Several factors may influence the spread of communicable diseases including COVID-19 in the community. The first case of COVID-19 was reported in the latter part of December in the year 2019 from China . The disease caused by SARS-CoV-2 is mostly milder but its communicability or spreading potential is much higher than that of the virus which led to Middle East Respiratory Syndrome (MERS) in the year 2012 and almost similar to that of one which sourced the outbreak of SARS in the year 2002 , which may be attributable to its ability to be spread by asymptomatic or pre-symptomatic carriers as well [9, 10]. General thermal screening to detect the presence of fever may many-a-times misses out such a case which could be one of the explanations of speedy spread (within around three months from its initiation) of this new illness to trap a large portion of the World and to get the label of a pandemic . Once its human-to-human transmission was confirmed, public health measures were taken by various nations at their administrative level but still community engagement is equally or rather more valuable to control the spread of COVID-19. People throughout a nation may have diverse knowledge, beliefs, and practices that may directly or indirectly affect the community transmission of COVID-19. Therefore, awareness of the general public of a nation towards COVID-19 (especially its transmission) seems worth to be evaluated.
This study found the presence of correct knowledge, positivity in attitude, and the appropriate practices towards the spread and prevention of transmission of COVID-19 in the majority (> 50%) of the participants.
Because of a lack of evidence on this issue towards this novel ailment especially from India, there is a tiny scope to compare our findings with those of others. However, the relevance of each of the KAP questions used and the responses received for them are discussed here.
SARS-CoV-2 has mainly transmitted through respiratory droplets (diameter < 5–10 µm) and touching the contaminated surfaces [11, 12]. Respiratory droplets are generated by coughing, sneezing, and even talking especially loudly. Though most of the participants knew the mode of spread of COVID-19 (QK1), a considerable proportion thought of its spread not happening by talking closely, by sharing the same bed and eating in the same utensils [Table 2]. The presence of this knowledge may contribute notably to controlling the community spread of the disease.
The Coronavirus has been seen to remain viable on various surfaces for different time durations e.g. on metallic and plastic surfaces for 2–4 days, on the copper surface for 4 hours, and on the cardboard for 24 hours . The surfaces (which had previously come in contact with a SARS-CoV-2 infected person) touched unknowingly by healthy persons within a specified time frame, may lead to contraction of the infection by them. Therefore it becomes important to clean such contaminated surfaces effectively. Sodium hypochlorite solution of a strength of 1% has been recommended for this purpose  but this knowledge was lacking in almost two-thirds of the participants in this study (QK2) [Table 2].
Appropriate use of a medical mask may prevent the acquisition of contagion from an infected person(s). But inappropriate use, on the other hand, may rather harm including causing wastage of resources. A medical mask can be applied properly maximum for 6–8 hours or until it becomes damp, whichever is earlier [15, 16]. Mask is recommended to be used by COVID-19 patients, healthcare workers, or other persons providing them care, and persons who have flu-like symptoms . Keeping in mind the harmful effects caused by the inappropriate use of a mask including discomfort experienced, higher risk of infection to self and others due to its mishandling and because of limited resources, its routine use by the general public (who is not at high risk to acquire the disease) is not recommended [15, 16]. Moreover, the use of a mask may give a false sense of undue protection and may make the public to overlook more important measures to be followed like frequent handwashing. This knowledge is lacking in more than two-thirds of the participants (QK3) [Table 2]. Moreover almost half of the participants have not read or not been told by some trained person about the appropriate use of a mask (QK4) [Table 2]. Lack of this knowledge may affect the transmission of the disease unfavorably in the direct and/or indirect way (by depleting the resources and making them unavailable for those who are in a real need).
Separation (quarantine or isolation) is required for persons suffering from COVID-19 or for those who have come in close contact with such patients . For QK5, wide variation in the responses was noticed. Around 30% of the respondents attempted it correctly, the same number of respondents of this question did not know that separation is not only for COVID-19 patients rather it is for their close contacts or suspected cases who might or might not have contracted the infection, as well, 26% of the respondents did not know that fever, cough, and difficulty in breathing are not exclusive to COVID-19 and 11% did not know that frequent hand washing is recommended for all and not only for COVID-19 caregivers [Table 2].
