INTRODUCTION:

The coronavirus disease 2019 (COVID-19) emerged in Wuhan, China at the end of 2019. Since then, it has spread to 213 countries and territories (1) and had been declared as a global pandemic by the World Health Organization (WHO) on 11th March 2020 (2) To date, there are 26, 573, 612 positive COVID-19 cases recorded with at least 874, 858 deaths globally, with these numbers constantly changing.¹

The first case of COVID-19 in India, which originated from China, was reported on 30 January 2020. As of 3rd September 2020, the Ministry of Health and Family Welfare (MoHFW) has confirmed a total of 3853406 cases, 2970492 recoveries and 67376 deaths in the country. India currently has the largest number of confirmed cases in Asia and has the third highest number of confirmed cases in the world after the United States and Brazil with the number of total confirmed cases breaching the 100,000 mark on 19 May, 200,000 on 3 June, and 1,000,000 confirmed cases on 17 July 2020. On 29 August 2020, India recorded the global highest spike in COVID-19 cases on a day with 78, 761 cases surpassing the previous global highest daily spike of 77, 368 cases which was recorded in the US on 17 July 2020.

India's case fatality rate is among the lowest in the world at 2.41% as of 23 July and is steadily declining. By mid-May 2020, six cities accounted for around half of all reported cases in the country – Mumbai, Delhi, Ahmedabad, Chennai, Pune and Kolkata. As of 24 May 2020, Lakshadweep is the only region which has not reported a case. On 10 June, India's recoveries exceeded active cases for the first time.

The first case of the COVID-19 pandemic in the Indian state of Maharashtra was confirmed on 9 March 2020. Maharashtra is a hotspot that accounts for nearly one-third of the total cases in India as well as about 40% of all deaths. As of 7 July, the state's case fatality rate is nearly 4.3%, which is lower than the global average but significantly higher than other Indian states with large numbers of cases. Mumbai is the worst-affected city in India, with about 100,000 cases. About half of the cases in the state emerged from the Mumbai Metropolitan Region (MMR) (3)

Lockdown measures were perceived as necessary to curb the spread of the virus as rapid human-to-human transmission occurred and much about the virus has remained unknown. Due to the obscurity of this novel virus, there has been a lot of confusion and misunderstanding about the virus itself, how it can spread and the necessary precautions that should be taken to prevent infection. This becomes increasingly challenging with the vast amount of misinformation and disinformation shared on social media that is clouding people’s understanding of COVID-19. (4)

In the end, India is facing daunting and predictable challenges in enforcing the lockdown and also making sure the poor and homeless are not fatally hurt. Much of it, will depend on whether the economic and living consequences of the lockdown strategy are carefully managed, and the consent of the people is won. "If not, there is a potential for very serious hardship, social tension and resistance."(5). The Maharashtra government further extended the lockdown imposed as a precautionary measure to contain the spread of COVID-19 till 31 September (6).

The knowledge, attitudes and practices (KAP) toward COVID-19 play an integral role in determining a society’s readiness to accept behavioral change measures from health authorities. KAP studies provide baseline information to determine the type of intervention that may be required to change misconceptions about the virus. Assessing the KAP related to COVID-19 among the general public would be helpful to provide better insight to address poor knowledge about the disease and the development of preventive strategies and health promotion programs. Among the lessons learned from the SARS outbreak is that knowledge and attitudes are associated with levels of panic and emotion which could further complicate measures to contain the spread of the disease. (4)

STUDY TITLE:

Knowledge, Attitude and Practices towards Covid-19 Outbreak in Maharashtra State.

AIM OF THE STUDY:

To improve and enhance the knowledge, attitude and practices among the general population to maintain, promote, and protect their health during the Covid-19 outbreak.

PROBLEM STATEMENT:

“A study to assess the knowledge, attitude, practices and create awareness towards Covid -19 outbreak, among the urban and rural residents of Maharashtra State”

OBJECTIVES:

To assess the knowledge, attitude and practices towards Covid -19 outbreak, among the urban and rural residents of Maharashtra State

To create awareness regarding the Covid -19 outbreak

To associate the findings with the selected demographic variables.

METHODS:

Study design:

A quantitative approach was utilized to achieve the objectives of this study. A survey is most appropriate as it allows large populations to be assessed with relative ease. In this study, a cross-sectional survey was deemed most appropriate to gather information on COVID-19. Data collection was performed online using the Google forms. The call for participation was made on social media.

