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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 22  |  Issue : 3  |  Page : 66-71

Knowledge, attitude, and practice toward COVID-19 among pregnant women in a tertiary care hospital during the COVID-19 outbreak


1 Department of Medicine, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Obstetrics and Gynecology, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
3 Department of Community Medicine, SHO, Visakhapatnam, Andhra Pradesh, India
4 Medical Officer, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Date of Submission02-Jul-2020
Date of Decision04-Jul-2020
Date of Acceptance18-Sep-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Surg Lt Cdr (Dr) Vaidehi D Thakur
Department of Obstetrics and Gynecology, INHS Kalyani, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_81_20

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  Abstract 


Background: During COVID-19 pandemic, Indian health authorities implemented massive measures to control the rapid spread of infection. Nonetheless, even during pandemic, pregnant women need constant obstetrics consultations during the antepartum period and adequate care during intrapartum and postpartum period for uneventful outcome. Undeniably, adherence to these control measures is largely affected by knowledge, attitude, and practices (KAP) towards COVID-19. Aims and Objectives: To assess knowledge, attitude, and practice towards COVID-19 amongst pregnant women and to find the association of demographic variables (age, place of residence, and education) with KAP. Materials and Methods: The cross-sectional, descriptive study was conducted for pregnant women attending the outpatient department of Obstetrics in a tertiary care Defense hospital. We investigated 506 pregnant women serially from Obstetrics OPD of the hospital for KAP towards COVID-19 with a questionnaire of 14 questions. The study population was assessed for the KAP score and association of demographic variables with KAP. Descriptive statistics were used to describe the findings. Median and standard deviation (SD) were calculated for KAP and Pearson's Chi-square test was used to analyze the association of demographic variables with KAP. Results: In our study scores for adequate knowledge, positive attitude, and good practices were 75.3 %, 73.9%, and 92.7 % respectively. The analysis of the association of various demographic variables with KAP about COVID-19 revealed significant association. Conclusion: The majority of pregnant women was knowledgeable about COVID-19 and had positive attitude and good practices. However, health authorities may need to take proactive steps for this vulnerable subpopulation.

Keywords: Attitude, COVID-19, knowledge, practices, pregnant women


How to cite this article:
Kamal D, Thakur VD, Swain SK, Vikneshram C R. Knowledge, attitude, and practice toward COVID-19 among pregnant women in a tertiary care hospital during the COVID-19 outbreak. J Mar Med Soc 2020;22, Suppl S1:66-71

How to cite this URL:
Kamal D, Thakur VD, Swain SK, Vikneshram C R. Knowledge, attitude, and practice toward COVID-19 among pregnant women in a tertiary care hospital during the COVID-19 outbreak. J Mar Med Soc [serial online] 2020 [cited 2020 Dec 3];22, Suppl S1:66-71. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/3/66/299588




  Introduction Top


The coronavirus (COVID-19) infection is a unique infectious disease caused by novel coronavirus 2 (SARS-CoV-2). The outbreak first occurred in Wuhan, China, in December 2019.[1] The World Health Organization (WHO) announced it as a public health emergency of international concern on January 30, 2020.[2] India registered the first case of COVID-19 on January 30, 2020.

The transmission of COVID-19 is largely through respiratory droplets to close contacts of the infected individual while coughing, sneezing, or speaking. Fomites and feco–oral transmission of the virus are another important modes of transmission. However, to date, there is no evidence of feto–maternal transmission of the disease.[3] Common symptoms include fever, dry cough, shortness of breath, fatigue, anosmia, loss of taste, diarrhea, and myalgia. Nearly 18.5% of the patients develop severe complications, which include pneumonia and acute respiratory distress syndrome. Although there is no definitive therapy available, few medicines such as favipiravir, hydroxychloroquine, remdesivir, ribavirin, tocilizumab, and plasma therapy have been suggested for the treatment of COVID-19 apart from symptomatic and supportive therapy.[4]

The fight with COVID-19 is a constantly evolving one, and Indian health authorities adopted enormous measures to control the spread. The WHO recommended a series of preventive measures to halt the spread of the disease and its associated mortality.[5]

Pregnancy is one of the important milestones in a woman's life. During pregnancy, women are extremely apprehensive and anxious about their progress.[6],[7],[8] According to CDC guidelines, pregnant and breastfeeding women are subgroups that need extra precaution to avoid COVID-19 infection. They are at an increased risk for severe illness from COVID-19 compared to nonpregnant people. There are fears of adverse maternal and perinatal outcomes due to distinctive immunological suppression during pregnancy. In addition, there may be an increased risk of adverse pregnancy outcomes, such as preterm birth, among pregnant people with COVID-19.[9] Consequently, even during a pandemic, pregnant women need constant obstetric consultations during the antepartum period and adequate care during the intrapartum and postpartum period for the uneventful outcome.

