Introduction

At the end of December 2019, an outbreak of novel coronavirus 2 (SARS-CoV-2) (here after motioned coronavirus disease 2019 [COVID-19]) infection occurred in Wuhan, China, that raised spread around the world in a limited time period [1]. Later 11 March 2020, the World Health Organization (WHO) has declared COVID-19 as pandemic infection [2] covers almost all countries worldwide [3] As of 11 April 2021, it had caused over 29 000 00 deaths with 134 million confirmed cases worldwide [4,5]. As of 7 April 2021, 669 million population administered the vaccination [4]. Most cases report severe respiratory illness and deaths occurred among adults with comorbidity of diabetes, hypertension and cardiovascular complications [6].

India is highly susceptible to COVID-19 due its population density. Symptoms of COVID-19 include fever, fatigue, cough, malaise, and shortness of breath, similar to the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) [7]. Global concerns on novel coronavirus disease rapidly increased due to the transmission rate faster, coupled with the death toll raised globally [8]. Resident's health behaviors and personal hygiene implementations such as social distancing of a minimum one meter and handwashing for 20 s are essential to control the coronavirus spread and more demanding in a country like India where the most rural population are deprived of essential sanitary needs [9]. Despite medical emergence, the increasing prevalence day-by-day questing about the knowledge gained by the public about these policies. Adherence to precautionary measures as per the standard guidelines is essential to prevent the spread of the disease, which might be subjective to the general population's knowledge and attitudes toward COVID-19. Evidence indicates that knowledge among general residents is vital in dealing with pandemics [10]. Several confused conceptions about COVID-19, limited knowledge, underestimation, panic emotions, stigmatization, and negative attitude of communicable disease cause unnecessary worry and excessive panic, mislead the goal of the policies and aggravate the disease pandemic [11].

A few public reports were available that assessed the effect of policies associating the level of knowledge, attitude and practice (KAP) about COVID-19 infection among various population. Also, in growing pandemic situation, it is becoming important to know the public responses to make appropriate measures to develop and promote polices to control and manage this disease. In this study, we investigate community responses in COVID-19 among Indian residents. The online survey was conducted with the questionnaire describing the knowledge, attitudes and practices while COVID-19 among the Indian population. The outcome of this investigation recommends policies to the government towards reducing the COVID-19 pandemic and similar conditions in future.

Materials and methods Study design

This cross-sectional survey was conducted in Indian population using Snowball sampling technique. A structured online questionnaire was designed using a Google form, which was appended with a respondent's consent form. Investigators sent the link of the questionnaire through WhatsApp, E-mails, LinkedIn, and Facebook. All participants were stimulated to roll out the questionnaire to as many individuals as possible so that the online questionnaire link would be forwarded to individuals apart from the first contact point. The survey was conducted between April and July 2020 during the lockdown period imposed by the Indian government with the social distancing policy. Hence, online survey was approved by the institutional ethical committee under the current critical condition. The individual aged 18 years and above, having access to the internet, able to read, write and speak English language and giving informed consent to participate in this study were recruited. Being an online survey, enable us to collect immediate responses for questionnaire from various states in India. Participation in this study was anonymous, consonant, and voluntary.

Knowledge, attitudes, and practices questionnaire design

The questionnaire was obtained from a study of Zhong et al.[11] after getting permission from the investigators. The questionnaire used in this study was initially drafted and modified based on the Indian context by obtaining the opinion from epidemiology and public health experts. Before online survey, questionnaire was pretested to 15 participants to make questionnaire easier and simpler to understand that can be filled within few minutes. However, the data derived from the initial testing was excluded from the final analysis. The questionnaire consisted of five sections. Section I provided the information related to survey title with an ethical clearance number and brief description about the study. Section II, includes socio-demographic variables such as age, sex, marital status, education, residential location, and information about the family members living together. Section III included 11 knowledge questions related to clinical symptoms, spreading, recovery, comorbid & severity of COVID-19, infection through animals/birds, quarantine, effective ways of prevention, and vaccine. Section IV included six attitude questions towards COVID-19, comprising, precautionary measures, attitude towards receiving a vaccine on COVID-19 Section V included four practices towards COVID-19 prevention to avoid overcrowding places, wearing the mask, when symptoms persist in avoiding contact with people/family, and hand washing practice. Section V included questions and suggestions related to precautionary steps that individuals have to follow, meeting the respondents’ essential commodities, the expectation of respondents from the government towards this crisis with valuable suggestions to prevent the spread of the virus.

