Knowledge, Attitude and Practices (KAP) Regarding the Prevention against COVID–19 Infection at the Outset of Outbreak in Pakistan Amongst Smart Phone Users

Background and Objective: At the outset of outbreak of Coronavirus disease-19 (COVID-19) infection in Pakistan, there had been a lot of confusion regarding the preventive measures in general public. The objective of current study was to determine the knowledge, attitude and practices regarding the home preventive measures against COVID-19 infection amongst smart phone users at the outset of outbreak in Pakistan. Methods: It was a cross-sectional online survey to determine the knowledge, attitude and practice amongst the smart phone users regarding the preventive measures against Corona infection. Total 388 questionnaires were submitted in one week in first week of April 2020. The data was collected through online questionnaire which were disseminated through WhatsApp groups. The completed questionnaires were compiled and analysed by using SPSS software version 21. Frequencies of responses were calculated. Results: A total of 196 (50.5%) participant were in the age category of 17–25 years with female predominance. Three hundred and 66 (94.3%) preferred washing hands with soap and water for 20 or more seconds, two thirds of the participants also agreed on the role of sanitizers. Only 159 (41%) knew what social distancing meant. Regarding the disinfection of eatable and non-eatable, almost half of the participants agreed to use soap and water. Considering the most effective disinfectant, 225 (43.8%) preferred Dettol. Surgical mask and N-95 masks were considered the effective ways to avoid droplet infections. Regarding the survival of the virus in different media, majority of the responses were completely ignorant. Conclusion: There are still gaps in knowledge, attitude and practices regarding prevention against Coronavirus infection at the outset of this out-break in Pakistan.


INTRODUCTION
Coronavirus infection is an acute respiratory tract infection caused by a newly discovered Coronavirus which affects nearly 210 countries around the globe. 1 According to World Health Organization (WHO) statistics, it has emerged as a pandemic in a very short span of time with a very grave public health issue. 2 The world has faced similar pandemics in past like severe acute respiratory syndrome Coronavirus (SARS-CoV) in 2002-2003, H1N1 influenza in 2009, Middle East respiratory syndrome Coronavirus (MERRS-CoV)in Saudi Arabia in 2012. 2 As of 15 th May, 2020 there has been around 37,218 confirmed cases and 803 individuals have lost their lives in Pakistan and figures are rising every day. 3ovel Coronavirus is a single stranded RNA virus, which is a zoonotic disease and has led to human infection predominantly through air droplets. 4Initially patients suffering from Coronavirus presented with pneumonia of unknown origin lateron the Chinese Center of Disease Control and Prevention declared that the illness was due to novel virus of Coronavirus family also called COVID-19. 5It can present as common cold to severe disease such as adult respiratory distress syndrome. 4s of today, there has been no definitive treatment and specific protection against this infection;only health education and preventive measures can play an important role in the impediment of the spread of this infection. 6ifferent health agencies both international and national have played pivotal role in dissemination of information through electronic, print and social media in the development of awareness regarding the preventive measures like frequent hand washing, covering the nose and mouth with mask, use of disinfectants and maintenance of social distancing. 1,7Apart from valid information a lot of myths are also circulating through social media. 8his survey was conducted in first week of April 2020, when the number of cases was steadily rising in Pakistan and awareness regarding the preventive measures was at a very preliminary stage.Thus, the objective of the current study was to determine the knowledge, attitude and practices about the home preventive measures against this deadly diseaseamongst the smart phone users.

METHODS
This cross-sectional online survey was conducted by the Department of Community Medicine at Fatima Memorial College of Medicine and Dentistry, Lahore after an Institutional Ethical Approval.The aim was to determine the knowledge, attitude and practice of smart phone users between age group of 15-60 years of both genders, regarding the preventive measures against Coronavirus infection.An online questionnaire using Google Forms was developed and distributed through WhatsApp contacts of the authors of this study.All participants were requested to forward the questionnaire to as many contacts as possible.The survey comprised of a total of eighteen questions, the first three about the demography of respondents, and the rest regarding the knowledge, attitude and practises of home preventive measures.The questions were developed from the perspective of an educated smart phone user who has access to the internet resources, and the availability of local products that act as disinfectants, cleaning products and personal protective equipment (PPE) recommended for general public by WHO and centre for disease control (CDC).The survey was conducted from the1 st to the 7 th of April, 2020.

STATISTICAL ANALYSIS
The completed questionnaires were compiled and analysed by using SPSS software version 21.
Frequencies of different responses were calculated.

RESULTS
Total Likewise, 142 (36.6%) considered that it stayed on plastic and wood for less than or equal to 72 hours (Fig: 1).Moreover, 154 (39.7%) said that in stayed in air for less than or equal to 2 hours (Fig: 1).More than one-third, 155 (39.9%), of the respondents considered health professionals, while almost the same number chose social media as the most beneficial source of information for awareness about the spread of COVID-19 (Fig: 2).

