Abstract
World is suffering from a pandemic situation due to coronavirus disease (COVID-19) since December 2019. In this emergency, everyone at individual/country/global level is trying to contribute at their best with their available knowledge and resources. However, more and more research and developmental activities are going on but, the reality is far away for a grass-root level health professional. They rely on the indirect sources, that is, published or unpublished literature, social media, internet etc. Many a time, these sources may share an unrealistic or false positive/negative information. Our study was intended to assess the knowledge, attitude and practices related to COVID-19 among the healthcare professionals of different levels.
We conducted an online survey after the initiation of the first lockdown in India. Our research team in consultation with the subject experts designed a mix method-based study tool and shared it by sending emails to 1,200 participants.
A total of 180 respondents participated in the online survey of which 34% were government health professionals and 24% were working with a research/academic institution. All participants were between 23 and 74 years age group (mean 39 years). Participants shared their views on first, knowledge about symptoms, preventive measures and treatment options for COVID-19. Second, on attitude towards handling COVID-19 pandemic using social distancing, following lockdown and travel advisory, etc. Third, on the practice of non-pharmaceutical measures to prevent COVID-19.
We found that the social media platform acted as one of the most important platforms for awareness generation regarding COVID-19 but it was also generating stigma among people. Till the time of the survey, there is still a dearth of knowledge about social distancing and what it means, especially physical distance of 1–3 metres and correct usage of mask in different situations. Various important issues pertaining to infant feeding practices, mother and childcare and disposal of dead bodies of COVID infected persons require deliberations and awareness.
Background
In the current decade, rise of new human pathogens and re-emergence of many new diseases are a matter of great concern. Emerging infections defined as the diseases which became prevalent in recent decade and have chances to grow rapidly soon. Such emergence of infection is usually proliferated in new areas if it is being undetected in the population or due to the realisation of an infectious etiology in already established diseases (Dikid et al., 2013). There are estimates that suggest that about 60% of the infectious disease and 70% of emerging infections occurring in humans are zoonotic and derived from wildlife. In India, viral infections are of three major categories, respiratory viral infections, bat borne viral infections and arboviral infections. Pandemic influenza H1N1, highly pathogenic avian influenza (AI) infection (H5N1) and the Middle East respiratory syndrome coronaviruses (MERS-CoV) represent three pathogens causing serious hazard in this category (Gopalakrishnan et al., 2013).
Coronavirus disease 2019 is a new respiratory disease that is caused by novel coronavirus and was first identified in Wuhan, China in the last month of 2019. This highly infectious disease spread like a forest fire and by March 2020 the virus has touched 80 countries.
India being the second most populous country in the world, reported its first case of COVID-19 infection from a student in the state of Kerala in India. The affected student was studying in China and had recently returned from Wuhan. Eventually, the number of COVID-19 cases is rising every day since its first case was detected on 30 January 2020. As of 15 April, India had 12,000 confirmed cases, 210 recovered cases and around 400 deaths. Considering the high infectivity, the Government of India has taken several measures including nationwide lockdown to bring down the infection proliferation of COVID-19. However, successful implementation of these measures depends on the knowledge and awareness of people about the disease, mode of transmission and preventive measures.
IIHMR University, a premier public health university has therefore taken the initiative to conduct a rapid survey among the public health professionals worked in global polio eradication initiative and other government health programs to understand the knowledge, attitude and practice of preventive measures.
Objectives
The study was intended to achieve these three objectives:
To assess the knowledge regarding the symptoms and preventive measures of COVID-19
To measure the attitude of public health professionals towards dealing with COVID-19 pandemic
To assess the intention to practice the non-pharmaceutical measures recommended by the government to prevent spread of COVID-19 infection
Methodology
Research team conducted the study immediately after lockdown 1.0 in India. Research study was cross-sectional in nature. As, it was not possible to collect the data through personal interviews during this spatial period, it was decided to collect the data through online survey. A total of 1,200 respondents working as public health professionals were reached through emails.