Ethical approval:

The Ethics Committee of D.E. Society’s Smt Subhadra K Jindal College of Nursing approved the study protocol, procedures, information sheet and consent statement. Participants who gave consent to willingly participate in the survey would click the ‘Continue’ button and would then be directed to complete the self-administered questionnaire.

Recruitment procedure:

This cross-sectional survey was conducted from 15th May 2020 to 15th July 2020. Members of the Maharashtrian public above the age of 15 and currently residing in the state were eligible to participate in the survey. We utilized several strategies to reach as many respondents as possible all over the state within the data collection period. Two main platforms used in disseminating this survey were social media WhatsApp and Facebook. A standardized general description about the survey was given in the WhatsApp message/social media postings before the link was provided to both English and Marathi language versions of the questionnaire. A total of 931 participants took part in the survey.

Study instrument:

The survey instrument consisted of the following:

1) Demographics section, which surveyed participants’ socio-demographic information, including, age, gender, educational status, occupation/professional status, religion, income status, if a medical professional, history of chronic illness, number of inhabitants living in the village or town, rural or urban area of living, name of the place and district, information related to number of children, elderly living in the family and number of people living in the household.

2) Questionnaire to assess knowledge about COVID-19;

3) Checklist to assess practices relevant to COVID-19, and

4) Likert scale to assess attitudes toward COVID-19

The survey was offered in the English and Marathi languages.

To measure knowledge about COVID-19, the items in the questionnaire included questions related to the disease transmission, signs and symptoms, risk factors/etiological factors, the virus, and its viability on different surfaces, diagnostic measures, preventive and control measure. Every right answer was marked with one mark and the wrong answer scored zero marks.

To assess the practices related to Covid 19, the checklist had items with yes/no options related to the practices to be followed to prevent and control the disease and was classified as good practices and poor practices.

To assess the attitude towards Covid 19, the Likert scale had items with the options allowing the respondents to choose between responses as strongly disagree, disagree, neutral, agree and strongly agree. And was classified as positive attitude and negative attitude.

RESULTS AND FINDINGS:

Analysis is a process of organizing and synthesizing data in such a way that research questions can be answered, and hypothesis tested. The analysis and interpretation i.e. result of the data collected from 931 samples through a Descriptive cross section research design with quantitative research approach was done. Non-probability sampling technique was used for selection of sample and the objective was to assess the knowledge, attitude and practices towards Covid -19 outbreak, among the urban and rural residents of Maharashtra State. The collected data are tabulated in master sheet and analyzed by using descriptive and inferential statistics as per the following objectives of study.

The data collected was coded and analyzed as per objectives of the study under following headings.

Section I: Description of Socio demographic profile

Section II: Description of knowledge attitude and practices towards Covid -19

Section III: Association of findings with the sociodemographic variables of respondents

Section I: Description of Socio demographic profile of respondents (n=931)

Table No: I Description of Socio demographic profile

S. No	Variable	Frequency	%
1	Age
a	15 -25 yrs.	612	65.74
b	25 -35 yrs.	158	16.97
c	35-45 yrs.	70	7.52
d	>45 yrs.	91	9.77
2	Gender
a	Male	475	51.03
b	Female	456	48.97
3	Education
a	Uneducated	14	1.51
b	Primary education	15	1.61
c	Secondary education	55	5.91
d	Higher Secondary	121	13.00
e	Undergraduate	483	51.88
f	Postgraduate	221	23.74
g	Doctorate	22	2.36
4	Religion
a	Hindu	741	79.59
b	Muslim	34	3.65
c	Christian	121	13.00
d	Others	35	3.76
5	Occupation
a	Private service	225	24.15
b	Government employee	49	5.27
c	Business	75	8.06
d	Medical/health professional	281	30.19
e	Any other, please specify	301	32.33
6	Income
a	5000-10,000/-	272	29.22
b	11,000-30,000/-	267	28.67
	30,000- 50,000/-	96	10.32
c	50,000-80,000/-	106	11.38
d	Above 80,000/-	190	20.41
7	Are you a Medical Professional
a	Yes	361	38.78
b	No	570	61.22
8	Do you have any chronic illness
a	Yes	72	7.73
b	No	859	92.27
9	How many inhabitants live in your village or town you live?
a	≤ 5,000 inhabitants	163	17.51
b	5,001 - 20,000 inhabitants	127	13.64
c	20,001 - 100,000 inhabitants	96	10.31
d	100,001 - 500,000 inhabitants	100	10.74
e	> 500,000	107	11.49
f	I don’t know	338	36.31
10	Where do you live?
a	Rural area	334	35.88
b	Urban area	597	64.12
11	Do you have children living with you?
a	Yes	360	38.67
b	No	571	61.33
12	Do you have elderly people living with you?
a	Yes	552	59.29
b	No	379	40.71

Section II: Description of knowledge attitude and practices towards Covid -19

Table No: II Description of knowledge on Covid -19

S.N.	Level of Knowledge	Frequency	Percentage
1	0-8(Poor)	280	30.08
2	09-16 (Average)	434	46.61
3	17-25 (Good)	217	23.31
Overall		931	100

Overall Mean knowledge score was (13.78.±0.38) which is 55.12%. It showed that most of the respondents had Average Knowledge.