The H1N1 pandemic taught us that knowledge and attitude toward infectious diseases play a crucial role in precise practices for curtailing the spread of the disease. Anxiety and fear among the population further clouds the efforts to prevent the spread of infection.[10] Adherence to preventive measures by the population is crucial for the control of spread, which is mainly affected by their knowledge, attitudes, and practices (KAP) toward COVID-19.[11] Pregnant women who constitute a vulnerable group need to be more cautious and hence KAP of preventive measures against the spread of the virus among them is of utmost importance.

The primary aim of our study was to assess the KAP level among pregnant women. Association of demographic variables (age group, education, and place of residence) and KAP was studied as a secondary outcome.


  Materials and Methods Top


This cross-sectional, descriptive study was conducted from April 25 to May 30, 2020 on pregnant women attending the outpatient department of the obstetrics and gynecology department in a defense service hospital. STROBE checklist of items was included here for reporting our study.[12] The sample size was estimated to be 385, anticipating that 50% of the study participants have good KAP with a 5% level of significance, 5% absolute error margin, and a 95% confidence interval. The study followed the principles of the Helsinki declaration. Ethical approval was acquired from the ethics and research committee for the study.

A questionnaire was developed from pretested and validated standard questionnaires as recommended by the WHO on preventive measures against COVID-19, with few minor modifications as deemed necessary for our study.[5],[9],[13],[14] A pilot study on the first fifty pregnant women was conducted for testing the correlation of the self-made questionnaire with a standard questionnaire as the valid measure and further involvement in the study.[15],[16] Pearson's correlation value r = 0.72 (P < 0.01) for self-made questionnaire with high significance for its correlation with standard questionnaire accepts its validity. The internal consistency for the KAP questionnaire was acceptable as Cronbach's alpha was 0.76 for its reliability. Thus questionnaire was found to be both reliable and valid for further study.

Verbal and written informed consent was taken before the formal survey from each participant. Participants who were willing for the study signed the consent. A printed questionnaire was given to each participant separately in the outpatient department of the hospital. Participants filled the questionnaire in the outpatient department of the hospital. While administering the questionnaire, consents were verified from the participants. A single trained medical assistant with a good knowledge of the local language, Hindi, and English was selected to administer the questionnaire. The questionnaire consisted of two parts – demographic variables and KAP. The knowledge part of the questionnaire contained nine questions. The patients were assessed for general awareness (K1–K2), transmission routes (K3–K5), and practices to prevent spread (K6–K9). The questions were given an option of yes/no with an additional “Not sure” option in some questions. A scoring system was applied to assess the level of KAP of each participant: 1 point for each correct answer and 0 point for an incorrect/not sure answer. With a total of score 9 for knowledge, the respondents were grouped into two categories –adequate and inadequate knowledge. Attitude toward COVID-19 was measured by two questions (A1–A2). With a total score of 2 for attitude, the respondents were grouped as having a positive or negative attitude. The practices were assessed by three questions (P1–P3). With a total score of 3 for practices, the respondents were classified into two categories – good or poor practices. The median value was determined for the KAP score. Respondents scoring equal to or more than a median score were classified as having adequate knowledge, a positive attitude, and good practice.

Statistical Package for Social Sciences software (version 25, International Business Machines (IBM), at Armonk, New York, United States) was used to analyze the data. Descriptive statistics (frequency with percentage) were used to describe the findings. The median and standard deviation were calculated for KAP. Pearson's Chi-square test was used for the association of demographic variables with KAP.


  Results Top


We interviewed a total of 532 pregnant women who attended obstetrics outpatient department of our tertiary care defense hospital. Twenty-six of them expressed unwillingness to participate in the study. We finally enrolled 506 pregnant women (95.1%) in our study. [Table 1] shows the sociodemographic details of the respondents.
Table 1: Frequency distribution of sociodemographic characteristics

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The majority of respondents were aware of the COVID-19 pandemic. In our study, scores for adequate knowledge, positive attitude, and good practices were 75.3%, 73.9%, and 92.7%, respectively [Table 2].
Table 2: Knowledge, attitude, and practice scores

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The median score for knowledge was 7 (standard deviation [SD] ± 1.266). The median score for attitude was 2 (SD ± O.543), whereas the median score for practice was 3 (SD ± 0.298). Hence, respondents scoring 7 or more for knowledge were grouped as having adequate knowledge. Respondents scoring 2 for attitude and 3 for practices were grouped as having a positive attitude and good practices, respectively [Table 3].
Table 3: Median and standard deviation of knowledge, attitude, and practice scores

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Association of various demographic variables (age group, education, and place of residence) with KAP about COVID-19 was analyzed. The determinants of knowledge scores were education and place of residence (P < 0.01). However, no significant association was found between age group and knowledge. Attitude score had a significant association with age, education, and place of residence. The practice score had a significant association with age and place of residence. However, no significant association was found between education and practices [Table 4].
Table 4: Association of demographic variables (age group, education, and place of residence) with knowledge, attitude, and practice

