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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2021  |  Volume : 63  |  Issue : 4  |  Page : 383-390
Knowledge, attitudes, and practices about COVID-19 among Kashmiri population: A cross-sectional study


1 Department of Psychiatry, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Social and Preventive Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India
4 Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India
5 Department of English, St. Stephen's College, Delhi University, Delhi, India
6 Department of Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India

Click here for correspondence address and email

Date of Submission28-Apr-2020
Date of Decision19-May-2020
Date of Acceptance16-Jun-2021
Date of Web Publication07-Aug-2021
 

   Abstract 


Background: Nations across the globe are investing enormous resources to contain the coronavirus disease 2019 (COVID-19) pandemic. Assessing community knowledge and behavior could help in designing effective health-care policies tailored to the need of target population.
Aims: We aimed to assess the knowledge, attitudes, and practices (KAP) about COVID-19 among Kashmiri population and to determine the association of KAP scores with the sociodemographic variables.
Settings and Design: This was a cross-sectional study conducted via various online platforms.
Materials and Methods: A structured questionnaire was formulated which was divided into three scoring sections assessing KAP about COVID-19 and a nonscoring section assessing individual reactions. A link to the survey was disseminated through social media platforms. A total of 1051 individuals participated.
Statistical Analysis: Descriptive statistics were used for assessing the demographic characteristics of participants. Inferential statistics (Mann–Whitney U-test and Kruskal–Wallis test) were used for comparison.
Results: Majority of the participants belonged to the age group of 20–39 years (75.4%), were unmarried (66.6%), were from urban background (54.9%), and had education of above high school (96.3%). In general, scores suggested that participants possessed adequate knowledge (mean ± standard deviation: 10.07 ± 1.134), had good attitudes (11.85 ± 1.42), and followed good practices (12.26 ± 1.42) regarding COVID-19. However, we found the correlations between KAP scores to be weak.
Conclusions: A knowledge–praxis gap was highlighted in the studied population which was especially true for the vulnerable age group of > 60 years. The findings call for attention of health-care policymakers to design need-based, locally adaptable, and practicable interventional strategies for target population.

Keywords: Attitudes, COVID-19, Kashmir, knowledge, practices

How to cite this article:
Imtiyaz BS, Jamwal C, Hussain A, Roub F, Tariq R, Qayoom I, Syed J, Renzu M. Knowledge, attitudes, and practices about COVID-19 among Kashmiri population: A cross-sectional study. Indian J Psychiatry 2021;63:383-90

How to cite this URL:
Imtiyaz BS, Jamwal C, Hussain A, Roub F, Tariq R, Qayoom I, Syed J, Renzu M. Knowledge, attitudes, and practices about COVID-19 among Kashmiri population: A cross-sectional study. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 18];63:383-90. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/4/383/323381





   Introduction Top


Coronavirus disease 2019 (COVID-19) is an infectious disease which caught attention in late December 2019, when explosion of cases bearing presentation of atypical pneumonia began emerging from the Wuhan city of the Hubei province in China.[1] COVID-19 has currently infected over a hundred million people in more than 200 nations, and the dynamics may change as the situation continues to evolve.[2] It was declared a pandemic on March 11, 2020, by the World Health Organization (WHO).[3] As of May 31, 2021, India had a total of 2,026,092 active cases, 25,692,342 recoveries, and 329,100 deaths due to COVID-19, since its first reported infection on January 30, 2020.[4] Kashmir has been reported to have the highest number of cases per million population compared to the rest of India.[5]

People within and across different cultures and geographies are reacting differently to COVID-19. Understanding perceptions and reactions of relevant populations during pandemics may help in communication about health risks and encourage compliance with prescribed guidelines.[6],[7] Knowledge, attitude, and practice (KAP) surveys can be used to establish a baseline or to evaluate intervention-related changes in public understanding, thoughts, and skills.[8] Experts suggest that time-to-time measurement of knowledge and practices in the community may be pertinent in averting future waves of this deadly pandemic.[9]

Despite widespread efforts made by the government to implement prevention and control measures against COVID-19 in Kashmir, evaluation of public access to information, its practicability as well as a contextualized understanding of perceptions and reactions of Kashmiri population to COVID-19, remains largely underassessed. The findings of this study could help facilitate designing of more effective health-care policies for relevant population groups. We aimed to assess KAP about COVID-19 among Kashmiri population and to determine the association of KAP scores with the sociodemographic variables.