Study Population
Our study universe consisted of a population of individuals who had/have been directly involved in implementing activities under the Global Polio Eradication Initiatives (GPEI). They could be a part of any of the activities, that is, funding, policy, programming and/or research cycles in India. The universe included respondents from field level staff to senior level managers. It included people who have worked at the five GPEI core partners (WHO, Rotary, UNICEF, BMGF and CDC), along with Government organisations at any level and people from academic/research institutions and NGOs.
Tools
A questionnaire was designed by our research team. It consisted of a mix of both close-ended (80%) and open-ended (20%) questions. The questionnaire was supplemented by an information sheet describing the study objectives. The survey was administered in English language. Three experts in the field of epidemiology and public health reviewed the content and had undertaken face validity of the questionnaire. The tool was pilot tested through 20 online interviews among varying stakeholders (sample was not included) to ensure lucidity of questions and to reduce ambiguity of questions.
The online survey was conducted using Microsoft Form application. All responses were retrieved into an excel sheet for data cleaning and data analysis. Data analysis was conducted using IBM SPSS software (v.23). Categorical variables were described using frequency and percentages. Continuous variables were summarised using mean and standard deviation.
Ethical Consideration
To protect the rights of participants, the online questionnaire was accompanied with the informed consent. Respondents was asked to provide their approval before participating in the study. To keep their confidentiality, responses were kept anonymous and a recognition code was assigned to each questionnaire in order to send a reminder to those who did not respond to the questionnaire. To ensure confidentiality, specifics of participants were kept in a password-guarded computer that was available only to the research team members.
Results & Discussion
Demographics
A total of 180 respondents voluntarily took part in the study (Response rate—15%) including 64% male respondents and 26% females working in the area of public health in India. Around 34% of the respondents were working as a government health professional, 24% mentioned working in a research organisation/academics and 16% reported working with GPEI partner organisation and 9% were associated with non-governmental organisations (Figure 1). Respondents belonged to 23–74 years of age group with a mean 39 years and a median 36 years. On asking the respondents, whether they can get infected with the virus, around two third of the respondents believed that anybody can be infected by the novel coronavirus (COVID-19) if s/he comes in contact with any person suffering from the disease.
Knowledge towards Symptoms, Preventive Measures and Treatment of COVID-19
Knowledge on the symptoms, preventive measures and treatment was assessed by a set of 10 questions (listed below).
Mode of Transmission
As per WHO, COVID-19 spreads through respiratory droplets or droplets of saliva caused by an infected person through coughing and sneezing. On asking the respondents regarding the mode of transmission of COVID-19 virus, majority of the respondents (97%) were aware that it spread via respiratory droplets of infected person.
As per WHO, risk of COVID-19 transmission can be reduced by averting connection with sick wild animals or rotten animal products. Any contact with living animals in the wet market (e.g., rodents, birds, stray cats and dogs and bats) should be prevented (World Health Organization [WHO], n.d.). Around one third of the respondents reported that eating wild animals would result in COVID-19 infection in humans.
Symptoms
The common symptoms of COVID-19 are fever, dry cough and difficulty in breathing. Some other symptoms include pain and aches, diarrhoea, sore throat and runny nose, fever, cough and shortness of breath were confirmed as major symptoms of COVID-19. Other symptoms like muscle pain, runny nose, headache and diarrhoea were reported by quarter of the respondents. (Figure 2) Around 60% of the respondents do not differentiate between common cold and coronavirus and were not aware that stuffy nose and sneezing are not common symptoms of COVID-19 and occur in rare cases.
Vulnerability towards Infection
As per WHO, people suffering from COVID-19 who are showing mild to moderate respiratory problems generally do not require special treatment. Geriatrics population having comorbidities like diabetes, hypertension, respiratory disease, cancer and cardiovascular diseases have higher chances of developing serious ailments. Around 22% of the respondents were still ignorant towards the vulnerability of the disease, serious disease outcomes occurring in the elderly and patients with diabetes, chronic renal disease, hypertension and cardiovascular disease.
