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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 14-21

Knowledge, attitude, and practice toward prevention and management of COVID-19 among indian nurses: A cross-sectional study


1 Department of Epidemiology, Insitute of Liver and Biliary Sciences, New Delhi, India
2 Project ECHO and Prakash, Insitute of Liver and Biliary Sciences, New Delhi, India
3 College of Nursing, Insitute of Liver and Biliary Sciences, New Delhi, India
4 Department of College of Nursing, Insitute of Liver and Biliary Sciences, New Delhi, India
5 Department of Psychiatry, Insitute of Liver and Biliary Sciences, New Delhi, India

Date of Submission16-Dec-2020
Date of Decision20-Jan-2021
Date of Acceptance31-Jan-2021
Date of Web Publication23-Mar-2021

Correspondence Address:
Dr. Mohit Varshney
Department of Psychiatry, Institute of Liver and Biliary Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jascp.jascp_16_20

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  Abstract 


Background: To plan suitable policy against COVID-19 pandemic, it is important that the nurses have updated knowledge related to prevention, diagnosis, treatment, and management of COVID-19 and have an optimistic attitude and good practices in managing the patients during the pandemic crisis. Thus, we conducted a study on the knowledge, attitude, and practices (KAP) related to COVID-19 among Indian nursing professionals. Methodology: A cross-sectional study was conducted from April 22 to May 22, 2020 using a pretested 37-item-self-reported e-questionnaire among nursing professionals above 18 years of age, working in health-care setting across 25 states. The questionnaire consisted of four sections: demographic details, knowledge (26 items), attitude (6 items), and practice (5-itmes). KAP questionnaire was shared through e-mail, SMS, and WhatsApp groups. Results: A total of 1182 participants responded to the online survey with 94% completion rate. The study analyzed the data for 1110 nurses with a mean age of 30 ± 6.7 years and 68% being females. The mean KAP score was 16.82 ± 3.3, 9.77 ± 2.03, and 18.37 ± 3.29, respectively. Knowledge was significantly correlated with attitude (r = 0.1316) and practice (r = 0.1526). Practice and attitude were also found to be positively correlated (r = 0.4398). Good knowledge related to COVID-19 was significantly affected by age, gender, location, and type of facility (<0.01). Conclusion: The study raised concerns regarding poor knowledge, anxiety, and fear from COVID-19 duty affects the health-care workers (HCWs) performance and provides resistance in working. A comprehensive training program for HCWs focuses more in terms of infection, prevention, control, and management and maintaining good mental health is required.

Keywords: COVID-19 pandemics, developing country, health-care workers, knowledge, attitude, and practices, need assessment


How to cite this article:
Rastogi A, Syed S, Bansal A, Ramalingam A, Sharma T, Kumar V, George M, Varshney M. Knowledge, attitude, and practice toward prevention and management of COVID-19 among indian nurses: A cross-sectional study. J Appl Sci Clin Pract 2021;2:14-21

How to cite this URL:
Rastogi A, Syed S, Bansal A, Ramalingam A, Sharma T, Kumar V, George M, Varshney M. Knowledge, attitude, and practice toward prevention and management of COVID-19 among indian nurses: A cross-sectional study. J Appl Sci Clin Pract [serial online] 2021 [cited 2021 Apr 19];2:14-21. Available from: http://www.jascp.com/text.asp?2021/2/1/14/311760




  Introduction Top


The dramatic outburst and subsequent spread of COVID-19 across 215 countries has engrossed the entire globe, resulting in more than 12.5 million cases and 556,000 deaths over a period of just 7 months.[1] The transmission of the disease has been so rapid to the effect that COVID-19 was upgraded from a public health emergency of international concern as on January 31, 2020 to pandemic on March 11, 2020 in a short span of 40 days.[2],[3] Further, the breadth and the depth of the consequences associated with the crisis of COVID-19 can be understood from the sufferings of the countries, even the ones having the best health infrastructures in the world.[4]

India, with its limitations in health-care infrastructure and human resources for health, would have easily become the worst affected nation had it not been for the timely, well thought out measures implemented to address the pandemic.[4] These include suspension of all international flights, nationwide lockdown for over 70 days, shutting down of malls and other public places, closing down of schools and universities, and suspension of religious places.