Study outcome

Each question's scoring was given based on the correct knowledge, optimal attitude, and suitable practice. The primary outcome, KAP score, was a composite score obtained using the participant's responses to the 11, 6, and 4 questions used in each domain. The plausible ranges of scores for the section III was between 0 and 22, section IV was 0 and 12, and section IV was 0 and 6 for the designed KAP questionnaire on COVID-19 pandemic.

Statistical analysis

The completed responses were exported from Google Forms to Microsoft Excel for coding the data. The relevant statistical procedure such as Pearson's correlation, t-test, ANOVA, univariate and multivariate analysis were assessed based on data types to determine the association the variables with KAP scores. Statistical analysis was performed using SPSS version 26 was used to analyze the data. P-value <0.05 was considered as statistically significant throughout the analysis. Additionally, ArcMap 10.7.1 was used to obtain spatial plots. Overall spatial autocorrelation was obtained using Moran's I statistic to investigate any spatial dependence in the data [12,13].

Results Sociodemographic of Respondents

Study involves 2059 participants irrespective of age, gender, and socio-economics. Sociodemographic characteristics of the respondents were illustrated in Table 1.

Table 1 - Socio-demographic characteristics of the study respondents (n = 2059). Questions Frequency Percentage (%) Age  18–30 1345 + 99 64.7 + 4.8  31–45 475 22.8  46–55 104 5.0  56–75 53 2.5 Sex  Male 918 44.2  Female 1157 55.7  Transgender 1 .1 Marital status  Single 1339 64.5  Married 722 34.8  Others 15 0.7 Level of education  Primary 31 1.5  Intermediate 77 3.7  Secondary 198 9.5  Graduation 931 44.8  Post-graduation & above 839 40.4 Occupation  IT sector 163 7.9  Medical 225 10.8  Allied health 306 14.7  Nursing 89 4.3  Pharma sector 61 2.9  Engineering 115 5.5  Business 84 4.0  Student 629 30.3  Others 404 19.5 Disease zone  Red 851 41.0  Orange 443 21.3  Yellow 184 8.9  Green 598 28.8

Most of the participants were from the state of Karnataka (n = 654, 31.5%), Kerala (n = 311, 15%), Tamil Nadu (n = 157, 7.6%), Maharashtra (n = 131, 6.3%), Delhi (n = 111, 5.3%) (Fig. 1).

Fig. 1:

Geographic representation of the respondents for KAP towards COVID-19.

KAP score towards COVID-19 among the state-wise residents descriptive were presented in choropleth maps (Fig. 2Fig. 3Figs. 2−4).

Fig. 2:

State wise distribution of the score on knowledge towards COVID-19 among Indian residents (n = 2059).

Fig. 3:

State wise distribution of the score on attitude towards COVID-19 among Indian residents (n = 2059).

Fig. 4:

State wise distribution of the score on practice towards COVID-19 among Indian residents (n = 2059).

Univariable analysis findings

Among the respondents, the average knowledge and attitude and practice score was 16.9 ± 2.0 (1.0, 22.0), 9.5 ± 2.0 (0.0, 12.0), and 4.0 ± (4.0, 4.0) (0.0, 5.0), respectively. Since the practice scores ranged between 0 and 5, non-parametric correlations and tests were applied. No linear relationship of knowledge was observed with attitude (r = 0.18) and practice (r = 0.09) score. Similarly, attitude and practice scores are not correlated with each other (r = 0.07).

