|Year : 2020 | Volume
| Issue : 3 | Page : 72-77
Knowledge, attitude, practices and behaviour study regarding COVID-19 amongst health care workers of armed forces in North-Western part of India
Vikram S Grewal1, Kuntal Bandyopdhyay2, Punita A Sharma3, Rekha Rani4, Atul Kotwal5
1 Col Health, HQ SWC Medical Branch, Jaipur, India
2 Officer Commanding, 48 FHO, Bathinda, India
3 Brig MNS, HQ SWC Medical Branch, Jaipur, India
4 HQ SWC Medical Branch, Jaipur, India
5 MG Med, HQ SWC Medical Branch, Jaipur, India
|Date of Submission||17-Jul-2020|
|Date of Decision||27-Jul-2020|
|Date of Acceptance||01-Aug-2020|
|Date of Web Publication||29-Sep-2020|
Lt Col Kuntal Bandyopdhyay
Officer Commanding, 48 Field Health Organization, Bathinda - 151 004, Punjab
Source of Support: None, Conflict of Interest: None
Background: A concerted effort has been made by the Government of India and the Armed Forces to train all health-care workers (HCWs) in various aspects of the prevention and management of COVID-19. This study was conducted to evaluate the efforts by assessing their knowledge, attitudes, practice, and behavior regarding COVID-19. Materials and Methods: A quick online survey, using a web portal and social media platform with a pretested questionnaire, was conducted. Responses were collected for 3 days and analyzed. Results: A total of 988 HCWs participated, including 61 (6.17%) specialist officers, 98 (9.91%) medical officers, 17 (1.72%) dental officers, 135 (13.66%) nursing officers, 518 (52.4%) paramedical staff, and 159 (16.09%) supporting staff. There was a high prevalence (>90%) of knowledge related to symptoms and transmission of the disease with no statistically significant difference in knowledge based on the category of HCW except for bleaching powder requirement (0.001) and chemoprophylaxis (0.001). The majority of the participants (>95%) agreed that lockdown, infection control programs, and repeated training of HCWs are good measures to control COVID-19 spread. Observing full precaution while handling personal protective equipment was the only practice which demonstrated a significant association with increasing qualification of the participant (P < 0.001). Conclusions: Levels of knowledge, positive attitude, and good practices are high among HCWs in the Armed Forces, however, feeling of anxiousness and worry prevail being frontline workers with maximum proximity toward patients. Aggressive, continuous, relevant target population-oriented information, education, and communication is the need of the hour, with structured and programmed interventions for positive mental health during course of the pandemic.
Keywords: Attitude, behavior, COVID-19, health-care worker, knowledge, practice
|How to cite this article:|
Grewal VS, Bandyopdhyay K, Sharma PA, Rani R, Kotwal A. Knowledge, attitude, practices and behaviour study regarding COVID-19 amongst health care workers of armed forces in North-Western part of India. J Mar Med Soc 2020;22, Suppl S1:72-7
|How to cite this URL:|
Grewal VS, Bandyopdhyay K, Sharma PA, Rani R, Kotwal A. Knowledge, attitude, practices and behaviour study regarding COVID-19 amongst health care workers of armed forces in North-Western part of India. J Mar Med Soc [serial online] 2020 [cited 2021 Jun 20];22, Suppl S1:72-7. Available from: https://www.marinemedicalsociety.in/text.asp?2020/22/3/72/296567
| Introduction|| |
There is a surge of coronavirus disease (COVID-19) cases across the globe, with a total of more than 13 million cases (five million active cases) and more than half a million deaths globally (as on July 13, 2020). With new cases and deaths being added regularly to the tally, the pandemic is still raging with varied fear and apprehension among the general population worldwide, attributed mostly to the lack of definitive cure or vaccine for the same, owing to its novelty as a disease agent. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel strain with suggested zoonotic origin (from bats), similar viruses of the same family such as severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) have been known to cause serious respiratory diseases in the past and had zoonotic origins as well.,
India had started with a proactive approach, intense information, education, and communication (IEC) activities, nonpharmacological interventions, and strict containment measures by the stakeholders but is presently facing a steady increase in daily new cases. At present, India has 878,254 cases (301,609 active cases) and 23,174 deaths (as on July 13, 2020), with 651 cases/million and 17 deaths/million.,
Due to its high infectivity rate and easy mode of transmission (via direct respiratory droplets, fomites, and possible airborne transmission), the virus is posing serious challenges to the health professionals and administrators alike. Health-care workers (HCWs) are at the forefront of all preventive as well as curative activities concerned with COVID-19 and are, therefore, at the highest risk of contracting the disease as an occupational hazard. Thus, it becomes vital for them to be well informed and updated about all aspects of the disease including preventive measures in a bid to safeguard their own health as well as of their families and the clientele.