Around 32% of the public health professionals were not aware about the infant feeding guidelines for children born to mother infected/susceptible for coronavirus.
Preventive Measures for COVID-19
Quarantine
Quarantine is the physical disconnection and controlling the travel of healthy people who have possibly been exposed to an infectious disease to reduce the risk of them infecting others (Centers for Disease Control and Prevention, 2017). This definition differs from isolation that states that people should be physically separated from the healthy individuals if suffering from any contagious disease. However, these two words are often used interchangeably, in risk communication and public awareness (Manuell & Cukor, 2011). The word ‘Quarantine’ was first used with regards to leprosy and was widely used in response to the Plague (Black Death) in Venice, Italy in the year 1127 (Newman, 2012). Most recently, quarantine has been used in the recent outbreak of COVID-19) (Public Health England, 2020). The duration of quarantines last for the upper limit of the incubation period of the virus, which is 14 days. It has been found that majority of the public health professionals (97%) were aware about the quarantine guidelines and standard incubation period for it. They also knew that if anyone come in contact with an infected person, s/he should get her/himself tested and put in home quarantine for 14 days.
Use of Masks
Government of India issued a guideline on using masks immediately after WHO declared COVID-19 as a pandemic. It is clearly stated that medical mask should be used only by those suffering from symptoms, healthy person should use other measures like hand hygiene, washing hands, avoiding public places etc. Use of N95 respirators/masks are unanimously recommended to be used by health care workers because it provides protection from respiratory droplets. This message has percolated well among the health care professionals and majority of the respondents (93%) said N95 masks are meant for health care professionals.
Treatment of COVID-19
At this time, there is no particular vaccine or therapies available for COVID-19, but infection can be prevented by using non-pharmaceutical measures. Around 97% of the respondents confirmed that no vaccine has been made for COVID-19, but disease is self-limiting in majority of the cases.
Source of Information
Social media platform has played a crucial role in disseminating information related to COVID-19. Seven out of 10 respondents mentioned TV as their major source of information for COVID-19 related information. More than two-thirds of the respondents got the information from the social media sites like Facebook, Twitter, LinkedIn and Whatsapp. (Figure 3).
Knowledge about Symptoms, Preventive Measures and Treatment of COVID-19
Attitude towards Handling COVID-19 Pandemic
Attitude towards COVID-19 was measured by the set of 10 questions listed below in Table 2 about the agreement on controlling the pandemic and winning the fight against COVID-19.
Attitude towards Handling COVID-19 Pandemic
Social Distancing
Due to the lack of any therapeutic intervention, the only strategy to combat the pandemic is to decrease the chance of intermingling of infectious and vulnerable or high risk groups by reducing contact through social distancing (Lewnard & Lo, 2020). Social distancing refers to a host of public health measures aimed at reducing social interaction between people based on touch or physical proximity. This can include ‘avoid religious congregations, mass gatherings and maintaining distance (approximately 6 feet or 2 metres) from other people when possible’ (Center for Disease Control and Prevention, 2020). Majority of the respondents (96%) strongly agree that infections can be prevented by avoiding going to crowded places and avoiding public transportation. Though advisory has been issued for physical distancing, but people were still confused about whether it is 3 or 6 feet distancing which is needed.
Lockdown
India’s version of social distancing started when Janata Curfew was observed on 22 March 2020. The second lockdown was for a three-week period with effect from 25 March 2020. All places of gathering like multiplexes, shopping malls and complexes and other public places were closed. Any kind of social, public, political, sports, entertainment, academic and cultural gatherings were prohibited. Religious places like temples, mosques, gurdwaras and churches were locked. Limited activity was permitted during the lockdowns. Majority of the public health professionals (96%) understood the importance of lockdown and were ready to follow the lockdown for a period of 21 days. Almost 93% feel that social restriction is must have to prevent the spread of the deadly virus. Very few people (2%) agreed that visiting places of worship is fine during this difficult time.