A significant association (χ221, 0.05 = 51.77, P < 0.001) was observed between having a vulnerable group at home and the disease zone where the respondent resides. Despite this fact, a significant association was noted between staying with a vulnerable group at home and following the government's lockdown measures (χ214, 0.05 = 36.04, P = 0.001). The findings revealed that people who stay with a vulnerable group are less likely to go to crowded places during the pandemic (χ27, 0.05 = 118.01, P < 0.001). Isolating themselves from family if symptoms persists (χ214, 0.05 = 13.84, P = 0.462), wearing mask while leaving home (χ27, 0.05 = 11.91, P = 0.104) and practicing self-hygiene (χ221, 0.05 = 16.39, P = 0.747) were not associated to staying with the vulnerable group.

The knowledge scores did not differ significantly across the various disease zones (F(3,2055) = 0.87, P = 0.456) and gender (t(0.05,2056) = 1.12, P = 0.262). A significant difference in knowledge was noted based on their education status (F(4, 2054) = 2.98, P = 0.018); specifically, a poorer knowledge was observed among the participants who were educated till intermediate when compared to those educated till graduation (P = 0.04) and post-graduation (P = 0.01). The knowledge score was observed to be significantly different (F(8,2050) = 3.6, P < 0.001) among the participants with a different occupation. Businessmen (P = 0.005) and students (P = 0.041) were found to have significantly lower knowledge than medical professionals. The participants who work for the pharma sector had improved knowledge of COVID-19 when compared to those handling their own business (P = 0.015).

The attitude scores differ significantly across the disease zones (F(3,2055) = 21.56, P = 0.01) with the participants in orange (P = 0.001) and green (P = 0.023) zone having better attitude than those residing in the red zone. Males and females had similar attitude towards COVID-19 pandemic (t(0.05,2056) = 1.70, P = 0.090). No significant difference in attitude was noted based on their education status (F(4, 2054) = 1.47, P = 0.209). The attitude score was significantly different (F(8,2050) = 2.34, P = 0.017) among the participants with a different occupation.

The practice scores differ significantly across the disease zones (P < 0.001), with the participants in the red zone, have better practice than those in orange (P < 0.001), yellow (P < 0.001), and green (P < 0.001) zone. The practice score among those residing in the orange zone differed significantly from that among the green zone (P = 0.007). However, no significant difference was observed in practice among yellow zone residents than those in green and orange (P > 0.05). Among respondents the Male gender had improved practice towards COVID-19 pandemic (P = 0.008) than the female. A significant difference in practice was noted based on their education status (P = 0.027) with a significant difference in the score among those who attained secondary education compared to those who attained post-graduation and above (P = 0.007). The practice score was observed to be significantly different (P < 0.001) among the participants with different occupations. IT personnel had a better attitude as compared to allied health (P < 0.001), medical professionals (P = 0.026), students (P < 0.001), and others (P = 0.004). Medical professionals (P = 0.021), businessmen (P = 0.040), and others (P < 0.001) had improved practice over students. Age, education, and occupation were found to impact the respondents’ knowledge score significantly.

Multivariable analysis findings

On investigation, age, education, and occupation status were observed to impact the knowledge status; however, other social-demographic characteristics were not significant, as presented in Table 5. For a unit increase in age, the knowledge score is expected to increase by 0.016 units.

Table 5 - Social- demographic factors influencing the knowledge, attitude, and practice scores among residents of India, n = 2059. Characteristics Levels Adjusted estimates 95% CI t statistic P value Knowledge Age 0.016 0.005,0.027 2.88 0.004 Education Secondary −0.199 −0.99, 0.59 −0.50 0.622 Intermediate −0.837 −1.701, 0.028 −1.90 0.058 Graduation −0.089 −0.834, 0.656 −0.23 0.815 Post-graduation and above −0.092 −0.839, 0.656 −0.24 0.810 Occupation Medical 0.351 0.022, 0.680 2.09 0.037 Allied health 0.205 −0.080. 0.491 1.41 0.159 Business −0.711 −1.197, −0.227 −2.88 0.004 Engineering −0.351 −0.772, 0.070 −1.63 0.102 IT sector −0.304 −0.675, 0.068 −1.60 0.109 Nursing −0.035 −0.508, 0.438 −0.15 0.885 Pharma sector 0.499 −0.063, 1.061 1.74 0.082 Others −0.136 −0.435, 0.163 −0.90 0.371 Attitude Disease zone Green 0.296 0.092, 0.500 2.841 0.005 Orange 0.439 0.214, 0.665 3.826 <0.001 Yellow 0.146 −0.166, 0.457 0.917 0.359 Practice Disease zone Green −0.236 −0.301, −0.171 −7.127 <0.001 Orange −0.148 −0.220, −0.077 −4.071 <0.001 Yellow −0.196 −0.295, −0.097 −3.894 <0.001 Age 0.008 0.006, 0.011 6.041 <0.001