The HCWs of the Armed Forces are equally susceptible to the disease themselves as are their civil counterparts and maybe more so with almost all hospitals as mixed COVID-19 and few as pure COVID-19 facilities. There is no study assessing the knowledge, attitude, and practice (KAP) of the Indian Armed Forces HCWs regarding COVID-19. Comparable studies on influenza and MERS-CoV are available,,, providing meaningful insight into the domain of KAP of the population in response to various viral respiratory pandemics as the epidemiological features and control modalities are similar. Few studies on COVID-19 are available covering the HCWs in general from various countries,,,, whereas only one study is available from India.
Apart from hospital preparedness, the entire gamut of preventive activities was carried out aggressively at all levels with an extraordinary zeal, to bridge the gaps and with an aim to bring an effective increase in knowledge, translating into positive attitude, practice, and behaviors against COVID-19 for the serving personnel, their dependents, and also the HCWs. A concerted action has been taken to empower the HCWs toward the Infection Prevention and Control and all protocols related to COVID-19. A formal IEC and Behavioural Change Communication (BCC) campaign was launched in the 1st week of February 2020 and is continuing. The guidelines were formulated based on the available information on the official sources, and these are being regularly updated as the pandemic is progressing. An in-built feedback mechanism of implementation exists. This study was thus carried out to assess the knowledge, attitude, correct practices, and behavior toward COVID-19 among HCWs of the Armed Forces in the northwestern part of India during the current pandemic. The aim was to assess the gaps in these areas and strengthen the activities, if required.
| Materials and Methods|| |
The study was conducted as a quick online cross-sectional survey. The sample size was calculated by assuming a prevalence of 50% appropriate knowledge and keeping a margin of error at 5% and alpha-error at 5% with 95% confidence interval. The calculated sample size came out to be 385. As the training and other characteristics of HCWs are almost similar, a design effect of 2 was taken into account and a total sample size of 770 was calculated. To cater for loss of information due to incomplete forms or no response due to nonsubmission, an additional 20% was added to the sample size making the final sample size to be 963. However, a total of 988 HCWs participated in the survey before closing the access as online links had already been sent to the environment, and all HCWs of the defined geographical area were invited. The spectrum of participants included specialist officers, medical officers, dental officers, members of nursing services, all paramedical staff (like nursing technician, nursing assistant, operating room assistant, health assistant, laboratory assistant, dental operating room assistant, blood transfusion assistant, and ambulance assistants), and all supporting staff in health-care establishments (like chef, housekeeper, and hairdresser), who agreed to take part in the survey on their personal mobile phones.
The online questionnaire included a total of 32 questions encompassing all domains such as knowledge (16), attitude (5), practices (4), and affective component or behavior (6). The instrument was prepared from reliable sources (such as WHO and MoHFW resource materials/policies on COVID-19) and was finalized after pilot testing on a subgroup of 30 individuals from the same population. The survey was unlinked and anonymous. The pretested questionnaire was loaded on to a web-based survey portal www.surveymonkey.com. The URL link generated was forwarded to all HCWs on a social media application, and wide publicity was accorded. Station and unit social media groups were utilized to disseminate the link. The link was available to participants who simply clicked on it to open the questionnaire. Once all questions were answered, the participant clicked DONE button to submit response. The response counter was open for 3 days and closed at a count of 988 responses. The submission of the form was taken as consent of the participant. The questionnaire once attempted through the link sent on mobile could not be attempted again, thus preventing duplication. Descriptive analysis by MS Excel and inferential by Epi Info version 220.127.116.11™ (Epi Info version 18.104.22.168 by Microsoft [Centers for Disease Control and Prevention, Atlanta, Georgia])was carried out. Appropriate measures of descriptive and inferential statistics were used for statistical analysis. The study was approved by the Institutional Ethics Committee.
| Results|| |
A total of 988 HCWs serving in various health-care establishments in the defined geographical area were the participants. They were divided into six groups, based on their occupation or qualification, with 61 (6.17%) specialist officers, 98 (9.91%) medical officers, 17 (1.72%) dental officers, 135 (13.66%) nursing officers, 518 (52.4%) paramedical staff, and 159 (16.09%) supporting staff.
The results for the knowledge domain are depicted in [Table 1]. The study found a high prevalence of knowledge regarding symptoms and transmission of COVID-19, duration of quarantine, reverse transcription–polymerase chain reaction being the gold standard test, wearing of full personal protective equipment (PPE) by HCWs while attending to a severely ill patient of influenza-like illness, and other questions on PPE usage. The prevalence of knowledge was much lesser (50%–65%) for biomedical waste (BMW) handling, hydroxychloroquine prophylaxis, and the use of bleaching powder as a disinfectant solution, and it was very low (22.5%) for the use of PPE while engaged in contact tracing. There was no difference in knowledge based on the category of HCW except for bleaching powder requirement and chemoprophylaxis.
