Introduction

The coronavirus disease 2019 (COVID-19) is an emerging viral respiratory disease first reported in December 2019 in Wuhan, China, and has spread worldwide (1). The COVID-19 is highly contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) (2). The SARS CoV-2 belongs to a wide ranging family of virus, containing positive-sense single standard RNA, and genetically close to bat coronavirus (3). Due to rapid spread of this deadly disease to many countries, the World Health Organization (WHO) declared it as Public Health Emergency of International Concern (PHEIC) on 30 January 2020. Later, on March 11, the WHO declared COVID-19 as a pandemic, after affecting over 110 countries and territories around the world (4). As of 18 August 2021, the global count of COVID-19 confirmed cases are 209,413,871 with 4,395,176 deaths (5).

In Pakistan, the first confirmed case of COVID-19 was reported on 26 February 2020, in an individual with a travel history to Iran. By 20 May 2020, Pakistan had 45,898 laboratory confirmed cases with 985 COVID-19 associated deaths. Sindh Province had the highest number of cases (n=17,947) followed by Punjab (n=16,685), Khyber Pakhtunkhwa (n=6,554), Baluchistan (n=2,885), Islamabad (n=1,138), Gilgit Baltistan (n=556), and Azad Jammu Kashmir (n=133) (6).

COVID-19 can spread through direct, indirect and close contact with an infected person through saliva or droplets, when an infected person coughs, sneezes and talks. The incubation period of the virus is 4-14 days (7). The main clinical symptoms of COVID-19 are fever, dry cough, fatigue, myalgia and difficulty in breathing (8). Other symptoms like loss of the senses of smell and taste were also reported in some cases (9), while some people have experienced nasal congestion, diarrhea and runny nose (10).

The elderly and persons with chronic medical ailments like diabetes, cancer and cardiovascular diseases are more likely to get severe infection (11). Several vaccines are being used to prevent and control COVID-19 all over the countries (12). Infection can also be prevented as per recommendations including frequent hand washing with soap and water or alcohol-based sanitizers, maintaining physical distancing from others, covering coughs and sneezes to protect others and avoiding hands away from mouth, nose and eyes (12, 13).

Islamabad and Rawalpindi have also been affected by COVID-19 epidemic. Many preventive measures have been adopted to control the virus in the twin cities including suspension of local transport, closing of public places, ban on crowds, establishment of the quarantine centers and isolation facilities. On 23 March 2020, the Government of Pakistan declared a smart lockdown all over the country including Islamabad and Rawalpindi (14).

The residents of Islamabad and Rawalpindi were advised to stay at home to avoid close contact with others. To ensure the ultimate success, the citizen’s devotion to these control measures is important which is generally influenced by their knowledge, attitudes and practices (KAP) to COVID-19 according to KAP theory (15).

The aim of the study was to identify the current status of the knowledge, attitudes and practices regarding COVID-19 among general population of twin cities in Pakistan during the rapid rise period of the COVID-19 outbreak.

Methodology

Participants

This cross-sectional survey was conducted from 5 to 19 May 2020, the week during smart lockdown in Islamabad and Rawalpindi, Pakistan. Because it was not feasible to do a community-based national sampling survey during this special period, we decided to collect the data online.

This web-based survey was carried out through various social media platforms by relying on the authors' networks with local people living in the twin cities. By clicking on the link, the participants could view the questions and answer them. A three-page questionnaire was posted/reposted on groups of their WhatsApp and Facebook accounts. This questionnaire contained a brief introduction on the background, objective, procedures, voluntary nature of participation, declarations of anonymity and confidentiality, and notes for filling in the questionnaire, as well as the link and quick response (QR) code of the online questionnaire. Persons who were of Pakistani nationality, were aged 18 years or more, understood the content of the poster, and agreed to participate in the study were instructed to complete the questionnaire via clicking the link or scanning the QR code. The questionnaire was distributed by local residents; only residents from Islamabad and Rawalpindi were given access to fill this questionnaire.