Only significant variables are reported. Reference category: Disease zone, red; education, primary; occupation, student.

Respondents residing in the orange and green zone had a better attitude than those residing in the red zone. However, respondents with higher age and residing in the red zone were expected to practice better than others. The findings point towards the difference in attitude and practice among the residents. Though the attitude was positive among the orange, yellow, and green zone residents, they had poor practice than those residing in the zone with more cases, the red zone. Table 5 also illustrates that the spatial autocorrelation measure, Moran's I, was observed as low as −0.04, −0.06, and 0.004 for knowledge, attitude, and practice.

Discussion

The KAP survey among country residents towards COVID-19 disease will help us customize the interventions for controlling disease spread and behavior change programs [14]. The current study on KAP towards COVID-19 among the Indian residents involved people from different states and demographic features. The average KAP score among the respondents was 16.9 ± 2.0 (1.0, 22.0), 9.5 ± 2.0 (0.0, 12.0), and 4.0 ± (4.0, 4.0) (0.0, 5.0), respectively. Age, education, and occupation were found to impact the respondents’ knowledge score significantly. Disease zones were observed to be associated with the attitude and practice among the respondents. The respondents had good knowledge of quarantine for 14 days to prevent infection, isolation, and treatment of infected persons, symptoms, treatment and spread through infected individuals’ respiratory droplets. Among the respondents, 75% had good practice towards COVID-19. The vulnerable population with COVID-19 are the elderly and individuals with comorbidities, more likely to have severe complications [15]. The online KAP study conducted by Afzal et al.[16] reported the association of demographic factors with the KAP towards COVID-19 disease. The study conducted by Chen et al.[17] in China, Anhui Province, has also shown that residents had excellent knowledge about the significant symptoms, prevention methods, transmission containing practice, treatment to novel coronavirus, and more awareness atypical symptoms. The KAP study conducted among Iran residents, with population & field-based surveys, concluded knowledge to be lower among socially deprived, lower educated, and elderly individuals. The people were not aware of symptoms, and when they should seek medical help if they are infected and required to have improved practice towards preventive measures [18]. The study conducted in Jammu and Kashmir, India, has concluded the respondents had good knowledge, with a positive attitude and sensible practice. Almost all the respondents had the elderly population staying in the home and were well aware of the transmission and precautionary measures [19]. COVID-19 infection causes higher mortality in the elderly population with comorbid conditions that include diabetes, heart disease, chronic pulmonary disease, and hypertension [20]. In the present study, only 72% of the respondents were aware that COVID-19 infection might be severe among the elderly and those with chronic illness or comorbid conditions. A significant number of respondents had the misconception that asymptomatic COVID-19 individuals are incapable of spreading the disease and also believed eating or contacting with animals/birds would result in the infection by the COVID-19 virus. The respondents had positive attitudes towards precautionary measures that could prevent COVID-19 infection, but 23.5% believed that protective measures are not sufficient for the prevention. Moreover, 71% said that if there is a vaccine against this, they are willing to take it, and 13% responded that they would not take the vaccine, whereas 16.1% were not sure. Azlan et al.[21] conducted the KAP survey among the Malaysian public, which showed that 80% of the population knew COVID-19, with a positive attitude and improved practices.