The details regarding attitude of the participants are depicted in [Figure 1]. The majority of the participants agreed (strongly agreed plus agreed) that active participation in infection control programs prevents the spread of COVID-19 (942, 95.33%), lockdown is an effective method in preventing the spread of COVID-19 (955, 96.65%), and repeated training of HCWs makes a positive difference in their performance, confidence, and safety (965, 97.67%). While there was an equivocal response to the question that managing COVID-19 in hospitals is not dangerous, there was evident disagreement (strongly disagree plus disagree) regarding the importance of community response in comparison to hospital preparedness (756, 76.51%).
In the responses to domain of practice, the answer of no/not decided/not noticed/do not know along with answers skipped by respondents was clubbed as NO to find the association with occupation of the HCW [Table 2]. Observing full precaution while handling PPE was the only practice which demonstrated a significant association with increasing qualification of the participant (P = 0.001). A majority of respondents demonstrated increased stress and anxiety for their family and loved ones and also perceived increased risk to COVID-19 being a HCW as compared to the general population [Figure 2]. There was a mixed response about enjoying life and things in present times, compared to life before COVID-19. Official advisories (42%) and social media (28.5%) were found to be the two most important sources of information on COVID-19 for the participants.
| Discussion|| |
With limited literature available on awareness of health professionals about COVID-19 and more so with no study available among HCWs of the Armed Forces, this study is probably one of the first in this domain. Our study participants were comparable to the HCWs in other settings in India and abroad due to almost similar training, exposure, etc.,,,
A high prevalence of correct knowledge among all subgroups of the HCWs suggests a good outcome of the efforts by the Armed Forces and Government of India toward these and inclusion of all categories of HCWs in these activities. Thus, this can be attributed to continuous IEC and training activities being carried out on a regular basis. The above finding is similar to the two studies in China, where 88%–89% HCWs demonstrated a high correct response rate, whereas comparable results were found in studies in Mumbai with 72% and Uganda with 69% prevalence.
The moderate-to-low knowledge (≤60%) regarding dead body management, BMW handling and management, the use of HCQ as prophylaxis, and the use of correct dilution of bleaching powder for use as a disinfectant and very low knowledge (22.5%) about precautions during contact tracing can be attributed to participants not keeping in pace, with the frequent updates to the existing guidelines due to COVID-19 being an evolving disease. It also reflects that HCWs probably do not perceive these as their core responsibilities. Comparable results were seen among HCWs in a study in Mumbai with only 48% aware about contacts and contact tracing. Thus, more emphasis is required in these areas.
Our finding of a significant association (P < 0.05), between correct responses of knowledge, with increase in qualification of the HCWs was also found among general population in China,, where knowledge scores significantly differed across age groups and education levels. Thus, higher educational qualification translated to higher knowledge scores.
The finding of role of IPC training and lockdown as preventive measures and repeated training as an effective measure was similar to the studies conducted in China with 90% and Nepal with 78% concordance. As the importance of community response in comparison to hospital preparedness alone was low in our population, this aspect should be addressed with regular behavioral change communication for the HCWs to sensitize them of the importance of preventive activities which are of equal significance as curative measures while dealing with a pandemic.
Our finding of the prevalence of correct practices regarding PPEs is comparable to studies in China with 89.7% and Uganda with 74% of participants following correct PPE protocols. The preference of handwashing with soap over hand sanitizers as means of disinfection was much lower in our study as compared to studies done in Mumbai with 87.9% and the UAE with 87%. This can be attributed to the easy availability and convenience of usage as compared to washing hands with soap and water for 20 s.
The increased stress and anxiety for their family and loved ones and also perceived increased risk to COVID-19 either all the time or most of the time, as found by us, could be attributed to the overwhelming media and social access and coverage. An overload of information and misinformation regarding morbidity and mortality statistics, along with other disturbing news, could be attributing causes. No studies to compare the results of awareness in the affective domain could be found. Official advisories as the most important source of information were similar to the study conducted in the UAE, with official advisories (35%) being the most sought-after source. However, another study in Iran found social media (39%) to be the most important source. These differences point to the concerted efforts by the Government of India and the Armed Forces regarding these activities and the reliability of their advisories in various settings in our country.