This is a common practice to use a tissue paper for coughing or sneezing but mishandled one may become a potential source of the pathogen. For QK6, more than two-thirds of the participants knew the correct use of tissue paper for coughing or sneezing [Table 2]. SARS-CoV-2 can infect all age groups including children . Because of a different level of understanding in small children, it becomes important to explain and make them aware of the seriousness of the disease and precautions to be taken through age-appropriate means like comics, stories, etc. Around 14.5% of the respondents of this question did not give importance to making the children aware [Table 2]. Surprisingly, 6.4% of the respondents of the question did not know the vitality of frequent hand washing for the prevention of transmission of COVID-19 [Table 2]. One of the reasons for the lack of this crucial information could be inaccessibility to or a lack of sensitization to the awareness material.
For QK7, around 72% of the respondents had the correct knowledge of protecting others including close relatives from coming in their contact [Table 2] following their incidental contact with a confirmed case of COVID-19, and it is the first basic step to stop the spread of COVID-19 once one has got the infection.
While caring for a COVID-19 person at home, the person should be stayed in a separate well-ventilated room preferably with an attached washroom/bathroom to prevent his/her contact with other persons at the home/household. Ventilated room is recommended because continuous airflow keeps the level of viral particles in the surroundings low and thus reduces the risk of disease transmission to the caregiver(s) as well as may hasten the rate of recovery of the patient . One of the options in QK8 was framed to know this knowledge (importance of good ventilation while quarantining/isolation) among the public. But more than half of the respondents of the question lacked this knowledge. Around 2% of respondents had incorrect knowledge of regularly shaking the bedsheet/linen of the patient given a false sense of cleanliness [Table 2]. Rather this is a harmful practice  because it sheds the viruses in the surroundings, and in turn, increases the risk of transmission. Surprisingly around 8% of the respondents did not understand the actual meaning of quarantine and agreed with the option ‘one visitor at a time may be allowed to meet the patient’ [Table 2]. Lack of this critical knowledge seems troubling and warrants to take steps at the administrative or at a personal level to spread the correct knowledge about separation and its role in combating the COVID-19.
There was wide variation in the opinion of the public regarding the handling of the dead body of a COVID-19 patient (QK9) [Table 2]. The guidelines do not recommend bathing and hugging to the body for obvious reasons. In the Hindu community, the dead body is cremated (burnt to ash). The funeral may be allowed and ash may be collected because in the presence of high temperature during cremation the ash may be considered a sterile remnant and should not pose a risk of transmission of the infection .
‘Basic Reproduction Number’ (R0) of SARS-CoV-2 is calculated to be around ‘3’ which means on an average a sick person infects another three persons . Therefore, various places were locked-down partially or completely for the variable duration by the Governments of different countries including that of India, to reduce the movements of people and in turn to control the spread of infection. Besides this, a few additional steps have been taken by the regional Governments to supply the basic requirements to the doorstep of needy during the period of lock-down, to spread the awareness among the general public, and to improve infrastructure for management of the suspected and/or confirmed cases of COVID-19. Moreover, the Government of India has also launched a mobile application named ‘Aarogya Setu’ that can indicate a person about his/her suspected contact with a case of COVID-19 through artificial intelligence and it can also tell a level risk of acquiring the infection by a person by asking few pieces of information. Around 75% of all the respondents agreed with the steps taken by the Government to be helpful to control the spread of SARS-CoV-2, 9.7% of respondents of the question did not agree with it and the rest were neutral to answer QA1 [Table 3].
Social distancing is considered to be one of the best measures for self-protection as well as protecting others against COVID-19 . Keeping a physical distance from a person suffering from COVID-19 may or may not make him/her feel embarrassed/inferior depending on personal psychology. While answering QA2, slightly less than one-third of the participants agreed with ‘patient feeling embarrassed’ which may show their emotional lability and these persons had a lower level of knowledge with mean maximum knowledge score of 1.5, though half of the participants had a positive attitude agreeing with the option ‘not feeling embarrassed’ [Table 3].
While home caring for a person suffering from COVID-19, the minimum number of household members (preferably only one) should come in his/her contact to prevent the spread of the infection to other members . Around two-thirds of the respondents agreed with this fact in QA3 but still, around 27% of them agreed with ‘involvement of all the family members for caring for the patient to make him/her feel emotionally better’ and had a lower knowledge score with a mean value of 1.2 [Table 3].