   Materials and Methods Top


The study population included people currently residing in the Valley, able to comprehend the contents of the survey, and willing to participate in the study. The study excluded participants who did not provide consent to participate in the survey.

This was a descriptive cross-sectional study, and was conducted between March 28 and April 5, 2020, in the Valley of Kashmir, shortly following the announcement of a nationwide lockdown. When grappling with rapidly progressing infectious disease pandemics, as the COVID-19, it is imperative to evaluate the knowledge and behavior of target population in a short span of time in order to profit public health-care policies.[10] Further, a household-based survey was neither feasible nor recommended in the current scenario. Therefore, a pragmatic decision of collecting data via rapid online surveys was made. Time-bound collection of data by convenience sampling resulted in an effective respondent size of 1016.

The study instruments consisted of a self-designed questionnaire with three modules. The first module was devised to record sociodemographic variables such as age, gender, educational status, and occupation. Available literature on COVID-19 was thoroughly reviewed to develop the second module consisting of a KAP questionnaire. The knowledge subsection of KAP had 11 questions that assessed the level of COVID-19-specific knowledge of the participant. The knowledge questionnaire was devised after consulting the guidelines made available by the Ministry of Health and Family Welfare, Government of India, with regard to COVID-19 pandemic.[4] Attitudes related to COVID-19 and the practices adopted to avert or control the infection were gauged by five questions each. The items in the knowledge questionnaire had response options of true/false/not sure. Correct answer was assigned a score of 1 while an incorrect or “not sure” item was scored 0. Answer options available for K11 were yes/no/little bit and were scored similarly to the rest. The maximum score attainable for the knowledge questionnaire was 11 and minimum was 0. The attitude and practice items had Likert-based response options and were scored as 3, 2, and 1, based on attitudes or practices which could be good, fair, or bad, respectively. The maximum score achievable was 15 and minimum was 5. Higher scores indicated better KAP about COVID-19. There were additional four nonscoring open-ended questions to determine individual perspectives and reactions to the pandemic. The first question asked the participants, “In your personal opinion, what do you think of COVID-19 as?” The second question, “What is your preferred source of information on COVID-19?” aimed to look at the popular sources of information on COVID-19 among the participants. Respondents' coping activities were explored by asking, “How do you deal with the current scenario?” and finally, they were asked, “How do you communicate with neighbors?” in order to find out the ways of maintaining communication within neighborhoods during the lockdown. Responses were grouped into four common categories that are presented under the results section.

The survey was generated using Google Forms which is available to users free of cost and can be conveniently accessed using a smartphone. The authors used their social networks to invite people to take part in the study by sharing an online link to the survey form along with the participant information sheet. Participants were further requested to forward the survey link to their contacts. Facebook, Twitter, and Instagram allow interaction with wider audience from diverse backgrounds and hence these platforms were utilized to share the survey link along with the survey information sheet publicly. The survey information sheet briefed the participants about the identity and affiliation of the authors, goals of the survey, plan for its use, and dissemination of the survey results. The voluntary nature of participation as well as the declaration of anonymity and confidentiality was also highlighted. At the end of the description, helpline number/e-mail address was provided for those in need of professional help. Before participating in the survey, all participants were asked to indicate consent to take part by simply clicking on option “yes” to a question confirming the same.

Validation of questionnaire

The questionnaire was thoroughly reviewed by a panel comprising health-care professionals (three physicians, three epidemiologists, and two psychiatrists) who were not a part of the study. The purpose of this content validation was to ensure that the questions were not ambiguous and content was appropriate. Modifications were made with regard to structure and arrangement of questionnaire after the panel review. Piloting was performed before proceeding for the final data collection. A small-scale version of the complete survey was tested from patient recruitment to data analysis. For this, the researchers agreed to enroll twenty adult interviewees. The researchers invited the subjects to participate in the study via e-mail. Interviewees demonstrated their consent by signing the online consent form. They were then sent the questionnaire link. The response rate was recorded and the researchers observed that data collection progressed smoothly. An important factor was to ensure that the questionnaire items accurately addressed the research questions. The pilot also tested whether the questionnaire was comprehensible and appropriate, and that the questions were well defined, clearly understood, and presented in a consistent manner. Interviewee information statements were also tested for comprehension. The questionnaire was translated and back translated by linguistic expert from Kashmir University. The questionnaire was produced in English and Urdu versions. All comments were taken into consideration and errors amended.