In our study, we have observed improved practice among respondents residing with the vulnerable group towards safeguarding themselves from the COVID-19 infection. The attitude among residents of India's red zone was relatively poor compared to those in the orange zone, indicating the psycho-social impact due to the huge toll in the areas highly afflicted by the pandemic [22]. The respondents had good practice about using the mask when leaving home (92.9%) and a decrease in unnecessary out-of-home shuttling (84.9%). Moreover, 78.9% of the participants had started practicing handwashing for 20 s, 12.5% do it often, 7.3% wash their hands sometimes, and 1.4% responded that they never practiced 20 s hand washing procedure self-hygiene. Nearly 15.1% of the interviewees stated that they have gone to crowded places, and 7.1% have not worn masks while going out where their practice is compromised in terms of social distancing and wearing the mask. Australian resident reveals that 50% of the respondents assumed COVID-19 infection would affect their health, 19% had perseverance of getting an infection, and higher percentage of respondents had hygiene practices, avoidance behaviors, and adopting social distancing [23]. The Pakistani residents practiced well on social distancing, wearing the mask and handwashing procedures. The median knowledge score was significantly associated with sex, marital status, education, and residence [24]. The Egyptian survey showed less knowledge of COVID-19 among the elderly, lower-income participants, less educated, and rural populations. About 73.0% of the participants were considering forward to get vaccinated after the availability. More programs are needed to educate and upkeep the lower economic population. When the vaccine or treatment is approved, the authors recommended that the government control its utility to prioritize the vulnerable and needy groups [25]. Geldsetzer conducted a rapid online survey among the United States (n = 2986) and the United Kingdom (n = 2988) on perception towards the COVID-19 disease outbreak. The respondent had good knowledge of the transmission and symptoms of the disease [26]. The survey conducted in Germany showed that participants had a high knowledge level, but acceptance of vital protection behaviors was low, and risk perceptions were specifically low among the elderly [27]. Robust infection control and prevention methods are the most critical intervention to control the virus [28]. KAP understanding of COVID-19 among poor populations needs a tailored-made community health response [29]. The presented study's findings accentuate the necessity to have virtuous KAP concerning COVID-19 in the current scenario. No linear relationship of knowledge was observed with attitude and practice amid Indian residence.

Conclusion

Considering the participants’ suggestions and the increasing number of COVID-19 cases, though a complete lockdown may not be feasible, schools, colleges, recreation centers, and religious gatherings may remain closed to prevent the spread. This finding will help policymakers concentrate on the socioeconomic groups, which is lacking in knowledge and attitude and improve their practice towards COVID-19.

Acknowledgements

The authors would like to acknowledge the respondents and people who shared our link further to get the responses.

Conflict of interest

There are no conflicts of interest.

Funding: This study was not funded by any agency or organization.

Ethical approval: Not applicable.

Research Data: Research data is available with corresponding author and will be communicated as per request.

Authors’ contributions: M.K. and V.A. conceived the study, conducted the questionnaire and data entry. S.R. and K.S. performed the statistical analysis. M.K. drafted the manuscript. U.K.S., K.S., V.A., A.F.S., S.R., P.P., M.A. reviewed the manuscript. All authors read and approved the final manuscript.

Authors’ approval: The manuscript has been read and approved by all the authors.