Table No: III Description of practice regarding Covid-19

S.N.	Practices	Frequency	Percentage
1	0-10(Poor)	05	00.54
2	11-20 (Good)	926	99.46
Overall		931	100

Overall Mean practice score was (18.31± 0.21) which is 91.55 %. It showed that most of the respondents had good practices regarding Covid-19.

Table No: IV Description of attitude regarding Covid-19

S. No	Level of attitude	Frequency	Percentage
1	Negative (1 to 45)	-	-
2	Neutral (46 to 90)	575	61.77
3	Positive (91 to 135)	356	38.23
Overall		931	100

Overall Mean attitude score was (88.05±2.78) which is 65.55%. It showed that most of the respondents had neutral attitude towards Covid-19

Table No: IV Study participants overall KAP level towards Covid-19

Study participants overall KAP level towards Covid-19 was 23.31% of the respondents had good knowledge score, 99% of the respondents had good practice score and 38% of the respondents had positive attitude towards covid-19.

Section III: Association of findings with the sociodemographic variables of respondents.

Table No: VI Association of knowledge score with the selected sociodemographic variables

S.N.	Variables	χ²	Level of significance
1	Age	3.04	Not Significant
2	Gender	2.47	Not significant
3	Education	6.11	Significant
4	Religion	0.18	Not significant
5	Occupational status	5.55	Significant
6	Income status	0.24	Not significant

df – 1, table = 3.84, p≥ 0.05, not significant

Chi square values were calculated to find out the association between knowledge score with the selected sociodemographic variables. The findings revealed that there was a significant association found between knowledge score with the sociodemographic variables like Education and Occupational status, which were (χ²= 6.11 and 5.55) respectively.

Table No: VII Association of Attitude score with the selected sociodemographic variables

S.N.	Variables	χ²	Level of significance
1	Age	1.37	Not significant
2	Gender	1.07	Not significant
3	Education	4.14	Significant
4	Religion	2.18	Not significant
5	Occupational status	5.87	Significant
6	Income status	1.24	Not significant

df – 1, table = 3.84, p≥ 0.05, not significant

Chi square values were calculated to find out the association between Attitude score with the selected sociodemographic variables. The findings revealed that there was a significant association found between attitude score with the sociodemographic variables like Education and Occupational status, which were (χ²= 4.11 and 5.87) respectively.

Table No: VIII Association of Practice score with the selected sociodemographic variables

S.N.	Variables	χ²	Level of significance
1	Age	2.07	Not significant
2	Gender	2.47	Not significant
3	Education	1.07	Not significant
4	Religion	2.02	Not significant
5	Occupational status	1.14	Not significant
6	Income status	1.17	Not significant

df – 1, table = 3.84, p≥ 0.05, not significant

Chi square values were calculated to find out the association between practice score with the selected sociodemographic variables. The findings revealed that there was no significant association found between practice score with the sociodemographic variables.

DISCUSSION:

COVID-19 is a relatively new virus that has had devastating effects within the short time since it was first detected in December 2019. To date, there has been limited published data on population knowledge, attitudes and practices toward COVID-19, specifically in Maharashtra. The novelty of this disease, along with its uncertainties, make it critical for health authorities to plan appropriate strategies to prepare and manage the public. It is therefore of utmost importance that the knowledge, attitudes and practices of the population be studied to guide these efforts.

Based upon the analysis of the study the following was found in the study conducted;

With regards to the description of socio demographic profile mentioned in the section 1, the below mentioned were the findings:

With the variable of age, majority of the samples were in the age group of 15-25 years of age (65.74%), while the least number of the samples were in the age group of 35-45 years of age (7.52%)

As per gender, there was more less an equal distribution with male samples (51.03%) and female samples (48.97%)

In the variable of Education, most of the samples were graduates (51.88%) and postgraduates (23.74%) very less samples were uneducated (1.51%), with primary education (1.61%) and secondary education (5.91%)

In the religion of the samples, majority of the samples were Hindus (79.59%) the least number of the samples were Muslims (3.65%)

As per the occupational status of the samples most of the samples 32.33% of samples mentioned their occupation in the option of any other, whereas (30.19%) samples were medical/health care professionals, there were (5.27%) samples who were in government services

In the Income status large number of the samples (28.67%) samples earned an income between 11,000-30,000, and there were (10.32%) samples who had an income between 30,000- 50,000

In the data regarding, if the sample belonged to a medical profession. 38.78% were medical professionals whereas 61.22% were non-medical professionals

Regarding the data, if the sample had any chronic illness it was noted only 7.73% had chronic illness, remaining 92.27% were free of any chronic illnesses.