Despite these unprecedented national measures at state and country level, the success or failure of these efforts largely depends on the management of the existing COVID-19 patients. Nurses and other health-care workers (HCWs) are at the frontline and stage a crucial role in winning the battle against COVID-19. Nurses are leading full-scale public health operations with their involvement in each and every step of management of the pandemic from caring of the affected patients to protecting the public at large.[5] Role of nurses during COVID-19 or any other pandemic commences from the initial assessment and triaging, sample collection and diagnostic testing, assessing the severity of patients, following which providing necessary care to patients with mild-to-moderate symptoms, catering to intensive care of critically ill patient, and are also involved in care of the dead bodies.[6] Despite the resource constraint working conditions in Indian hospitals and concerns regarding personal and family safety, nursing professionals have maintained their sense of duty and are dedicated to patient care. Further, personal sacrifice and professional collegiality of nursing fraternity have increased due to increased burden on the health system during the COVID-19 pandemic.[5] Henceforth, it is necessary that self-care of nurse is ensured and they are able to manage the patients appropriately during pandemic times.

Thus, to plan suitable interventions, it is important that the health-care professionals, especially the nurses are updated about the current advances in knowledge about prevention, diagnosis, treatment, and management of COVID-19. Previous studies have reported poor knowledge, and awareness about the disease results in inefficient management and unexpected outcome in the patients as well as the care provider.[7],[8],[9],[10] Moreover, knowledge has shown to affect the attitudes and practices of the individuals.[11] In addition to this, it also creates a certain reticence to work among health-care professionals and may also result in contracting the infection themselves in the absence of correct information.[7] Moreover, correct and updated knowledge plays a much more important role, especially in the context of COVID-19, where the collective knowledge about the disease is rapidly evolving.

In addition to knowledge, attitude, and practice (KAP) also serve as important components in influencing the performance of HCW.[12] In order to perform the duties in an optimistic manner, a positive attitude toward the disease is most important.[10] It has been reported that globally, approximately 450,000 HCWs have been infected and 600 nurses in particularly have died due to COVID-19 while treating coronavirus-infected patients.[13] However, in addition to positive attitude, it is also necessary that HCWs remain safe and infection free during the times of the pandemic to ensure and cater to as many people possible. Hence, it is necessary to understand the practices of the HCW at the time of pandemics.

In a resource-constraint country like India where nurses-to-patient ratio is 1.3/1000 patients (ideally being three nurses per 1000 patients), it becomes much more critical that the existing staff is trained, updated about the COVID-19, and following the good practices to prevent infection among themselves.[14] Previous studies have shown that there is a great need to upgrade the existing knowledge of HCWs to overcome the challenges of patient management and also to address the associated stigma and fear of acquiring the infection through occupational exposure.[15]

At present, we do not have evidence about the current status of KAP among HCWs, particularly nursing staff from India. The present study aims at assessing the KAP among nurses working in health-care facilities across India.


  Methodology Top


Study design and setting

This cross-sectional survey was conducted among the nursing staff working in health-care facilities across India from April 22, 2020, to May 22, 2020. Due to the nation-wide lockdown at the time of data collection and following the norms of social distancing as advised by the Ministry of Health and Family Welfare, it was not feasible to undertake a community-based survey during the midst of pandemic. We collected data using a self-reported questionnaire through online survey platform SurveyMonkey.

Study population

ILBS regularly conducts training for nursing professionals across the country for various aspects related to liver diseases and has a network of nursing professionals who had participated in these training courses. This network comprises staff nurses, student nurses, and faculty nurses from 15 to 16 states who work in both government and private health-care facilities. Using this network, the link of the survey was shared through e-mail, SMS, and WhatsApp groups with nursing professional above 18 years of age, working in health-care setting (Hospitals, College of Nursing, Healthcare NGOs, and Clinics, etc.) in India.

Study tool

A 37-item, pretested KAP questionnaire consisted of four sections: demographic details, knowledge (26 items), attitude (6 items), and practice (5 items), which focused on all aspects of prevention and management related to COVID-19 infection [Supplementary File 1].

Section A consisted of demographic details such as age, gender, state, marital status, sector of health-care facility, and educational qualification. Section B included 26 items for assessing the knowledge with ten true or false questions and 16 multiple choice questions. Knowledge section was divided into five major domains:

(i) general Information regarding coronavirus (K6, K11, K12, and K14); (ii) symptoms and transmission (K2, K3, K4, and K8); (iii) infection, prevention, and control practices (K1, K5, K7, K17, K18, and K22); (iv) sample collection and bio-Medical waste management (K9, K10, K15, and K16); and (v) management of COVID-19-positive patients (K13, K19, K20, K21, K23, K24, K25, and K26). Each item was given a score of one except question K25, which had two components and was scored double making the total score of the knowledge section to be 27. Section C consisted of six questions related to attitude of HCWs, all of them had responses scored on a 3-point Likert scale of no, may be, and yes. The attitude of HCWs was assessed in two domains (i) attitude toward personal protection (A2, A3, and A4) and (ii) attitude toward the patient care (A1, A5, and A6). The responses of “No” was coded as 0, “May be” as 1, and “Yes” as 2. The total score of the attitude section ranged from 0 to 12. Section D assessed the practice using five questions having options on a 5-point Likert scale ranging from 0 to 4 (never – 0, rarely – 1, often – 2, sometimes – 3, and always – 4). The score of the practice section ranged from 0 to 20. The questions aimed at gauging the adaptability of the nursing professionals in following the safety precaution guidelines during the COVID-19 pandemic such as maintaining social distancing, cleaning of high infected areas, frequent hand wash, sequence of donning and doffing of personal protection equipment, etc.

