Knowledge, attitude, and practices (KAP) towards COVID-19 among Nepalese residents during the COVID-19 outbreak: An online cross-sectional study

The objective of this study was to assess the knowledge, attitude and practices of COVID-19 among Nepalese population, as containment of the disease is only possible with the change in behaviours as preventive measures. A web-based cross-sectional survey was conducted for a period of two month among Nepalese residents aged ≥ 18 years using a previously validated tool. Unrestricted self-selected, convenient sampling method was adopted to generate a heterogeneous sample. Data were analysed in SPSS version 22 using chi-square/Fisher-exact test, independent t-test, multiple linear regression and binary logistic regression. differed across gender.

India border, establishment of temporary -delegates corona hospital in various parts of the country [10].
On 24 March, Government of Nepal announced a lockdown, which was extended for the seventh time until 2 June 2020 [11]. The consequences and impact of the lockdown have been felt throughout the country.
To achieve a victory against COVID-19 and end the lockdown period in Nepal, measurement of people's obligation towards preventive measures of COVID-19 is necessary. In addition, the containment of the disease is possible only with the change in behaviours as preventive measures. Therefore, for effective planning and implementation of preventive measures, it is crucial to examine the KAP of Nepalese population during COVID19 outbreak. Very few researches have conducted in Nepal for assessing KAP of Nepalese people. This study describes the KAP of Nepalese people during the COVID-19 outbreak in Nepal with delivering the valuable recommendations. In addition, it would provide appropriate strategies to policy maker to develop the effective intervention for controlling COVID19 and improving the situation in further outbreaks.

Study design, participants and Data Collection
A web-based cross-sectional survey was conducted between 1 March and 29 April 2020 for a period of two months. The morbidity from COVID-19 was one on 1 March while the number of cases reached to 57 at the end of April, affecting 14 districts in six provinces of Nepal with no cases reported in Karnali province [9]. The online survey was conducted to all Nepalese population age > 18 years and residing in any seven provinces of Nepal. Since the population was general people, only excluded was people <18 years of age. The online survey was preferred due to the pandemic situation and unable to conduct a community-based survey as well as the urgency of data collection considering the situation. Also, Management Information system (MIS) report from Nepal Telecom Authority (NTA) stated that the internet penetration rate was 72 % (as 14 January 2020) [12] with literacy rate of 66 % (CBS 2011 Report) in Nepal, adequate for conducting online survey [13].
Unrestricted self-selected, convenient sampling method was adopted to generate a heterogeneous sample [14]. The sample was 769 with 3 incomplete data, which have been excluded making the nal sample of 766.
Measurement of knowledge, attitude, and practices related to COVID-19, a previously validated tool was used. The tool was used to measure knowledge, attitude, and practice of COVID-19 among Chinese residents [15]. Permission was obtained to use the tool. The tool was adapted to t the local context with some minor revisions with a few additional questions. After the nalization of the tools, the questionnaire for the survey was developed into a web-based system using an online Google form. The questionnaire was promoted through the authors' network using Facebook, WhatsApp, email and LinkedIn for wider circulations to reach residents of all over Nepal. The online self-administered technique was adopted for data collection.

Study instruments and Variables
The online survey questionnaire consisted of two sections: the rst part consisted of socio-demographic information while the second part consisted of information related to Knowledge, attitude, and practices related to COVID-19.

Socio-Demographic Section
The socio-demographic information included questions related to age, sex, education, occupation, and the province of current residence.

COVID-19 related KAP
The questions related to knowledge, attitude, and practices were divided into three different sections with a total of 16 questions. The questions about knowledge focused on clinical features of COVID-19, transmission, and prevention & control with a total of 12 questions. The responses for knowledge parameters were true, false, and don't know. One score was given for the correct answer and zero for incorrect/don't know the answer. In this way, the total score for knowledge parameters ranged from 0-12, where higher scores indicated better knowledge. The measurement of attitude consisted of two questions related to the participant's consensus on control of the disease and the participant's self-assurance of the country in winning the ght against COVID-19. The practice parameter was measured using two questions related to going to crowded places and wearing a mask while going outside. In contrast to the validated tool, three additional questions related to practice were added related to washing hands after sneezing and coughing, frequently touching face, mouth, and nose with hands and covering mouth and nose with elbow or tissues while coughing and sneezing.

Data analysis
All the data received from the online system were checked for completeness. We received a total of 769 responses, however, 3 forms were incomplete and hence excluded from analysis, with a total of 766 responses for the nal analysis. The data were managed in MS EXCEL v.2010 and analyzed in IBM SPSS version 22 software (SPSS Inc. Chicago IL, USA). Univariate analysis such as frequencies, percentage, mean and standard deviation of demographic variables and KAP were calculated. Furthermore, chisquare/Fisher-exact test, independent t-test, multiple linear regression and binary logistic regression tests were used to compare the knowledge, attitude, and practice behaviours with socio-demographic variables. Con dence intervals (CIs) of 95% were used to quantify the associations between sociodemographic variables and KAP. Knowledge score were standardized for carrying out analysis. For statistically signi cant for all statistical tests, two-tailed p-values<0.05 were considered.