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  Discussion Top


Although the influence of COVID-19 infection in pregnancy is yet to be fully established, the distinctive immunological suppression during pregnancy may cause a detrimental effect on maternal and perinatal outcomes. Little is known regarding the current awareness for COVID-19 among pregnant women.[17] There has been no systematic review to evaluate this subset of the population until now. A few studies revealed a high level of outbreak-aggravated prenatal anxiety among pregnant women. They were more apprehensive regarding the transmission of the infection to the fetus (feto–maternal transmission) and its effect on the newborn, the safety of breastfeeding practices if infected with COVID-19, and the increased risk of abortion during this COVID-19 pandemic.[6],[7] Like few KAP surveys conducted in India and other parts of the globe, our survey also revealed adequate levels of knowledge, positive attitude, and good practices to prevent the spread of COVID-19 infection.[18],[19]

The majority of the respondents were aware of COVID-19 and about it being dangerous. Significant predictors for knowledge were education and place of residence. An adequate knowledge among respondents primarily might be due to the sample characteristics, as 83.6% of the respondents had the education of graduation and above. Furthermore, this survey was conducted amid the lockdown period during which the respondents gained information through various sources. Similar results were found in other studies for COVID-19.[17],[18],[19] The continuous health education in the cantonment areas might also be responsible for more awareness among women staying in these, which is reflected in our study. However, there was a lack of knowledge among respondents regarding the transmission of disease through refrigerated food as only 66% could answer correctly. In addition, almost half of the respondents (49.9%) were not aware of the role of breast milk in the transmission of COVID-19. Probably, this might be due to inadequate information circulated through various sources [Table 5].
Table 5: Responses to questionnaire on coronavirus disease 2019

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Overall, the respondents had a positive attitude toward COVID-19. Nearly 78.9% of the respondents agreed for isolation if infected with COVID-19 and 90.9% agreed that the Indian government has taken positive steps to reduce the spread of the disease. These positive attitudes might be because of the various steps initiated by the government such as social distancing; wearing masks; and closure of public transportation, schools, colleges, malls, public places, sports, entertainment, etc., These current results are in line with those of similar studies, which showed a positive attitude among the public.[19],[20] Nevertheless, an adequate knowledge level among the respondents was reflected in safe practices. A high level of practice was observed during the survey. Almost 93.7% of the respondents had not visited any crowded places. Nearly 99% and 99.4% of the respondents practiced safety measures such as social distancing and hand sanitization, respectively. Respondents in the cantonment area were having adequate knowledge scores and a positive attitude. According to KAP theory, good knowledge and attitude are reflected in better practices. However, in our study, respondents staying in the civil area scored higher for practices, which is not adherent in line with the KAP theory. This might be due to the strong emphasis by social media, newspapers, television channels, and government health agencies to educate the populace mainly on attaining good practices, which had percolated in both cantonment and civil respondents. Respondents staying in cantonment area probably were more confident due to strict preventive measures such as enforcing social distancing, restriction of movements, compulsory usage of masks, and rigorous regular checks for the same taken by local health authorities. Hence, they could have been more casual in practices despite the good and adequate knowledge.

We intend to share the study findings with health officials to convey the effect of their measures and to address the gaps to tailor the needs of the community. Our study results could help health authorities to make policies specifically for pregnant women with low KAP (e.g., low education) who are at high risk of contracting the disease. The initiatives would also help allay anxiety and fear among the respondents. Better knowledge and practices might lead to a reduced rate of infection in this susceptible group.

Strengths and limitations

To the best of the researchers' knowledge, this is one of the initial studies to investigate specifically KAP for COVID-19 targeting pregnant women in India. The data were collected during an intense lockdown period and hence the study results would help authorities for future strategies. Our study was specific to pregnant women and if required the results may be utilized for targeting health policies particularly for this subpopulation.

Few demographic variables in our study such as good education levels and socioeconomic status might have overestimated the level of KAP compared to studies in other parts of India.[21] Furthermore, it may not be a true representative and hence may not be generalized to the entire population. The questionnaire was tailored for targeted pregnant women and so might have limitations for broader KAP study. The data used were from a self-reported questionnaire and hence could have had reporting bias. Further, research should be multicentric for better assessment of KAP among defense personnel.


  Conclusion Top


Awareness about the disease forms the cornerstone for educational activities and is used as an index by the health authorities. Knowledge about the disease and implementing the measures for curtailing the spread would eventually help curb the infection. The results of our study suggest that more emphasis should be placed on pregnant women with low KAP who are at high risk for contracting the disease. Our results may help health authorities in recognizing these target populations for reducing COVID-19 infection.

Acknowledgement

Mr Laxmikant Umate is a statistician and he has helped us in analysing the data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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