Ethical considerations

The first page of the online questionnaire consisted of consent form which clearly stated about the background and objectives of the study. It also informed the respondent that they were free to withdraw at any time, without giving a reason, and all information provided by them would be kept anonymous and confidential.

Data management and statistical analysis

The data were extracted in excel sheet from SurveyMonkey. The personal details of the participants such as name, mobile number, and e-mail ids were excluded from the final data sheet and unique identity numbers were allotted to maintain anonymity and confidentiality of the participants. The data were coded and cleaned for data analysis.

Percentages were used to describe the proportion of HCWs who correctly answered the knowledge-related questions. Proportions of attitude and practice questions were also calculated based on the responses received on the respective Likert scales. KAP of the HCWs related to COVID-19 were assessed as scores. Since the tool was testing knowledge domain, those scoring more than >75% of the total knowledge score were considered to have “good knowledge” and those scoring <75% were considered to have “poor knowledge.” Attitude questions were categorized as optimistic if the participants selected “yes” option and was considered pessimistic for the “may be” and “no” responses.

Mean knowledge, attitudes, and practice scores were compared with demographic characteristics using independent samples t-test, one-way analysis of variance, or Chi-square test as appropriate. Pearson's correlation analysis was also performed between mean KAP scores.

The study employed univariate and multivariable logistic regression for data analyses. Univariate analysis was used to tabulate the frequency of demographic statistics along with odds ratio, their 95% confidence intervals (CIs), and P value. A binary logistic regression analysis was performed to identify and quantify the associations between the demographic factors and knowledge and attitudes. The statistical significance level was fixed to conventional value of P < 0.05 (two sided). All analyses were performed using the Statistical Package for the Social Sciences (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22 Armonk, Chicago, Illinois: IBM Corp, USA).


  Results Top


A total of 1182 responses were received through online survey across 25 states conducted during April 22, 2020, to May 22, 2020. We excluded responses of 72 individuals from the final analysis which had either incomplete or missing sections of demographic details or section related to KAP. The present study had an overall response rate of 94%. The typical time spent by a participant in filling the questionnaire ranged from 17 to 22 min. The data were analyzed for 1110 participants with a mean age of 30.2 ± 6.7 years. The study participants consisted of 68.4% of females and 31.6% were males. Approximately 44.0% of the total participants were working in the government sector whereas the remaining 56.0% belonged to private and other sectors. Of the total participants, 53.0% of the participants were graduates, 26.6% participants were postgraduates and above, whereas remaining 20.4% belonged to others category. In addition, a total of 598 (53.9%) participants were living with a partner [Table 1].
Table 1: General characteristics of the 1110 participants

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Knowledge related to prevention and management of COVID-19

The mean knowledge score was 16.82 ± 3.3 out of maximum score being 27 (range: 4–27). The correct responses received by the participants varied from as low as 20.27% to as high as 98.29% across various questions on the knowledge domain [Supplementary File 1]. The study participants scored highest in the domain assessing the knowledge related to general information about coronavirus (mean score of 2.96 out of 4) and biomedical waste management of COVID-19 (mean score of 2.98 out of 4), whereas least score was observed in domains assessing the knowledge related to the management of coronavirus patients (mean score of 3.53 out of 9), followed by infection, prevention, and control measures during the coronavirus pandemic in health setting (mean score of 3.48 out of 5). Univariate analysis suggests that knowledge level significantly varies across age, location, and type of facility currently working, whereas no significant difference was seen in knowledge score with respect to gender and education of the participants [Table 2].
Table 2: Association of demographic factors with knowledge, attitude, and practice scores related to prevention and management of COVID-19