Ethics clearance for the study was granted by the Institutional Ethics Committee, Government Medical College, Srinagar.

Statistical analysis

Information gathered via questionnaires was coded into variables. The Kolmogorov–Smirnov test was applied to declare the nature of data distribution. Both descriptive and inferential statistics were calculated involving Chi-square, Kruskal–Wallis, and Mann–Whitney test. Pearson's correlation coefficient was used to evaluate the relationship between the study variables. P <0.05 was taken as statistically significant. The data were analyzed using the Statistical Package for the Social Sciences software, version 25.0 (SPSS Inc., Chicago, IL, USA).


   Results Top


A total of 1051 responses were received. Out of these, 35 responses were excluded from the study on account of missing information or nonfulfillment of the inclusion criteria.

Characteristics of study population

Of the total study population, the majority belonged to the age group of 20–39 years (75.4%) and were unmarried (66.6%). Maximum respondents were from an urban residence (54.9%), and had an educational qualification of above high school (96.3%). This was reflected in the occupation distribution as the majority were either professionals (41.6%) or students (33.3%). The details of sociodemographic characteristics are illustrated in [Table 1].
Table 1: Sociodemographic characteristics of the study population

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Knowledge about coronavirus disease 2019

The mean knowledge score of the population was 10.07 (±1.13), suggesting an overall 91.5% correct response rate. Response rates to items on the knowledge questionnaire are shown in [Table 2].
Table 2: Responses to the coronavirus disease 2019 knowledge items

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Attitude toward coronavirus disease 2019

The average score of attitudes toward COVID-19 was 11.85 (±1.42). Around 86% of the population said that they would “definitely” self-report symptoms of COVID-19 or a travel history from COVID-19-affected areas. Staggering 86.3% of the respondents blamed China either “definitely” or “somewhat” for causing COVID-19. Only 17.2% of the participants were sure that having a diagnosis of COVID-19 would not lead to stigmatization in the society [Table 3].
Table 3: Attitudes of the participants toward coronavirus disease 2019

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Coronavirus disease 2019 prevention practices

The mean score for COVID-19 prevention practices in our study population was 12.26 (±1.42). [Table 4] depicts responses to individual practice items.
Table 4: Practices related to coronavirus disease 2019

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Association of sociodemographic variables with mean knowledge, attitude, and practice scores

An increase in mean knowledge scores was observed with increasing age of the participants (P < 0.01). Other factors significantly associated with higher mean knowledge scores were female sex, having an education level of above high school, and working as a professional. A statistically significant difference in mean knowledge scores was also identified between residencies, with urban population having higher mean knowledge scores [Table 5].
Table 5: Association of sociodemographic variables with mean knowledge, attitude, and practice scores

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Education seemed to have an effect on mean attitude scores. Those having an education level of below high school scored significantly lower on attitude scale than those with an education level of high school and above (P < 0.05) [Table 5].

Participants identifying as females, from urban areas, and with education above high school were found to have higher practice scores, and the differences were statistically significant (P < 0.05). With regard to age, participants who were between 20 and 39 years of age had mean practice scores higher than the two extremes of age, i.e., <19 years and more than 60 years (P < 0.01) [Table 5].

Correlation between knowledge, attitude, and practice scores

A weak correlation was found between knowledge–attitude (Pearson's r = 0.14, P < 0.01), knowledge–practice (Pearson's r = 0.08, P < 0.05), as well as attitude–practice (Pearson's r = 0.06, P = 0.05).

Sources of information and individual perspective on coronavirus disease 2019, coping activities, and maintaining communication during lockdown

Social media (70%) and television (20%) were the two most preferred sources of information on COVID-19 among the participants. Only 10% of them turned to radio or other sources like e-newspapers. From an individual viewpoint, 70% of the respondents believed that COVID-19 is an infectious disease, 25% thought of it to be a curse from God, and the remaining 5% felt that it was an international conspiracy. Majority of the study population (65%) reported engaging in religious activities postlockdown to deal with the situation, 25% said that they shared jokes and humorous content with friends and family for the same, and 10% felt that they “could not deal with the crisis.” Communication with neighbors was maintained via telephone by 71%, 11% engaged in window-to-window conversations with neighbors, and 8% of the study population caught up with their neighbors by having group chats at local shops or going for group walks in the evening. However, 10% of the participants did not communicate with their neighbors at all.