In the data collected to know the place of residence of the samples, most of the samples 64.12% lived in urban areas whereas 38.67% of samples lived in rural areas

In the data collected to know if the samples had children living with them 38.67% samples had children living with them , whereas 61.33% had no children living with them and in the data collected to know if the samples had elderly people living with them 59.29% samples had elderly people living with them whereas 40.71 % had no elderly people living with them.

With regards to the description of knowledge attitude and practices towards Covid -19 mentioned in the section 2, the below mentioned were the findings:

In description of knowledge on Covid -19, Majority of the samples (46.61%) samples had average knowledge, (30.08%) sample had poor knowledge and the least number of samples (23.31%) had good knowledge

In description of practices on Covid -19, Majority of the samples (99.46%) samples had good practices related to Covid 19 whereas only (00.54%) had poor practices

In description of attitude on Covid -19, Majority of the samples (61.77%) samples had a neutral attitude related to Covid 19, (38.23 %) had a good attitude towards Covid 19, whereas no samples had negative attitude towards Covid 19

The study participants overall KAP level towards Covid-19 was 23.31% of good knowledge, 99.46% of good practices 38.23% of positive attitude towards the disease.

With regards to the association of findings with the sociodemographic variables of respondents. mentioned in the section 3, the below mentioned were the findings:

Only the selected demographic variables of age, gender, education, religion, occupational status and income status were associated with the findings,

It was noted that knowledge score of the samples showed association with the variables of education and occupational status only

Also, it was noted that attitude score of the samples showed association with the variables of education and occupational status only

While it was noted that the practice score of the samples showed no association with any of the selected variables.

Admittedly, COVID-19 has been a major public health problem around the world. Scientists all around the globe are working tirelessly to explore different vaccines and treatment options. Social scientists, especially those in public health and health communication, are working to identify the levels of knowledge, attitudes and practices on COVID-19 among the public as to design cost-effective public health campaigns and education programmes. The current study was in fact, undertaken to find out the knowledge, attitude and practices of the public in Maharashtra, and brought out the level of good knowledge related to the disease is yet deficient 23.31%, the practice scoring although shows good practice by as much as 99.46% it cannot be relied upon, as the practices were not been observed, also the attitude scoring showed only 38.23% of samples to have a positive attitude towards the disease.

The study shared a pdf file with all the samples to create awareness about the disease, after the samples had answered the survey, this awareness material was regarding the answer key with rationales to the questions put up in the knowledge section, and information related to all the good practices along with the rationales for following them in the right way, and information for building a positive attitude towards the disease

LIMITATIONS:

1. Sampling for the study was conducted via a convenience sample through the networks of the researchers and disseminated through different social media platforms (WhatsApp, Facebook) As a result, there is a possibility of bias as underprivileged populations may not have been able to participate in the study.

2. Additionally, when compared to current population statistics in Maharashtra, the sample of the study were over-representative with the age of most of the samples being in the young age group of 15-25 years of age, also the educational status of the samples was, most of them being undergraduates and postgraduates and comparatively very less samples being illiterate or having primary and secondary education only, even there were decent number of samples who were health care professionals. Therefore, there are limitations to the representativeness of the findings. A more systematic, inclusive sampling method is warranted to improve representativeness and generalizability of the findings.

3. A further limitation of the present study is the possibility of participants giving socially desirable responses. As this study used self-reported data, it is possible that participants may have answered attitude and practice questions positively based on what they perceive to be expected of them

RECOMMENDATIONS, CONCLUSIONS:

The study recommends the following:

More number of health teachings/awareness campaigns to be conducted (online/offline) by health care professionals, and to be directed towards specific target groups like the slum dwellers, the uneducated, the risk groups.

Adding more of demonstration videos in the teachings to enhance the proper practices related to the preventive measures to be followed.

The study recommends the use of study designs like pretest posttest design, where effectiveness of the awareness material in preventing the disease could be possible.