Ethical approval
Ethical approval of the study was taken from the Institutional Review Committee at Bharatpur Hospital, Nepal on 1 March 2020. The initial page of the form contained background, objectives of the study, and consent, followed by the questionnaire only after voluntary agreement by the participants. Anonymity and con dentiality of the participants were maintained at all levels of the study.
Among 12 knowledge questionnaire correct answer rates was 30-99%. The clinical symptoms and isolation period was the queries with the highest true answers while eating or contacting wild animals was the question with the least correct answers. The least rate (30%) was on a question related with the transmission, most of the participants (51%) reported false and 18.6% reported not knowing the reason whether COVID-19 virus would transmitted through eating or contacting wild animals ( Table 2).
We performed multiple regression analysis to investigate the relationship between demographic variables with knowledge scores. The analysis showed that knowledge score were signi cantly associated with occupation, education and practices at 95% con dence level. Health worker average knowledge level is higher than students, teachers and others by about 0.11 (β: -0.11, p<0.001), Education of higher secondary is lower than bachelor level by 0.025 (vs. bachelor, β: 0.25, p<0.05). One-unit increase in the standard deviation of the practice index is associated with a 0.091 standard deviation increase in the knowledge score index (β: 0.091, p<0.05) while xing other demographic variables (Table 3).

Attitude towards COVID-19 and its Correlates
The majority of the participants (71.5%) agreed that COVID-19 will nally be successfully controlled and this attitude was signi cantly different across genders (p=0.021) and residence province (p=0.015). About 80% of the participants had con dence that Nepal can win the battle against COVID-19. However, none of the socio-demographic characteristics were found to be associated with the con dence of winning the battle against the disease (Table 4).

Practices towards COVID-19 and its Correlates
Out of the total participants, the majority (93.1%) had not visited any crowded place and (92.4%) wore masks while going out recently. The practice of going to crowded place signi cantly differed across demographic characteristics (age p=0.039; gender p=0.001; marital status p=0.014; education p<0.001; occupation p<0.001; residence province p<0.001) and COVID-19 knowledge score (p=0.005) while the practice of wearing a mask while going outside signi cantly differed only across gender (p=0.042) ( Table  6).
The majority of the participants mentioned they wash their hands (85.7%) after sneezing or coughing and cover their mouth and nose with their elbows or tissue (93.73%) while sneezing and coughing and this practice was signi cantly different across occupation (p=0.026). About 77.02% of the participants had rarely or sometimes touched their face, nose, and mouth, while about 23% had frequent face, nose, and mouth touching habit. Gender (p< 0.01) and education (p<0.05) were found to be signi cantly associated with their practice of touching their face, nose, and mouth from their hand (Table 8).