The Ethics Committee of the National Institute of Health (NIH) approved our study protocol and procedures of informed consent before the formal survey. Participants had to answer a yes-no question to confirm their willingness to participate voluntarily. After confirmation of the question, the participant was directed to complete the self-report questionnaire.

Measures

The questionnaire consisted of two parts: demographics and KAP. Demographic variables included age, gender, marital status, education, occupation, and place of current residence (area). The survey was answered by 1,282 participants anonymously during the above-mentioned period.

According to guidelines for social distancing, wearing face mask, home isolation, and clinical management of COVID-19 by the Ministry of Health Services Regulation and coordination – Government of Pakistan (GoV), a COVID-19 knowledge, attitude and practice questionnaire was developed by the authors. The questionnaire had 14 questions (Table: 1): 5 regarding clinical presentations (K1-K5), 6 regarding prevention, control and transmission (K6-K11), 1 regarding isolation (K12) and 1 regarding vaccine of COVID-19. These questions were answered on a true/false basis with an additional “I don't know” option. A correct answer was assigned 1 point and an incorrect/unknown answer was assigned 0 points. The total knowledge score ranged from 0 to 14, with a higher score denoting a better knowledge of COVID-19. The Cronbach's alpha coefficient of the knowledge questionnaire was 0.71 in our sample, indicating acceptable internal consistency.

Statistical analysis

Frequencies of correct knowledge answers and various attitudes and practices were described. Knowledge scores, attitudes and practices of different persons according to demographic characteristics were compared with independent-samples t test, one-way analysis of variance (ANOVA), or Chi-square test as appropriate. Multivariable linear regression analysis using all the demographic variables as independent variables and knowledge score as the outcome variable was conducted to identify factors associated with knowledge regarding COVID-19. Data analyses were conducted with SPSS version 21.0. The statistical significance level was set at p < 0.05 (two-sided).

Results

Table 1

KAP questionnaire

Knowledge(True, False, Don’t know) Percentage (%)
K1: The main clinical symptoms of COVID-19 are fever, cough, and breathing difficulty. 95
K2: Do you think runny nose and sneezing are also symptoms of COVID-19 virus. 39
K3:Do you think early deduction and supportive treatment can recover patients from the infection? 90
K4: Persons with COVID-19 cannot infect to others when fever is not present. (6%) 6
K5: The COVID-19 spreads through coughing, sneezing and touching contaminated objects. 96
K6: Surgical mask could be used to prevent COVID-19? 84
K7: To prevent the infection, individuals should avoid going to crowded places such as train stations, shopping malls and avoid taking public transportations. 98
K8: : It is not necessary for children and young adults to take social distance measure to prevent the infection by COVID-19. 16
K9: Isolation (social distancing and stay at home) is an effective way to reduce the spread of the virus. 98
K10: The COVID-19 will be controlled by practicing hand washing, social distancing, and staying at home. 98
K11: The COVID-19 will be controlled by avoiding travelling across/within country during this outbreak. 94
K12: People having contact with COVID-19 patient should be immediately isolated in a proper place. 96
K13: The COVID-19 vaccine is available against this virus. 4
Attitude (Agree, Disagree, Don’t know)
A14: Do you agree that lockdown strategy can finally controlled the spread of COVID-19 virus? 41
A15: Do you have confidence that Pakistan can win the battle against the COVID-19 virus? 59
Practice (Yes, No)
P16: In recent days, have you gone to any crowded (social or religious) place? 25
P17If you have fever or cough, would you like to isolate/quarantine yourself? 86
P18: During COVID-19 outbreak, have you reduced the outdoor activities? 95

A total of 1,282 participants completed the survey questionnaire. Among this final sample, the average age was 30.65 years (standard deviation (SD): 10.42, range: (16-73) and 764 (60%) belonged to age group 16-30 years, 680 (53%) were women, 1,096 (86%) held a bachelor’s degree or above, 634 (50%) were engaged with government and private sector and 606 (47%) were married (Table 2). The correct answer rates of the 13 questions on the COVID-19 knowledge questionnaire were 68.3-96.6% (Table 1).