DISCUSSION
From the day Coronavirus infection was declared as pandemic, panic has been observed in people around the world.People are getting scared by observing the increasing trend of mortality related to it and are getting information regarding its prevention from different sources but still are confused because of information overload and lack of authenticity.When this study was conducted, it was the second week of lock down in Pakistan and general perception was that level of awareness was not up-to the mark.However, the results of the current study showed that 95% of the participants agreed that proper hand washing with soap and water for 20 or more seconds could be able to kill this virus which is also supported by the literature that soap can dissolve the lipid layer of Coronavirus thus leading to its desiccation. 7As the virus can survive on hand and body surfaces of the cases after sneezing and coughing so by simple hand washing can prevent its spread to healthy contacts. 9A study from Saudi Arabia conducted few years back after MERS-CoV about knowledge attitude and practices amongst individuals visiting shopping malls showed that people were well aware about preventive measures as shown in our study as well. 10While a recent study done in Chicago, USA amongst patients visiting 5 different out-patient clinics showed that one third were not aware of the preventive measures. 11It is reassuring that overall more than one third of the respondents in our survey were well worse with appropriate preventive measures.
Considering the importance of sanitizers in prevention, more than two third of the current study participants agreed that hand sanitizer could be effective while 16% were unsure.The data from the Communicable Disease Control agency in USA supported that alcohol or ethanol based sanitizers with more than 70% consistency can be very effective in killing the virus. 5,12This can be utilized very effectively in the prevention of spread of virus in health facilities. 13So, it will be more appropriate that alcohol based sanitizers to be used in health care settings as well as in places where there is no access to hand washing. 14As far as the general population awareness is concerned, it is not surprising that before this pandemic people were not aware about its use as disinfectant in daily routine. 15Therefore, it is worth to emphasize here that social and print media has been very instrumental in spreading its awareness at least amongst the segment of society represented in our study.However, the same cannot be generalized to less privileged and uneducated class.
The role of disinfectants in prevention of spread of virus or bacteria is not new. 2 Different disinfectants have been used since ages.The oldest and time-tested disinfection is exposure to sunlight which kills many bacteria and virusdue to its ultra violet light or to treat with chemicals. 16Before this pandemic, there was suboptimal use of disinfectants at all levels.The results of current study also suggested that about almost half of the respondent agreed to wash eatables with soap and water and to treat non-eatable products with chemicals which is in line with the guidelines. 17In the current situation of pandemic, it has been communicated through reliable agencies like WHO and CDC that Coronavirus can be transferred to households through contamination of eatable and non-eatable if handled by an infected person. 1,5,18Moreover, it stays on these products for many hours.The results of current study suggested that knowledge of respondents regarding the survival of virus on different surfaces was unsatisfactory.Hence it is recommended to either wash the eatables before use or to leave the product for at least 72 hours which kills the virus on them according to the product specification. 8he knowledge of common individual was scanty regarding which chemical disinfectant was most suitable for disinfection. 12In this regard, print and social media has created many confusions.However, there is an unmet need of evidence-based guidelines on use of various chemical disinfectants commercially available in the market. 19s Coronavirus spreads through droplets, so use of face mask was one of the earliest preventive measures which were communicated. 20But very soon the confusion arose about the type of mask which was found to be most effective.People developed the misconception that only N95 and surgical mask were most suitable one which led to scarcity of these mask for health professionals.The results of current study also depicted the same picture.Now it is highly recommended by the concerned health authorities that its spread can be prevented by any cloth face covering and specialized mask like surgical and N95 should be spared only for the front-line health care providers. 21Moreover, it is worth to emphasize here that there is great need to make people aware that this infection can be asymptomatic and still a person can spread the infection, which can only be prevented if everyone will use face mask and maintaining social distancing.
The word social distancing has also gained enough popularity during this pandemic. 22The public health domain of prevention has always emphasized on avoidance of overcrowding which play a major role in spread of many airborne infection not only Coronavirus. 9When participants were asked about the true definition of social distancing, results of current study suggested that more than half of the participants didnot have its understanding, and confused social distancing with self-isolation.According to CDC, social distancing is maintaining a distance of 6 feet or more with everyone at all times and avoiding public gatherings. 15,23Now data from the entire world has proven that the mode of transmission of this highly contagious virus can only be done by practicing social distancing. 23his was understandable that awareness about the time virus survives on fomites and surfaces and proper use of disinfectants for surfaces was inadequate due to lack of consensus amongst different sources. 19More than half of the subjects believed that Dettol had the ability to disinfect surfaces from Coronavirus.To date there is no laboratory study on present strain of Coronavirus, however studies on previous strains have shown 99.9% disinfection. 19On the other hand, CDC suggests using alcohol wipes and household bleach in diluted form with a stay time of at least few minutes. 23In the light of new information that Coronavirus can survive for considerable long period on metallic surfaces, there is an un-met need to do comparative laboratory studies on virucidal properties of various disinfectants.
This was re-assuring that more than one third of the respondents believed that source of information about preventive measures was being imparted to them by health professionals and almost same felt that they were being informed through social media. 24It is noteworthy that when preventive measures are disseminated on social, print or ecteronic media through health care professional, it might have better and stronger impact.

CONCLUSION
There are still gaps in knowledge attitude and practices regarding prevention against Coronavirus infection at the outset of Coronavirus infection outbreak in Pakistan.

LIMITATIONS OF STUDY
Data was collected online, from the smart phone users due to current situation of pandemic, so results cannot be generalised to general public of Lahore city, at large.Future prospective study should be conducted with large sample size and involving subjects from all classes of society, in order to generalize the results.

Fig. 1 :
Fig.1: Frequency distribution of responses regarding survival of virus in different Medias.

Fig. 2 :
Fig.2: Frequency distribution of responses regarding different sources of information.
Table-2).Considering the most effective disinfectant for surfaces, 225 (43.8%) answered in favour for Dettol (Table-2).Regarding the use of PPE by an individual while going to a public place, surgical mask and N-95 masks were considered the effective masks to be used (Table-2).
Biomedica -Vol.36,COVID19-S2.2020Nevertheless,379(97.7%) agreed on the benefit of social distancing (Table-2).Out of the total, 342 (88%) participants were aware of the role of disinfection in prevention of spread of disease (Table-2).Regarding the disinfection of eatables and non-eatables, almost half of the participants agreed to use soap and/or water for cleaning them (