Discussion
A similar online study of Nepal was found which assessed the KAP of COVID-19 on Nepalese residents [16]. The study comprised 760 participants and the range of correct answer for knowledge related questions were from 60 to 98.7% with the question on the risk of COVID-19 infection by eating or contacting domestic animals with least correct answers. Our study had 766 participants and the correct answer range for knowledge was between 30-99% with the least correct answer on the same question. Regarding attitude, 78.4% of participants were con dent that COVID-19 could be controlled successfully while this percentage was 71.5% in our study, and almost 80% (77.9%) were convinced that Nepal could win the battle against COVID-19 which was similar (80%) in our study. In terms of practice, 94.9% of participants recently had not been to crowded places and 88.2% were wearing masks correctly while for our study 93.1% had not been to crowded places and 92.4% wore masks while going outside [16].
The ndings of our study were also similar to the previous study conducted in China [15].On knowledge questions, the study showed the range of correct answers between 70.2-98.6% with overall 90% correct answers which differed signi cantly between gender, age, marital status, education level, and place of residence. However, in our study, the overall correct answer was 84.25% with the lowest score on the question related to the risk of COVID-19 by eating or contacting wild animals. The possible reason for this could be that wild animal are not reared or eaten in Nepal. Knowledge scores signi cantly differed across education and occupation. The study in China showed that majority (90.8%) of the respondents agreed that COVID-19 will be controlled successfully and this result was different across gender, education, occupation, and place of residence and 97.1% participants were con dent that China can win the battle against COVID-19 which differed across marital status and education level. In our study, the results regarding attitude were found to be relatively lower. This difference could be because of lower knowledge of COVID-19 among Nepalese than the Chinese population. In terms of practice, the knowledge score was notably associated as 96.4% of participants in China had not visited crowded places and 98% of them wore masks while going out.
Our study shows a higher score in KAP on COVID-19 compared to a study conducted in Paraguay [17] and Malaysia [18]. The study in Paraguay showed an overall correct rate of 62% in knowledge test with signi cant differences in age, gender, education, marital status, and residence [17], while the study in Malaysia showed overall correct rate in the knowledge of 80.5% with higher scores among females, those above 50 years old, people residing in central Malaysia [18] and those with higher incomes, which was lower than our study (84.25%). However, in the knowledge category, there were 13 questions related to knowledge. Likewise, only 66.28% agreed that COVID-19 will be successfully controlled which was signi cantly different across age, gender, education, marital status, occupation, residence, and knowledge on COVID-19 in Paraguay but our study showed a higher rate of 71.5%, with a difference across gender and province of residence. The study in Malaysia, however, showed 83.1% agreed COVID-19 could be successfully controlled and 95.9% were con dent that Malaysia could win the battle against COVID-19. The practice scores in the Paraguay study were lower than our study where 88.35% of participants recently had not visited any crowded place and 74.31% used masks while going outside. The scores were lower in Malaysia where 83.4% avoided crowded places and only 51.2% wore a mask when going outside.
Another study in Malaysia [19] to examine knowledge, perception and communication behaviour among publics in Malaysia showed that the level of knowledge, risk perceptions and positive communication behaviour related to COVID-19 was high, where the majority of the respondents correctly answered knowledge related questions, perceived the risks and impacts of COVID-19 seriously. Likewise, a similar study in Kenya in informal settlements [20] showed knowledge regarding COVID-19 symptoms and highrisk groups were accurate however some misconceptions remained regarding speci c symptoms and considering children as high-risk groups. Another study conducted in Egypt to assess the knowledge, perceptions, and attitude of the public towards the disease showed that the participants had good knowledge and positive attitude towards the protective measures against COVID-19, which was mainly gained through social media and the internet. However, older and lower-income participants, less educated, and people of rural areas had lower knowledge about the disease [21]. Similarly, a study in Peru to assess the knowledge, attitudes, and vulnerability perception during coronavirus outbreak showed that Peruvians had adequate knowledge of COVID-19 and they correctly identi ed the symptoms and transmission of the disease. Knowledge of COVID-19 was strongly correlated with age, education, and occupation. The participants also had signi cant perceived susceptibility to the contracting virus, contracting a virus from others, and displaying stigmatized behaviour [22]. Furthermore, our study showed that participants from other provinces are more likely to go to crowded places, which can justify the increment of COVID-19 cases among people residing in provinces other than Province 3 in Nepal. All participants were literate with at least higher secondary education and the majority of them were students, teachers, or health workers (69%) with less participation from other occupational groups. These characteristics could have led to high knowledge about the disease and less likely to go to crowded places. Some related information such as a source of information, stigma related to COVID-19, fears associated with it could not be assessed. Currently, Nepal is leading to exponential transmission and increment of COVID-19 cases [9], which requires further studies to reveal the factors behind this issue.
As of 13 May 2020, the total number of Polymerase Chain Reaction (PCR) tests was 21,340 and rapid tests were 60,319. With these tests, Nepal identi ed a total of 219 COVID-19 positive cases of which 35 were recovered & discharged and the remaining others were either in contact with health workers or in isolation and observation. A total of 184 cases were in isolation and 14,313 people were under quarantine [23]. Hence, there is a need to increase the number of tests and identify cases as early as possible and conduct systematic screening of contacts of the cases.

Limitations
Since the study is designed for web-based survey, this study would have several limitations, particularly the generalizability of the ndings. Some participants may randomly select the responses to spend the least amount of time to respond to the questionnaire and it could not be generalized on people who don't use internet.

Conclusions
Our study identi ed that majority of the respondents had good knowledge, attitude, and practice towards COVID-19; however knowledge on some questions was poor. Overall, the level of KAP was found to be satisfactory though, it is lower compared to other countries. Hence, there is a need to provide education and awareness of COVID-19 to the people using the available means and different languages to different ethnic communities where COVID-19 cases supposed to be reaching peak. Also, people should be encouraged to stay at home, comply with the lockdown, wear mask correctly, and wash hands frequently or use hand sanitizers or alcohol rubs as available. National and the local bodies should give emphasis to public health measures with developing and adopting appropriate guideline. With combined and collective efforts, Nepal can win the battle against COVID-19.

Data Availability
The data used to support the ndings of this study are available from the corresponding author upon request.

Funding Statement
This research received no speci c grant from any funding agency in the public, commercial, or not-forpro t sectors.

Ethics Declarations
Ethics approval and consent to participants The KAP study was approved by the Bharatpur Hospital Institutional Review Board. A written informed consent was obtained from all participants via online survey form.

Consent for publication
Not applicable.