References 1. Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown etiology in Wuhan, China: the mystery and the miracle. J Med Virol 2020; 92:401–402. 3. Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, et al. Corrigendum to “World Health Organization declares Global Emergency: a review of the 2019 novel coronavirus (COVID-19)” [Int. J. Surg. 76 (2020) 71−76]. Int J Surg 2020; 77:217. 4. Martinez-Perez C, Alvarez-Peregrina C, Villa-Collar C, Sánchez-Tena MÁ. Citation Network Analysis of the Novel Coronavirus Disease 2019 (COVID-19). International journal of environmental research and public health 2020; 17 (20):7690. 5. Wu Yi-Chia, Chen Ching-Sunga, Chan Yu-Jiuna,b,c,∗ The outbreak of COVID-19: An overview, Journal of the Chinese Medical Association: March 2020 - Volume 83 - Issue 3 - p 217–220. 6. Sanyaolu A, Okorie C, Marinkovic A, Patidar R, Younis K, Desai P, et al. Comorbidity and its Impact on Patients with COVID-19. SN Compr Clin Med 2020; 2:1069–1076. 7. Deng CX. The global battle against SARS-CoV-2 and COVID-19. Int J Biol Sci 2020; 16:1676–1677. 8. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497–506. 9. Dahab M, van Zandvoort K, Flasche S, Warsame A, Ratnayake R, Favas C, et al. COVID-19 control in low-income settings and displaced populations: what can realistically be done? Confl Health 2020; 14:54. 10. Chirwa GC, Sithole L, Jamu E. Socio-economic Inequality in Comprehensive Knowledge about HIV in Malawi. Malawi medical journal: the journal of Medical Association of Malawi 2019; 31 (2):104–111. 11. Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, Li Y. 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; 16:1745–1752. 12. Nilima, Puranik A, Shreenidhi SM, Rai SN. Spatial evaluation of prevalence, pattern and predictors of cervical cancer screening in India. Public Health 2020; 178:124–136. 13. John AE, Nilima, Binu VS, Unnikrishnan B. Determinants of antenatal care utilization in India: a spatial evaluation of evidence for public health reforms. Public Health 2019; 166:57–64. 14. Reuben RC, Danladi MMA, Saleh DA, Ejembi PE. Knowledge, attitudes and practices towards COVID-19: an epidemiological survey in North-Central Nigeria. J Community Health 2021; 46:457–470. 15. Guo YR, Cao QD, Hong ZS, Tan YY, Chen SD, Jin HJ, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res 2020; 7:11. 16. Afzal MS, Khan A, Qureshi UUR, Saleem S, Saqib MAN, Shabbir RMK, et al. Community-based assessment of knowledge, attitude, practices and risk factors regarding COVID-19 among Pakistanis residents during a recent outbreak: a cross-sectional survey. J Community Health 2021; 46:476–486. 17. Chen Y, Jin YL, Zhu LJ, Fang ZM, Wu N, Du MX, et al. The network investigation on knowledge, attitude and practice about novel coronavirus pneumonia of the residents in Anhui Province. Zhonghua Yu Fang Yi Xue Za Zhi 2020; 54:E004[in Chinese]. 18. Honarvar B, Lankarani KB, Kharmandar A, Shaygani F, Zahedroozgar M, Rahmanian Haghighi MR, et al. Knowledge, attitudes, risk perceptions, and practices of adults toward COVID-19: a population and field-based study from Iran. Int J Public Health 2020; 65:731–739. 19. Dkhar SA, Quansar R, Saleem SM, Khan SMS. Knowledge, attitude, and practices related to COVID-19 pandemic among social media users in J&K, India. Indian J Public Health 2020; 64: (Suppl): S205–S210. 20. Tavakoli A, Vahdat K, Keshavarz M. Novel coronavirus disease 2019 (COVID-19): an emerging infectious disease in the 21st century. Iran South Med J 2020; 22:432–450. 21. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: a cross-sectional study in Malaysia. PLoS One 2020; 15:e0233668. 22. Nilima N, Kaushik S, Tiwary B, Pandey PK. Psycho-social factors associated with the nationwide lockdown in India during COVID- 19 pandemic. Clin Epidemiol Glob Health 2021; 9:47–52. 23. Seale H, Heywood AE, Leask J, Sheel M, Thomas S, Durrheim DN, et al. COVID-19 is rapidly changing: examining public perceptions and behaviors in response to this evolving pandemic. PLoS One 2020; 15:e0235112. 24. Hayat K, Rosenthal M, Xu S, Arshed M, Li P, Zhai P, et al. View of Pakistani residents toward coronavirus disease (COVID-19) during a rapid outbreak: a rapid online survey. Int J Environ Res Public Health 2020; 17:3347. 25. Abdelhafiz AS, Mohammed Z, Ibrahim ME, Ziady HH, Alorabi M, Ayyad M, Sultan EA. Knowledge, perceptions, and attitude of Egyptians towards the novel coronavirus Disease (COVID-19). J Community Health 2020; 45:881–890. 26. Geldsetzer P. Use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: a cr