Shiva Raj Mishra, PhD for supporting us during preparation of the manuscript.

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Knowledge, attitude, and practice regarding COVID-19 infection among chronic disease patients visiting tertiary hospitals of Nepal: a cross-sectional study

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Version 1

Abstract

Background

Methods

Results

Discussion

Conclusion

Abbreviations

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References

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Version 1