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Knowledge score was further divided into good and poor: those scored >75% of the total score were considered to have “good knowledge” and those scored <75% were considered to have “moderate to poor knowledge.” Univariate analysis showed that the odds of having good knowledge related to COVID-19 was 2.3 (95% CI: 1.67–3.12; P < 0.001) times higher among HCW in government settings as compared to their counterparts working in private settings. Similarly, the odds of older participants (>30 years of age) have 1.63 (1.20–2.23) (95% CI: 1.20–2.23; P = 0.002) higher knowledge as compared to participants <30 years of age. The age, location, and type of facility were found to be significantly associated with knowledge. The logistic regression analysis showed that the independent predictors for having good knowledge related to COVID-19 are age, gender, location, and type of facility currently working (P < 0.001). The odds of male participants to have better knowledge related to coronavirus is 1.54 (95% CI: 1.10–2.17; P = 0.012) times the odds of female participants after adjusting for other variables [Table 3].
Table 3: Multi-variable analysis for factors affecting knowledge related to prevention and management of COVID-19

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Attitude related to prevention and management of COVID-19

The overall mean score of the attitude domain is 9.77 ± 2.03 (range: 0–12). The score of attitude domain dealing with personal protection was reported to be 5.36 ± 1.18 (range: 0–6), whereas the scores related to attitude related to patient management is 4.41 ± 1.21 (range: 0–6). The univariate analysis suggests that attitude score is significantly influenced by educational qualification of the participant (P < 0.001). The participants with higher education such as postgraduates and above (9.91 ± 1.48) had more positive attitude as compared to participants with graduation (9.81 ± 1.89) and other lower educational qualification (9.48 ± 2.62). However, difference in the attitude score in other factors such as age, gender, location, type of sector, and marital status was not found to be significant [Table 2].

The multivariable analysis was performed for all questions assessing the attitude related to patient management to explore the factors associated with it. The logistic regression performed for the questions related to the management of COVID-19, suggested males working in government facility are more willing to volunteer themselves for COVID-19 as compared to their counterpart (<0.001). However, fear and anxiousness related to COVID-19 was not found to be significant after adjusting for demographic variables suggesting anxiety related to COVID-19 among HCWs is affecting all groups equally. The logistic regression about educating the routine patients about social distancing was also not found to be significantly associated with demographic variables [Table 4].
Table 4: Association of factors associated with attitude of the participants related to prevention and management of COVID-19

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Practice related to prevention and management of COVID-19

The overall mean score of the practice domain was 18.37 ± 3.29 (range: 0–20). The practice related to prevention and management of COVID-19 significantly varies across age, place of residence, and with relationship status. The participants belonging to older age group (more than 30 years) residing in Delhi with a partner had a better practice score than their controls. The practice of management of COVID-19 is marginally affected by the type of facility currently working as it was found to be slightly better in HCWs working in government facilities (18.58±2.86) as compared to private facilities (18.21±3.60) [Table 2].

In addition to this, practice score was found to be positively correlated (P < 0.05) with knowledge score (r = 0.1526) and attitude score (r = 0.4398), whereas the knowledge was positively correlated with attitude (r = 0.1316).


  Discussion Top


The information about COVID-19 is evolving rapidly and amending on a diurnal basis, impacting prevention and management of the disease globally. HCWs (especially nurses) are the most affected by this phenomenon, as they are at the forefront, fighting against this highly contagious infection. Therefore, it is necessary that the nursing fraternity has adequate knowledge with respect to general information about the virus, transmission and its clinical manifestation, sample collection, bio-waste management, prevention and control measures, and existing management modalities. Previous studies have shown that good and updated knowledge has resulted in positive attitude and good practices among HCWs, especially during pandemics, whereas poor knowledge and incorrect beliefs have increased risk to their lives as well as their patient's lives.[16],[17],[18]

The present study sought to evaluate KAP toward prevention and management of coronavirus among frontline HCWs, specifically nurses. The results of the study disclosed moderate knowledge score of 16.82 ± 3.3, with 62.3% correct response toward prevention and management of coronavirus. The knowledge score obtained in our study among HCWs is much lower as compared to other international studies conducted in the United States (80%), Uganda (82.4%), and China (90%).[19],[20],[21] This could be attributed to the fact that these studies were conducted during early months of infection when limited amount of information was accessible and available, whereas this study is undertaken when the entire world is contributing to the knowledge pool of the virus, resulting in ample information. However, knowledge score in our study was having similar results with an Iranian study which mostly comprised doctors and medical students.[22] In addition to this, this study demonstrated the nurses had higher knowledge score related to clinical manifestation and transmission of the virus, but poor knowledge related to treatment modalities which are continuously being updated. These findings are in line with the finding of the Vietnam study suggesting the HCWs are having sufficiently fair knowledge regarding transmission and clinical manifestation of the disease caused by coronavirus.[18]