   Discussion Top


KAP surveys when conducted online can be safely and rapidly circulated among a large number of population for information generation during infectious disease outbreaks. In addition, these online surveys demand minimal resources and do not carry the risk of infection transmission that is involved if data are collected physically.[11]

Our study managed to recruit a relatively large sample (1016) during the critical early stage of the COVID-19 outbreak in Kashmir. There was a preponderance of participants who were unmarried, young, educated, students, and professionals. This section of our population is perhaps also the one that is more actively involved in outdoor activities and hence might be the target population for certain prevention and control policies. A recent KAP study on COVID-19 conducted in China also reflected a similar composition of study population.[12]

Our study suggests that majority of the participants were well informed regarding the course, modes of transmission, and prevention of COVID-19. Increased awareness about COVID-19 was also found in participants of studies done in India, China, Jordan, and Kenya.[12],[13],[14],[15] However, 30% of the participants in our study were not familiar with “cough etiquette,” which was unexpected in this section of the population. This finding could depict unfamiliarity either with the term itself or with the procedure. Nevertheless, it signifies that wherever possible, vital information about prevention practices should be theory based, explained in comprehensible local languages, and devoid of jargons.[16],[17]

The study revealed the presence of some negative attitudes in the respondents, for example, the tendency to conceal potential history of infection, pessimism toward implementation of control measures, and certain stigmatized views regarding the disease [Table 3]. While these attitudes may be indicative of misinformation and faulty beliefs in the community, concealing history of exposure to the infection might be done willfully by some people to avoid stigma and escape inconvenience and lengthy quarantine periods.[18],[19] The novelty of this disease coupled with the unprecedented, albeit crucial measures to contain the outbreak possibly created concerns and apprehensions in public regarding the effectiveness and implications of these measures. Historically, experiences with other infectious disease outbreaks, for example, tuberculosis, leprosy, and SARS, have taught us that myths, stigma, and misinformation cause significant barriers for treatment seeking and create an additional crisis of discrimination and injustice.[20],[21],[22] The WHO recently started a “myth buster” webpage to help dispel some of the myths commonly associated with COVID-19.[23] The alarming rise in disinformation makes it pertinent for individual nations to tackle the stigma and myths that arise in particular to their cultural and subcultural contexts.

As reported by Zhong et al., majority of the residents of Wuhan, China, expressed confidence in the eventual containment of COVID-19,[12] but such optimism was expressed by only about half of our study population. Barrage of information about exponential rise in infected cases, low testing rates in the country, and the collateral economic and humanitarian crises may have made the disaster appear especially invincible.[24],[25] Information dissemination regarding COVID-19 should be sensitively and responsibly approached. Alongside factual and precautionary guidelines, positive news about recoveries and the strong collective efforts underway to overcome this disaster should also be highlighted to boost public morale.

The H1N1 pandemic that infected more than a billion people globally in 2009–2010, had caught worldwide media attention which provoked substantial fear and anxiety among the general public.[26] Excessive news coverage on COVID-19 was followed by majority of our participants who admitted that it interfered with their routine activities. This practice could be responsible for provoking problematic stress and anxiety symptoms, as shown by Chakraborty and Chatterjee in the study conducted to assess the psychological impact of COVID-19 in West Bengal.[27] Our study highlights the need for time-to-time advisories from experts to help people balance between maintaining a healthy lifestyle and staying adequately informed during various phases of this catastrophe.[28],[29]

Practices adopted against COVID-19 by residents of Wuhan, China, during the rapid rise period of COVID-19 showed majority (up to 97%) of them complied with prescribed safe practices.[12] However, ardent adherence to precautionary practices such as avoiding outdoor worship places, regular hand hygiene, or wearing masks when commuting could not be ensured by all the participants of our study. Regardless of the debate whether wearing a mask is indeed helpful in prevention and control of COVID-19 infection or not, this practice may be insightful of people's self-evaluation of the situation as well as their preparedness at the early stage of this outbreak in Kashmir. Failure to observe these practices could suggest lack of vigilance, accessibility, or affordability for basic protective equipment.