Care during Corona Infection
Most of the respondents (96%) agreed that COVID-19 is a life-threatening virus and people affected with this virus should be kept separately in special corona wards made in the hospital. If anyone came in contact with any COVID-19 affected patient, they should be immediately isolated from the rest of the family and follow self-isolation. Although, in apparent infections and mild cases could be isolated at home as per the guidelines.
Travel Advisory
In view of the progressing situation of COVID-19 in the world, travel advisories have been issued by Ministry of Health and Family Welfare in which Indian citizens were advised to avoid travelling to countries showing high number of COVID-19 cases like China, Iran, Republic of Korea, Italy, Spain and Japan. An additional advisory was issued on 10 March 2020 that all passengers having travel history to China, Hong Kong, Republic of Korea, Japan, Italy, Thailand, Singapore, Iran, Malaysia, France, Spain and Germany are advised to undergo self-imposed quarantine for a period of 14 days from the date of their arrival. On checking the attitude of respondents towards travel advisory it was found that majority of the respondents agreed that if any Indian citizen had travelled to any of the COVID affected countries, they should immediately contact authorities or follow self-quarantine.
Practice of Non-Pharmaceutical Measures to Prevent from COVID-19
The assessment of respondent’s practice of various measures to prevent from COVID-19 was included behaviour of washing hands frequently, wearing masks if wanting to visit crowded places, postponing non-essential travel etc. If contracted with virus, ready to contact government medical officer and ready to cooperate with government by following quarantine. Most of the respondents 98% reported that they have started following the guidelines on hand washing and started cleaning hands with soap and water and if it is not available, started using alcohol-based sanitisers to prevent contracting the virus. As per WHO, there are no universal standards for infrastructure at quarantine facility, the only important thing is it should not enhance transmission. Generally, people are afraid of getting quarantined because of the media reporting on the unhygienic condition of the quarantine facilities and people are compelled to share basic facilities. These conditions are actually pushing people to escape quarantine by swallowing paracetamol tablets while doing airport check-ins (DW Made for Minds, 2020). Those people who are working in the area of public health are well aware of the importance of quarantine to curb the virus, therefore majority (97%) of the respondents stated they are ready to contact government authority if they came in contact with a COVID-19 affected person and definitely contact medical officer if they develop any symptoms of persistent cough, fever and fatigue. Regarding the use of mask, Center for Disease Control (CDC) recommended wearing masks for only symptomatic people and medical masks for those working in health care setting. It also urged people to wear mask/use face cover while purchasing groceries, pharmacy or at any crowded place (Kelleher, 2020). In India, around 84% of the people started wearing handmade mask whenever they go out for any work. Majority of the public health professionals (95%) who had already worked in global polio eradication initiative reported that they are happy to work as a volunteer and serve the community to combat against COVID-19
Practice of Non-Pharmaceutical Measures to Prevent COVID-19
Adverse Social Determinant—Stigma
The pandemic has adversely affected the social, psychological, economic framework of the country around the world. Low middle income countries (LMIC) have affected more due to layered challenges. In case of India, beside the increasing number of COVID cases and thousands of deaths, forecasted slowdown in the economy, stretched medical system and migrant crisis, there is also social challenges of stigmatisation and discrimination. Stigmatisation is dangerous not only because it triggers racism and xenophobia but mostly it puts everyone at risk. Although, government are majorly concerned with cases and treatment, but COVID-19 is linked to discrimination and prejudice. More than two third of the respondents (61%) confirmed that there was so much of fear associated with the disease resulting in creating stigma among various categories of people including foreigners, foreign returned Indians, medical professionals, airline cabin crew and other members and North Eastern people or people of Asiatic origin. Coronavirus has created stigma which has much greater magnitude if compared with HIV/AIDS. If we think of the marginalised group, they are pushed into further marginalisation. There is a high vulnerability group for stigmatisation: Frontline health workers, people who are in quarantine, migrant group, Asian origin people, people suffering with mild COVID-19 symptoms and their family members.