Table 2

Characteristics of participants

Characteristics Number of participants (%) Mean knowledge score ± standard deviation p-value
Gender Male 602 (47) 9.01 ± 1.62 0.031*
Female 680 (53) 9.27 ± 0.99
Age-group (years) (16-30) 764 (60) 9.15 ± 1.14 0.036*
(31-45) 388 (30) 9.21 ± 1.06
(46+) 130 (10.1) 8.89 ± 1.822
Marital status Married 606 (47.3) 9.17 ±1.25 0.0345*
Unmarried 654 (51) 9.09 ± 1.18
Others^ 22 (1.7) 9 ± 0.27
Education Intermediate and below 186 (14.5) 8.83 ± 1.38 0.001***
Graduate 558 (43.5) 9.19 ± 1.21
Higher (masters & above) 538 (42) 9.18 ± 1.12
Occupation Employed 634 (49.5) 9.17 ± 1.28 0.315
Unemployment 276 (21.5) 9.15 ± 1.14
Student 372 (29) 9.05 ± 1.28
Area of Residence Urban 1050 (82) 9.10 ± 1.18 0.399
Rural 232 (18) 9.14 ± 1.21

Table 3

Regression analysis

Characteristics Coefficient p value
Gender (male vs. female) -0.191 0.001***
Age-group (16-30 vs. 31-45) years 0.050 0.625
(46+ vs. 31-45) years -0.313 0.011*
Marital status (married vs. unmarried) 0.113 0.267
(others vs. unmarried) 0.368 0.188
Education (Intermediate and below vs. higher) -0.302 0.011*
(Graduate degree vs. higher) 0.006 0.958
Occupation (employment vs. unemployment) 0.006 0.958
(Student vs. unemployment) -0.014 0.918
Area of Residence (urban vs. rural) -0.029 0.021*

Multiple linear regression analysis showed that male gender (vs. female, β: -0.191, p <0.001), age-group of 46 and above years (vs. 31-45 years, β: -0.313, p <0.05), education of intermediate and below (vs. higher (master degree & above), β: -0.302, p <0.05), and area of residence urban (vs. rural β: -0.029, p <0.05) were significantly associated with lower knowledge score, however occupations: employment (vs. unemployment β: 0.006, p >0.05), student (vs. unemployment β: -0.014, p >0.05) and marital status: married (vs. unmarried β: 0.113, p >0.05), others (included separated, widowed and divorced) (vs. unmarried β: 0.368, p >0.05) had no significant effect on poor knowledge score. (Table 3).

Table 4

Attitudes towards COVID-19 by demographic variables

Characteristics Attitudes, n (%)
A1: Success in controlling COVID-19 p-value A2: Confidence of winning battle against COVID-19 p-value
Agree Disagree Don't know Agree Disagree Don't know
Gender Male 326 (48) 248 (37) 106 (15) 0.001*** 434 (64) 142 (21) 104 (15) 0.001***
Female 198(33) 270(45) 134 (22) 320 (53) 148 (25) 134 (22)
Age-group (years) (16-30) 308 (40) 316 (41) 140 (18) 0.766 484 (63) 38 (29) 30 (23) 0.001***
(31-45) 160 (41) 156 (40) 72 (19) 208 (53) 106 (27) 74 (19)
(46+) 56 (43) 46 (35) 28 (22) 62 (48) 10 (46) 4 (18)
Marital status Married 256 (42) 234 (39) 116 (19) 0.002*** 324 (54) 150 (25) 132 (22) 0.001***
Unmarried 266 (41) 266(41) 122 (19) 422 (65) 132 (20) 100 (15)
Others^ 2 (9) 18 (82) 2 (9) 8 (36.4) 8 (36.4) 6 (27.3)
Education Intermediate and below 88 (47) 62 (33) 36 (19) 0.083 132 (71) 281 (15) 26 (14) 0.001***
Graduate 236 (42) 226 (41) 96 (17) 342 (61) 128 (23) 88 (16)
Higher (masters & above) 200 (37) 230 (43) 108 (52) 80 (52) 134 (25) 124 (23)
Occupation Employment 234 (37) 278 (44) 122 (18) 0.015** 326 (51) 162 (26) 146 (23) 0.001***
Unemployment 112 (41) 108 (39) 56 (20) 164 (59) 56 (20) 56 (20)
Student 178 (48) 132 (36) 62 (17) 264 (71) 72 (19) 36 (10)
Area of Residence Urban 404 (39) 440 (42) 206 (20) 0.001*** 162 (70) 44 (19) 26 (11) 0.001***
Rural 120 (52) 78 (34) 34 (15) 592 (56) 246 (23) 212 (20)
^“Others” included separated, widowed and divorced
*P< 0.05, **P<.01, ***P<0.001.