Nearly a third of the participants admitted that they stocked up basic items for more than a month while another third reported that they did not stock these items at all. In a 21-day period of lockdown announced in India, it would appear reasonable to equip oneself with essential items enough for a period of 1 month. Stocking up of items for more than 1 month could amount to hoarding, whereas keeping oneself unequipped for the period of announced lockdown could mean underestimating the threat of infection, noncompliance with control measures, or possible risk-taking behavior. Studying behavior of the target population during pandemics could help in designing strategies which are need based and hence more likely to be complied with.

While acquisition of knowledge on COVID-19 was significantly higher in the older participants, they were less likely to show correct applicability of it. Studies propose that this group is relatively more vulnerable to the COVID-19 infection than the younger age group.[4],[30] It is plausible that anxiety produced by being aware about contracting the disease and having poor outcome could have affected the behavior of this population adversely.[31] Timely sensitization could minimize this fear and its potentially negative consequences on decision-making ability and behavioral flexibility, especially in high-risk groups. Our study highlighted a target population with overall lower KAP scores. These included male participants, those who were less educated, from rural background, and unemployed. This group is almost similar to the target group identified in a study assessing KAP about COVID-19 in China.[12]

In concordance with our findings, a cross-sectional study conducted on university students in Jordan also showed that social media was the predominant source of information on COVID-19-related news.[14] This has implications as social media can be utilized as a diverse and powerful tool for information dissemination, but without appropriate regulation of the streamed content, it can mislead masses very quickly and can vitiate all constructive efforts.

Praying and humor seemed to be the most common coping strategies adopted by the participants. Mental health professionals can utilize these findings when formulating advisories for relevant population. Further, communication with neighbors was restricted mostly to telephonic conversations. Interestingly, 11% of the participants conversed with neighbors from their windows, a tradition re-popularized by the Institute of Mental Health and Neurosciences using the social media hashtag trend “Daraev kin darbar” (Kashmiri for window-to-window conversation).[32] However, a small percentage still engaged in evening walks or meetings at local shops. This practice has been conventionally followed to maintain communication in Kashmir during periods of curfews. For successful physical distancing, people need to differentiate between the nature and emergency behind the present lockdown as opposed to the past curfews. This issue being unique to Kashmir needs specific attention in pandemic control strategies adopted for the Valley.


   Conclusions Top


Knowledge scores of the participants suggest that awareness campaigns have been reasonably successful with this sample section of population in Kashmir, but the acquired knowledge has not found proportionate realistic transcription that would reflect in positive attitudes or good practices of the section under study. It can be inferred that this knowledge–praxis gap could have emerged due to communication barriers or spurious or insufficient pragmatic understanding of the disseminated information. More so, public compliance depends upon feasibility, perceived risks, and perceived effectiveness of the proposed action. For the promotion of precautionary behavior in a specific target population, their peculiar sociocultural, economic, and psychological aspects have to be assessed and considered to develop a locally adapted approach to ensure feasibility and effectiveness. It is recommended that a large-scale, methodologically sound study evaluating KAP about COVID-19 in a population-representative sample should be undertaken to overcome the shortcomings of the present study. Further, assessment of public knowledge and practices should be conducted in different phases of the outbreak in order to guide the discourse of prevention and control policies as the pandemic evolves.

Limitations

The survey was carried out in the initial phase of COVID-19 in Kashmir and gives an insight into the initial response of the people of Kashmir toward the pandemic and the various intervention policies adopted to control it at that time. Despite recruiting a relatively large sample, the major limitations arose due to the sampling strategy and the medium of data collection employed. As is inherent in most studies conducted online, participation was restricted to those who had social media accounts, access to smartphones, and a stable internet connection. Therefore, generalization of results should be cautiously attempted.[33] Furthermore, responses to some items in the questionnaire may have been subject to social desirability bias. Some of the findings may be due to chance error only as we used only univariate analysis in our study. A multivariable-adjusted analysis would have been better but that too has its limitations. It was also felt that knowledge assessment remained incomplete as all myths and misconceptions regarding the pandemic could not be investigated in the present survey. Finally, it is also possible that the data might be confounded due to existing lockdown in Kashmir since August 2019.

Acknowledgment

Authors would like to thank Dr Roxanne Keynejad, ST4, General Adult Psychiatry, King's College, London for her valuable inputs in drafting the questionnaire.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Bushra Syed Imtiyaz
Department of Psychiatry, Government Medical College, Srinagar - 190 003, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_408_20

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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