Respondent’s Verbatim on the People Who are Experiencing Stigma due to Coronavirus Pandemic
‘Foreigners who have returned from other countries are not allowed to enter in their state’
‘There is a high stigma among religious groups who are not ready to cooperate with the government’
‘Family members, friends and acquaintance of foreign returned Indians who are in the radar of government for contact tracing’
‘Medical Professionals (Doctors, Nurses), on duty professionals who are showing signs of COVID symptoms’
‘Airline Cabin Crew and Pilot who are evacuating the stranded Indians from the COVID affected countries’
‘People who blindly believe in fake messages also creating a stigma among the North Eastern people and people of Asian origin’
‘Corona positive people and their immediate contact who comes under contact tracing’
Discussion
We have received tremendous response in a week’s time. Despite of the busy schedule of public health professionals, they could spare time for this survey. Majority of the people knew about the
Coronavirus and the news about the virus majorly reached through social media. The mode of transmission and symptoms being clearly explained in many platforms and this has even reflected in our survey where 97% of the people reported that virus spread through respiratory droplets. This is quite similar to the findings of surveys done in USA and UK. In our study, 92% of the respondents showed complete agreement with the government’s decision of lockdown for 21 days whereas in a similar study, 68% of the respondents were found to be agreeing with their government (Wolf et al., 2020).
Majority of the respondents agreed that infections can be prevented by avoiding going to crowded places and avoiding public transportation. Though advisory has been issued for physical distancing, but people were still confused about whether it is 3 or 6 feet distancing which is needed. Respondents have adequate knowledge on use of N-95 mask for the health service providers but whether medical mask or general mask is appropriate for general population is still doubtful for many. Around 83% reported using masks whenever they go out for purchasing groceries or in other crowded places which is a positive indication of disease containment.
In this pandemic, the biggest adverse social determinant is the highest level of stigma that has exacerbated polarisation by religion, caste, and class (Editorial, 2020). This spread of epidemic gives rise to anxieties and panic among communities and started avoiding/hating/doing violence against those people whom they perceived as the source of bringing the contagious virus. This ‘Other’ could be an international or national migrant, person belonging to minority group, marginalised caste and family members of corona positive persons even a health service provider. There is evidence that indicates that stigma and fear towards particular disease hampers taking of treatment and healthcare services and discourages adopting healthy behaviour. It could lead to severe health problems and difficulties in controlling outbreak.
Conclusion
There is still a dearth of knowledge about social distancing and what it means. The prescribed one metre or three feet distance to be maintain in any gathering is even confusing for many. In the coming weeks, the pandemic runs the risk of becoming more widespread than it needs to be because of dearth of such knowledge and recognition. General guidelines on the usage of masks changes from time to time, hence a clarification on the mask usage, which type and when and where to use mask properly is still required. Infant feeding practices for mother’s affected from COVID-19 and child immunisation is a growing concern at the time of lockdown. Guidelines on the disposal of dead bodies need to be informed to general population. This dreaded virus is killing us mentally before it ever kills us physically thereby leaving a permanent mental scar of fear. It might be created intentionally with the idea of thinning of population, mass hysteria and driving fear into people’s minds. Stigma and fear are the results of very poor knowledge about COVID-19 and this is compounded by large amount of fake news and false information generated today. Stigmatisation has several consequences not just for the victims but also for the community and society. Fear of stigmatisation forces people with mild symptoms to hide their health condition or avoid taking medical help which in turn leads to increase in number of cases. Though, social media platform acted as one of the most important platform to spread the information related to coronavirus but at the same time, it also helped in generating stigma among people. Hence there is dire need of balanced media reporting and to amplify the voices, stories of those people who have experienced COVID-19 and have recovered from it to emphasise that the disease is curable.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.