The strength of this topical study is the action taken based on the findings, converting this cross-sectional survey into translational research. Action plans were formulated keeping different strata of HCWs in mind and initiated at all desired levels, appropriate to the targeted HCW population. For doctors and nurses, comprehensive advisories and SOPs were prepared (from standard national guidelines and policies) and disseminated to all stations and units for easy access. Regular training in the form of webinars by experts and one-to-one communication was undertaken in each field. Follow-up advisories were updated on a regular basis owing to the dynamism of the disease. For paramedical and supporting staff, COVID-19 committees were formed at each medical unit with the aim of on-ground training and demonstration for ease of understanding and better grasp of all the disease facets. The roles and duties of each HCW were clearly explained, thus instilling a sense of responsibility and accountability. In addition, emphasis was also laid on bolstering positive mental health, including creation of local mental helplines and hiring a psychologist after conducting need analysis in the station.
There are a few limitations of the present study. The inherent issues of less information in a quick online survey with limited set of questions per domain and sampling bias were present. However, efforts were made to include all categories of HCWs. Despite these, the study delivers meaningful insights into the KAPB of HCWs during an evolving pandemic, and this information could be utilized for refinements in IPC measures in health-care facilities.
| Conclusions|| |
Overall, the results showed that IEC efforts were able to penetrate the target groups. However, few areas of concern, such as precautions during contact tracing, BMW management specific to COVID-19 scenario, and the use of hygiene chemicals for disinfection procedures, were also noticed. Similarly, emphasis has to be laid on importance of community participation.
With the involvement of multiple agencies and sources of information and the disease being new and evolving, there is a need for all HCWs to stay updated with the latest policies and guidelines issued from authentic and reliable sources only. Thus, it is recommended that every health-care establishment should have a “COVID-19 committee” encompassing important stakeholders of all strata, with the responsibility of preparing simplified standard operating procedures (SOPs) and training modules, specific to their own health setup with guidance from standard authentic resource materials only. In addition, reinforcements of the IEC activities for all HCWs should be undertaken on a regular basis.
We thank all the HCWs for their contribution toward the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lillie PJ, Samson A, Li A, Adams K, Capstick R, Barlow GD, et al
. Novel coronavirus disease (COVID-19): The first two patients in the UK with person to person transmission. J Infect 2020;80:578-606.
Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation and treatment coronavirus (COVID-19). Statpearls [internet]: StatPearls Publishing; 2020.
Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020;5:536-44.
Banerji A. The armed forces medical services response to COVID-19. Indian J Public Health 2020;64:S94-5.
] [Full text]
Alkot M, Albouq MA, Shakuri MA, Subahi MS. Knowledge, attitude, and practice toward MERS-CoV among primary health-care workers in Makkah Al-Mukarramah: An intervention study. Int J Med Sci Public Health 2016;5:952-60.
Asaad AM, El-Sokkary RH, Alzamanan MA, El-Shafei M. Knowledge and attitudes towards Middle East respiratory syndrome-coronavirus (MERS-CoV) among health care workers in south-western Saudi Arabia. East Mediterr Health J. 2019;25:564-8.
Askarian M, Danaei M, Vakili V. Knowledge, attitudes, and practices regarding pandemic H1N1 influenza among medical and dental residents and fellowships in Shiraz, Iran. Int J Prev Med 2013;4:396-403.
Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Novel Coronavirus (COVID-19) Knowledge and Perceptions: A Survey on Healthcare workers. MedRxiv. 2020;4:396-401.
Giao H, Han NTN, Van Khanh T, Ngan VK, Van Tam V, Le An P. Knowledge and attitude toward COVID-19 among healthcare workers at District 2 Hospital, Ho Chi Minh City. Asian Pac J Trop Med. 2020;13:991-5.
Olum R, Chekwech G, Wekha G, Nassozi DR, Bongomin F. Coronavirus disease-2019: Knowledge, attitude, and practices of health care workers at Makerere University Teaching Hospitals, Uganda. Front Public Health 2020;8:181.
Zhang M, Zhou M, Tang F, Wang Y, Nie H, Zhang L, et al
. Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. J Hosp Infect 2020;105:183-7.
Modi PD, Nair G, Uppe A, Modi J, Tuppekar B, Gharpure AS, et al
. COVID-19 awareness among healthcare students and professionals in Mumbai Metropolitan Region: A questionnaire-based survey. Cureus 2020;12:e7514.
Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al
. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci 2020;16:1745-52.
Hussain A, Garima T, Singh BM, Ram R, Tripti RP. Knowledge, attitudes, and practices towards COVID-19 among Nepalese Residents: A quick online cross-sectional survey. Asian J Med Sci 2020;11:6-11.
Datta R, Yadav A, Singh A, Datta K, Bansal A. The infodemics of COVID-19 amongst healthcare professionals in India. Medical Journal Armed Forces India. 2020;3:357-62.
Erfani A, Shahriarirad R, Ranjbar K, Mirahmadizadeh A, Moghadami M. Knowledge, Attitude and Practice toward the Novel Coronavirus (COVID-19) Outbreak: A Population-Based Survey in Iran. Bull World Health Organ, E-pub. 2020;30:155-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2]