Taking precautions at the personal level directly and/or indirectly affects the spread of communicable diseases including COVID-19 for obvious reasons. Almost 90% of the individuals show their agreement with the fact but few of them did not while answering QA4 [Table 3]. The reason behind this attitude of a minority of respondents is difficult to guess but may be related to the dearth of knowledge (Average knowledge score for these individuals was 1.2).
The innate immunity may play a role in combating a viral infection and reducing the severity of the symptoms  but it may not prevent an individual to get an infection at all, and the spread of the virus has been reported from asymptomatic carriers as previously mentioned. While responding to QA5, a few of the respondents showed having a negative attitude of not getting infected due to a strong immunity therefore not requiring precautionary measures. Rest ~ 85% agreed with the need to take precautions against it [Table 3]. But such a negative (in context with transmission) attitude even in a minority of people may prove to have grave consequences for self as well as for the rest of the society.
Exclusive breastfeeding to a newborn has become a norm because of its benefits not only to the baby but also to mothers. However, few conditions may not allow this practice like HIV infection in mother, breast abscesses, herpes simplex infection, active hepatitis B, etc. . Whether or not a nursing mother suffering from COVID-19 should breastfeed to her newborn has not been answered clearly because of a lack of evidence on its benefits versus risks. However, SARS-CoV-2 has not been detected yet in the breastmilk  More than 85% of the respondents opined not to breastfeed the newborns while answering QA6, of whom 69 (37.1%) were females [Table 3].
India is a large country with wide diversity even in Indian culture from region-to-region. Many practices in the ancient Indian culture seem to provide self-protection and in turn, diminish the societal spread of communicable diseases. Examples of such practices are greeting through 'Namaskar’, using copper utensils abundantly for storing water, not eating before taking a bath (cleanliness), using separate utensils for food, and so on. But on the other hand, a few of them in the culture may seem to aggravate the transmission of such ailments e.g. large spiritual gatherings, ‘Angapradakshinam’ practiced by Tamil Hindus [23, 24, 25] and open-defecation. The culture was considered to be protective by around 42% of the respondents and not by the 29%, the rest of the participants were neutral in this regard in response to QA7 [Table 3].
Several infections including those caused by viruses have been acquired by humans from animals either through their prolonged contact or through the food items obtained from them. The same has also been reported for the human infection of SARS-CoV-2. According to a few sources, SARS-CoV-2 spread originally to humans from unhygienic non-vegetarian food practices in China . One of the previous two Coronavirus outbreaks (SARS) had also its epicenter in China  which may support this hypothesis but still concluding remarks cannot be made based on available weaker shreds of evidence. More than 45% of respondents favored this food-habit as a risk factor whereas around 26% denied this supposition and rest were neutral while responding to QA8 [Table 3].
Most outbreaks of the diseases caused by Corona- and Influenza viruses (SARS, MERS, Swine flu, bird flu, etc.) indicate their affinity towards a colder climate, for this reason, it was conjectured for the current outbreak/pandemic also to be sensitive enough to be checked by the higher environmental temperature during summer , but nobody knows what is hidden in the womb of the future. For QA9, around 44% of the respondents opined the disease to remain prevalent in India for the next 1–3 months, 29% thought it to be for the next 3–6 months whereas only around 15% predicted it to last for more than 6 months [Table 3].
Hospitalization is needed for severe cases of COVID-19; asymptomatic close contacts and the cases with milder disease may be managed at home with quarantine . QP1 was framed to know the awareness regarding self-quarantine. Most (around 56%) of the respondents chose to practice self-quarantine which shows the presence of widespread knowledge among the general public regarding the importance of this fundamental step in combating with this calamity. But still, more than one-fourth of the respondents chose to go to a hospital, 8% to call a doctor at home and 6% to inform others about the illness by going to their homes and all these people choosing an inappropriate practice had an average knowledge score of 1.3 [Table 4].
During home-quarantine, a close-contact or a confirmed case of COVID-19 should restrict his/her activities to a separate room without coming in contact with other household members . QP2 was intended to know whether or not the people practice the quarantine correctly. More than half of the participants probably knew practicing quarantine correctly and therefore they chose the option ‘they will wear the mask all/most of the time’ considering the first option (‘restrict their activities to their household and household members-only') as inappropriate. But nearly 44% of the respondents chose the first option as the right practice [Table 4].