The majority of the nurses held an optimistic attitude toward the COVID-19 pandemic. Approximately 95.05% considered social distancing is important and they will educate their routine patients on importance of social distancing regularly to curb the impact of COVID-19, 93.33% believed that washing hands frequently can lower the risk of COVID-19 infection, 86.22% nurses were confident that the existing protocols will minimize the spread of COVID-19 infection to medical workforce, and around 76.92% would undertake a training on emergency related to health-care preparedness post-COVID-19. The analysis of demographic characteristics with attitude toward the management of COVID-19 patients suggested odds of male HCWs willing to volunteer themselves for COVID-19 duty is 1.51 (1.15–1.98) times the odds of female HCWs after adjusting for other variables (0.003). Similarly, odds of HCWs volunteer themselves for COVID-19 duty is 1.58 (1.16–2.13) times more in government health setting than odds of HCW working in private or any other settings (0.003).

The present study suggests a mean practice score of 18.37 ± 3.37. The practice score was found to be better in older age group (>30 years of age) as compared to the younger group. The findings of the study were supported by a similar study from Pakistan.[7] A study from Indian medical students also reported better practice in the older group.[23] This could be explained as with increasing age, experience also increases, resulting in better practices. The present study suggested that there is no difference in practice score with respect to gender. However, a study from Saudi Arabia suggested women tend to have better practice score as compared to males.[24] This inconsistency could be attributable to the fact that, in the present study, males had higher knowledge than females in our study, eventually resulting in no difference in practice score.

The study found mean knowledge score to be positively correlated with attitude (r = 0.1316, P < 0.05) and practice (r = 0.1526, P < 0.05). Mean practice score was also found to be positively correlated with attitude score (r = 0.4398, P < 0.05). These findings are supported by the previous studies undertaken in general population in Indonesia, China, and India.[25],[26],[27] This can be explained by higher knowledge results in positive attitude and good practices and similarly positive attitude results in good practices.

To the best our knowledge, this is one of the largest KAP study focusing on prevention and management of COVID-19 from India conducted during the times of pandemic. The study sample was proportionately balanced with respect to gender, as it included more females than males (2:1) similar to gender distribution of nursing staff in Indian settings.[28] In addition to this, the educational qualifications were in line with the existing proportions in India. Although the study included participants from almost all states across India, this study may not be generalizable to the HCWs working in rural and remote areas with limited access to internet and online health information resources as the questionnaire was circulated through internet and social media platforms. Furthermore, the HCWs having poor and weaker digital skills may not have attempted the online questionnaire.

Another limitation of the study is that the HCWs had a moderate knowledge score with exceptionally high practice scores which can be slightly overestimated as compared to actual practice as a tendency to provide socially desirable response. In general, social desirability is an inherent limitation of online surveys, and this could possibly explain high practice scores with modest knowledge scores.[29] An option of “may be” in responses was merged with “no” while analyzing the data as we considered being unsure as no [Supplementary File 1]. This was done to consider positive responses as those only who were sure, but the validity of this post hoc analysis was not determined. Moreover, since this was not a prevalidated survey tool, practice assessment might not be expected to correlate with knowledge assessment. However, content validation of survey questionnaire was done before initiating the study, and questions were excluded based on the same; giving the questionnaire good content validity.

Overall, despite the limitations, this was the first large-scale systematic attempt at capturing the KAP of Indian nurses with respect to prevention and management of COVID-19. The study raises concerns regarding poor knowledge about the infection, prevention, control, and management of COVID-19 patients in nursing fraternity. Moreover, anxiety and fear from COVID-19 duty affect the HCWs performance and provides resistance in working. Hence, it is necessary to design appropriate and comprehensive interventions on a national level to train the HCWs, especially the nursing fraternity; which covers all the aspects of COVID-19 but focuses more in terms of infection, prevention, control, and management. In addition, training regarding how to manage stress and anxiety to maintain good mental health during the pandemic-related crisis should also be a part of future training programs.


  Conclusion Top


The study raised concerns regarding poor knowledge about the infection prevention control and management of COVID-19 patients in nursing fraternity. Anxiety and fear from COVID-19 duty affects the HCWs performance and provides resistance in working. A comprehensive training program for HCWs focuses more in terms of infection prevention control and management and how to maintain good mental health during pandemic is required.

Acknowledgment

This research work is supported by grant from GILEAD INC under project ILBS ECHO. Authors are thankful to Dr S. K. Sarin, Director Institute of Liver and Biliary Sciences, for providing his valued guidance. We also extend our gratitude to the faculty of Institute of Liver and Biliary Sciences for their endless support.

Financial support and sponsorship

This research work is supported by grant from GILEAD INC under project ILBS ECHO.

Conflicts of interest

There are no conflicts of interest.











 
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