Approximately half of the respondents agreed that COVID-19 will finally be successfully controlled (41%) and half of the respondents disagreed (40%). The attitude towards the final success in controlling COVID-19 significantly differed across genders, education levels, occupation categories, marital status and residence places (p <0.05) (Table 4).

The majority of the respondents agreed that COVID-19 will finally be successfully controlled (59%). Percentages of reporting “disagree” and “I don’t know” were 23% and 18%, respectively. The attitude towards the final success in controlling COVID-19 significantly differed across genders, age groups, education levels, occupation categories, marital status and residence places (p <0.05) (Table 4).

Table 5

Practices towards COVID-19 by demographic variables

Characteristics Practices, n (%)
P1: Going to a crowded place p-value P2: With fever/cough quarantine yourself p-value P3: Reduce the outdoor activities p-value
Yes No Yes No Yes No
Gender Male 210 (31) 470 (69) 0.001*** 568 (84) 112 (16) 0.001*** 630 (93) 50 (7) 0.001***
Female 116 (19.3) 486 (81) 540 (90) 62 (10) 584 (97) 18 (3)
Age-group (years) (16-30) 196 (26) 568 (74) 0.809 656 (84) 30 (16) 0.212 720 (94) 44 (6) 0.454
(31-45) 100 (26) 288 (74) 344 (89) 84 (15) 372 (96) 16 (4)
(46+) 30 (23) 100 (77) 108 (89) 60 (11) 122 (94) 8 (6)
Marital status Married 148 (24) 458 (76) 0.732 526 (87) 80 (13) 0.783 580 (96) 26 (4) 0.012*
Unmarried 172 (26) 482 (74) 564 (86) 90 (14) 616 (94) 38 (6)
Others^ 6 (27) 16 (73) 18 (82) 22 (17) 181 (82) 4 (18)
Education Intermediate and below 136 (24) 422 (76) 0.069 156 (84) 30 (16) 0.092 164(88) 22 (12) 0.001***
Graduate 60 (32) 126 (68) 474 (85) 84 (15) 528 (95) 30 (5)
Higher (masters & above) 130 (24) 408 (76) 478 (89) 60 (11) 522 (97) 16 (3)
Occupation Employed 158 (25) 476 (75) 0.661 548 (86) 86 (14) 0.722 598 (94) 36 (6) 0.833
Unemployment 92 (25) 280 (75) 242 (88) 34 (12) 262 (95) 14 (5)
Student 76 (28) 200 (73) 318 (86) 54 (14) 354 (95) 18 (5)
Area of Residence Urban 68 (29) 164 (71) 0.134 920 (88) 130 (12) 0.007** 996 (95) 54 (5) 0.34
Rural 258 (25) 792 (75) 188 (81) 44 (19) 218 (94) 14 (6)
^“Others” included separated, widowed and divorced.
*P<0.05, **P<.01, ***P<0.001.

The majority of the participants had not visited any crowded place (74%), isolated their selves in case of fever/cough (86%) and reduced outdoor activities (95%) during study period. The practice attribute of respondents: visiting to any crowded (social or religious) place significantly differed across gender i.e. (p <0.05). Likewise, the attribute of adopting isolation/quarantine in case having cough or fever differed significantly across gender and area of residence (p <0.05). Similarly, the practice attribute of reducing outdoor activities significantly differed across gender, marital status and education level i.e. (p <0.05) (Table 5).