Appropriate hand cleanliness is vital to keep self-protected against SARS-CoV-2 infection. If hands are visibly dirty they must be washed with soap and under running water. If hands are not visibly dirty they may be cleaned using an alcohol-based hand rub/sanitizer but even then it is better to wash them with soap and under running water [15, 16]. Around 56% of respondents clean their hands with soap and under running water, around 30% use a hand sanitizer and about 11% use soap and water but not the running water for it [Table 4].
Frequent hand washing has been recommended as one of the most imperative steps for protection against COVID-19 as said above, but guidelines do not mention or recommend the frequency of handwashing because it is largely subjective and depends on various factors including work profile. For example a person sitting in his/her neat & clean office for most of the time of the day may require less frequent hand sanitization than a person serving in a health care facility. The responses received for QP4 showed wide variability in the frequency of handwashing with ‘5–10 times a day’ being the most common followed by 'more than 10 times, ‘3–5 times’, and ‘1–2 times’ a day respectively [Table 4].
SARS-CoV-2 is contained in the respiratory droplets of the infected person which may pour onto the other surfaces making them also a potential source of infection. Therefore the right practice of coughing and /or sneezing becomes very important for community transmission of the virus. It is recommended to cough or sneeze into the inner side of the elbow and not into the palms  because hands are the parts of the body that are touched to the external objects maximally. Nearly Sixty-four percent of the participants practice it into the inner side of the elbow whereas one fourth do it into their palms. Around 6.5% try to stop the reflex and 4.2% practice it into open (QP5) [Table 4].
Mode of greeting may also play an important role in the human-to-human transmission of the disease. For example, hands or other parts of the body of a person could become potentially infected with the pathogen after being touched to the nose or after laying of pathogens following an act of sneezing/coughing, so the infection may spread from a person to another by handshaking or hugging, the two common modes of greeting, unknowingly. ‘Namaskar' does not require touching to or being touched by the person in front therefore may seem to relatively be safer . Surprisingly more than three-fourths of the respondents greet through ‘Namaskar’, around five percent through a handshake, ~ 17% by other modes and none through hugging, which may indicate a high-level awareness among people about human-to-human transmission through 'touch' (QP6) [Table 4].
From the discussion above it seems to become apparent ‘how important to keep oneself protected from potential sources of infection, is?’, because SARS-CoV-2 has been seen to be spread by asymptomatic infected persons as well. Keeping in mind its higher/easy communicability it is recommended to reduce outdoor activities as low as possible. The next question (P7) was formulated to know the awareness of people and practice followed by them in this context. And it is soothing to know that more than 95% of the participants have understood the fact and have minimized their outdoor activities [Table 4].
As mentioned earlier, the SARS-CoV-2 is released in respiratory droplets of an infected person while coughing and/or sneezing but it is difficult for such a large size (outer diameter 50–200 nm) viral particle to travel beyond a distance of around 2–4 feet [11, 29]. Therefore it is recommended to keep a physical distance of at least one meter while communicating with others especially from those suffering from flu-like symptoms . This ‘social distancing’ could be one of the most effective measures to detain its community transmission. Around 92% of the respondents showed their awareness about this practice to answer QP8 [Table 4].
Because of the inhalational route being the key to the transmission of COVID-19, the use of a medical mask has been promoted a lot by the media. However, there is no convincing evidence showing the benefit of using a medical mask by the general public, and also governing bodies do not recommend its routine use by the general public as mentioned earlier. It was tried to know the extent of the use of a medical mask by the general public in India in QP9. More than two-thirds of the respondents have used it since the origin of the outbreak of COVID-19 [Table 4] which may indicate an impact of the promotion by the media.
Our study reveals a fair correlation between knowledge and attitude and between knowledge and practice and a good correlation between attitude and practices followed towards COVID-19. Moreover, the correlations among all the three KAP parameters were statistically significant [Table 6]. Thus the association among these three parameters indicates, attitude is affected to a significant extent by the presence of knowledge and similarly the practice followed (which directly relates to community spread of SARS-CoV-2) in a population is, in turn, affected significantly by its attitude. Therefore the presence of correct knowledge, positive attitude, and appropriate practices towards COVID-19 among the general public help control its spread in human society.