Study can be done on large sample size.

In summary, the present study was able to provide a comprehensive examination of the knowledge, attitudes and practices of the urban and rural residents of Maharashtra toward COVID-19. The findings suggest that the samples have an acceptable level of knowledge on COVID-19 and are generally neutral in their outlook on overcoming the pandemic. Even so, consistent messaging from the government and/ or health authorities are key to aid public knowledge and understanding of COVID-19. Additionally, some categories of the population may benefit from specific health education programs to raise COVID-19 knowledge and improve practices.

To conclude as, World Health Organization chief Tedros Adhanom Ghebreyesus said, the world must be better prepared for the next pandemic, and he called on countries to invest in public health. This will not be the last pandemic he said and added that “History teaches us that outbreaks and pandemics are a fact of life. But when the next pandemic comes, the world must be ready – more ready than it was this time.” Thus, equipping our public with complete knowledge related to pandemic diseases, impressing upon them the practices to be followed diligently during the pandemic, and having a positive attitude, will be helpful always in the long run.

REFERENCES:

1. https://www.worldometers.info/coronavirus/?referer=app

2. https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19

3. https://en.wikipedia.org/wiki/COVID-19_pandemic_in_India

4. https://en.wikipedia.org/wiki/COVID-19_pandemic_in_Maharashtra

5. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233668

6. https://www.bbc.com/news/world-asia-india-52086274

7. https://www.firstpost.com/india/maharashtra-extends-lockdown-till-31-july-whats-allowed-non-essential-markets

8. Mohfw.gov.in

9. www.who.int

10. www.unicef.org

11. Covid.aims.edu

12. Report of the WHO-China Joint mission on Coronavirus Disease 2019

13. Survey tool and guidance- WHO, Regional office for Europe

14. National Health Mission- Maharashtra

15. coronavirus.jhu.edu

16. M. Chandrakala, Knowledge and Attitude of Mothers towards MCH Services provided by the Primary Health Centers. Asian J. Nur. Edu. & Research 2(1): Jan.-March 2012; Page 15-17.

17. Lissa Paul, Ramya K. R. Knowledge and Attitude towards Alcoholism among Adolescents. Asian J. Nur. Edu. and Research 2(4): Oct-Dec. 2012; Page 212-214

18. K. Indumathy, Rebecca Samson, Suseela J.R. A Study to Assess the Knowledge Attitude and Practices of Mothers Regarding Prevention of Iodine Deficiency among School Children in a Selected Rural Area, Bangalore. Asian J. Nur. Edu. & Research 1(1): Jan.-March 2011; Page 54-56.

19. ValliammalShanmugam, Ramachandra, Raja Sudhakar Kantharaj. Parental knowledge and attitude towards Child’s Rights – An Indian perspective. Asian J. Nur. Edu. and Research 3(2): April.-June 2013; Page 56-60.

20. A Study to Assess the Knowledge and Attitude regarding to Breast Feeding among Antenatal Women attending Antenatal OPD, in Christian Medical College, Vellore. Asian J. Nur. Edu. and Research 3(3): July-Sept., 2013; Page 188-189.

21. Kavitha V., Karpagam. Assessment of Knowledge and Attitude of Antenatal Mothers Towards Caesarean Section and Normal Vaginal Delivery at Selected Hospital, Coimbatore. Asian J. Nur. Edu. and Research 3(3): July-Sept. 2013; Page 190-191.

22. Jagroop Kaur. A Study to assess the Knowledge and Attitude related to Diabetic foot and its Prevention among Diabetics Attending Medical Outpatient Department in selected Hospitals of Sri Muktsar Sahib, Punjab. Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 50-55.

23. M. Girija, N. Kokilavani. Effectiveness of Structured Teaching Programme on Knowledge, Attitude and Practice among Patients with Hypertension. Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 136-139.

24. Anita Rani Kansal, Rajinder Mahal, D. Behera, Rohit Sarin. A study to assess learning need, knowledge and attitude of nurses regarding tuberculosis care under RNTCP in two tertiary care tuberculosis institutions of Delhi, India. Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 30-34.

25. K. Lalitha, R. Pushpamala, M. Bramaramba. A study to Assess the knowledge and Attitude Regarding Organ Donation among Undergraduate Students Studying in a Selected Arts and Science College, at Guntur. Asian J. Nur. Edu. & Research 4(2): April- June 2014; Page 195-202.

Received on 12.09.2020 Modified on 16.12.2020

Int. J. of Advances in Nur. Management. 2021; 9(2):162-168.

DOI: 10.5958/2454-2652.2021.00037.8