Discussion

COVID-19 spread in the vulnerable population due to less knowledge and very diverse public opinion about the disease. (10). There has been limited published data on population knowledge, attitudes and practices toward COVID-19, especially in Pakistan. A lot of misinformation and uncertainty made this disease critical for health authorities to execute pertinent strategies and supervise the public opinion and practice (16). The present study found variation in opinion and beliefs of the respondents regarding COVID-19. The assessment of knowledge, attitudes and practices (KAP) towards COVID-19 was made by collecting data from the respondents of twin cities (Islamabad and Rawalpindi) in Pakistan.

Mostly young adults responded to this online KAP survey because the use of social media platforms and mobile phones is more common in the younger generation (17). We observed more response from the urban area of the twin cities where the respondents could easily access the internet services. It was found that the rate of correct responses of the COVID-19 knowledge questionnaire was high enough to indicate that most study participants had sufficient basic knowledge about COVID-19. Similar findings were observed in a study conducted by Al-Hanawi in KSA demonstrated correct answer rate 81.64% (18).

Among the participants, 95% were aware of the clinical symptoms and 90% knew that, with early detection and supportive treatment, patients can recover from the infection. The reason behind this is that most of the participants in our survey were educated i.e., they were holding a bachelor’s degree or above, and media played an important role in spreading information and creating awareness regarding COVID-19 (19). This reasoning is supported by another study which describes that more educated respondents are more knowledgeable about emerging communicable diseases (20).

As the questionnaire was being distributed amid the COVID-19 outbreak in the country, at that time people may have got awareness and knowledge about the disease and its spread, via print and electronic media (21). Moreover, public awareness campaigns launched by the Government of Pakistan along with the NIH also helped to improve the understanding of the general public regarding COVID-19 (22). Studies conducted in China (23) and Pakistan (24) also found similar results. Almost all the participants were aware of the fact that hand washing, social distancing and staying home are effective measures and help to prevent the spread of COVID-19. The WHO has already advised the same preventive measures to limit the spread of COVID-19 (25).

With reference to attitude, an optimistic approach was shown by participants toward COVID-19, many of the participants believed that COVID-19 will finally be successfully controlled. This positive attitude may be developed with some measures like imposing partial lockdown (14), suspended flight operation for specific time periods (26), closure of all educational institutes (27) and all non-essential markets (28) and launch of awareness campaigns using print and electronic media. Moreover, the knowledge of study participants about COVID-19 was higher, which also supports this belief. This finding agrees with another study held in China relevant to higher level of knowledge, trust and reasonable attitude towards interventions taken by the government during health emergencies (29).

Our results demonstrated that a majority of the participants took appropriate preventive measures against COVID-19 by avoiding going to crowded and religious places. The percentage of males (31%) visiting crowded places was higher than that of females (19.3%). In the local setting, the male population is involved in repeated outside movements for household, financial, trading and transportation purposes. Risk of exposure among males may be higher than among females in Pakistan. Females are more likely to self-quarantine when sick with fever or cough, as compared with males who feel cough or fever.

Association between educational level and reduction of outdoor activities for prevention and safety was assessed. Negative association (p=0.001) was found between education level and reduction of outdoor activities. As with increased education level, the tendency of going out seems to be reduced.

Conclusion

This study provided detailed information about the knowledge, attitude and practice regarding COVID-19. The study findings suggest that residents of Islamabad and Rawalpindi have reasonable level of knowledge on COVID-19. However, it is necessary to launch enormous health education and awareness campaigns to improve the knowledge and practices about COVID-19, to control its transmission.

Limitations

Due to the lockdown, we were not be able to approach more groups of people with low levels of education, elderly, and general public in the communities which would have generated diverse findings.

The data collection process was based on internet applications like WhatsApp and Facebook accounts. Social media is less likely used among individuals with old age and those who are uneducated for the research purposes. So, the study covers response mostly form young adults who were familiar with use of internet and smartphone technology.

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