Public knowledge, attitudes and practices towards COVID-19

Received Jun 22, 2020 Revised Aug 19, 2020 Accepted Sep 11, 2020 In an effort to control the COVID-19 outbreak in Indonesia, the government implemented rules such as clean and healthy living behavior by all components of public, isolation, and early detection. Community knowledge, attitudes and practices (KAP) towards COVID-19 play an important role in determining the readiness of the community in accepting policies in the form of behavior change from the health authority. The aim of this study is to determine the KAP toward COVID-19 in Yogyakarta, Indonesia. A cross-sectional online survey of 155 householders was conducted between 04 May 2020 and 18 May 2020. Descriptive statistics, t-tests and one-way analysis of variance were conducted. Most public have understood about causes symptoms, mode transmission, high risk groups, isolation and quarantine, and proper use of disinfectants but people have not been able to distinguish between how to increase immunity and how to prevent COVID-19 transmission. The public has a positive belief that the government will succeed in controlling and managing a health crisis. Public behavior to prevent COVID-19 transmission is good, except the use of disinfectants and stop smoking or prohibiting family members from smoking. Differences in public knowledge, attitudes and practices towards COVID-19 occur in different gender and occupational groups.


INTRODUCTION
In December 2019, a mysterious case of pneumonia was first reported in Wuhan, Hubei Province. The source of transmission of this case is still unknown, but the first case was connected to the fish market in Wuhan [1]. From 18 December to 29 December 2019, there were five patients treated with acute respiratory distress syndrome (ARDS) [2]. From 31 December 2019 to 3 January 2020 this case increased rapidly reaching 44 cases. In less than a month, the disease has spread to other provinces in China, Thailand, Japan and South Korea [3].
The sample studied shows the etiology of a new coronavirus [2]. Initially, the disease was temporarily named as the 2019 coronavirus novel (2019-nCoV), then WHO announced a new name on February 11, 2020 namely coronavirus disease  caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus [4]. This virus can be transmitted from human to human and spread widely in China and more than 190 other countries and territories [5] On March 12, 2020, WHO declared COVID 19 as a pandemic [6]. As of May 31, 2020, there were 5.934.936 cases and 367.166 deaths consistently implementing clean and healthy behavior. They were also asked about their belief in the leadership and resources the region had to fight COVID-19. To measure practice, participants were asked yes/no about their behavior to avoid or prevent transmission and ways to increase body immunity. Data collected will be analyzed using statistical package for the social sciences (SPSS), version 16. Descriptive analysis focuses on frequency and percentage while independent sample t-test and one-way variance analysis (ANOVA) analysis are used to determine differences between groups for the selected variable, namely gender, age, and occupation. The level of statistical significance uses a p-value <0.05. Internal consistency for the knowledge variable using the reliability test with Cronbach's alpha coefficient helps in determining the reliability of the variable. The results showed that Cronbach's alpha for knowledge (12 items) was 0.688. The results add to the belief that according to Griethuijsen, the Cronbach alpha range in 0.6 to 07 is considered adequate and reliable [20]. Therefore it is proven that items used to measure knowledge about COVID-19 can be accepted.
The Ethics Committee of Respati Yogyakarta University approved our research protocol, procedures, information sheets and approval statement. Participants who agree voluntarily want to participate in the survey will sign and click the 'Continue' button and will then be directed to start filling out the questionnaire themselves.

Demographic characteristics
Demographic characteristics of respondents based on age group, gender, and occupation group are shown in Table 1

Knowledge
Twelve questions were used to measure knowledge about the COVID-19 virus with details of community knowledge about COIVD-19 as shown in Table 2. Most people have understood COVID-19 disease agent (97.42%), but most of them do not understand well the symptoms of COVID-19, especially the symptoms of dry cough and runny nose, tiredness, and headache. The community has understood that transmission of this virus through droplet transmission occurs when a person is in close contact, but only 49.68% understand that viruses can be transmitted indirectly with surfaces in the immediate environment or with objects used on the infected person and there are still respondents assuming that the virus is transmitted through air that is inhaled by humans (21.29%). The community has understood that people with any age who have serious underlying medical conditions and older age are a high risk group, but only a small proportion stated that infants under two years old, pregnancy and breastfeeding are the groups included in it. Most respondents knew that people who had contact with an infected person should be standalone isolated for a period of 14 days but most assume that if they have shown mild symptoms should be isolated at the hospital. Most already understand that disinfectants are only used on surface of objects that are often touched. The results show that the community could not distinguish between ways to increase body immunity and ways to prevent COVID-19 transmission. The results of differences in knowledge score test about COVID-19 based on demographic characteristics are shown in Table 3.  The knowledge score test about COVID-19 in women is higher than men and statistically the difference was declared significant because the p-value< 0.05. Knowledge scores by age group showed no significant difference between the ages of adolescents, adults and the elderly because the p-value> 0.05. Respondent's knowledge score based on occupational group shows that the labor group has the lowest knowledge score compared to other types of work and statistically the difference in score in that group is stated to be significant because the p-value> 0.05.
COVID-19 is a new emerging disease with aggressive spread from human to human as the main source of transmission. SARS-CoV-2 transmission from symptomatic patients occurs through droplets that  [22]. In addition, it has been investigated that SARS-CoV-2 can spread through aerosols (produced through a nebulizer) for at least 3 hours [23]. The WHO has recommended to practice airborne precautions for medical staff performing aerosol-generating procedures like intubation and the new evidence confirms it [24]. Some case reports also indicate transmission from asymptomatic careers that generally have a history of close contact with COVID-19 patients [22,25]. New infectious diseases, aggressive spread and their effects, make it critical for health authorities to plan appropriate strategies to prepare and evaluating existing programs to prepare people to have the right knowledge, attitudes and behavior to counter COVID-19 and new normal post pandemic, so that the emergence of new cases and mortality due to COVID-19 can be controlled.
The Yogyakarta public living in the Kotagede Sub-district showed a high level of knowledge about COVID-19 with the score of each question item> 70% according to research conducted in China, where more than seventy percent of study participants had good knowledge [17,18]. Based on the results of this study there are some items of knowledge about COVID-19 that are not yet fully known by the public, such as the symptoms of dry cough and runny nose, tiredness, and headache. The community still assumes that COVID-19 transmission can be airborne. Infants under two years old, pregnancy and breastfeeding are not included in the high risk group. The community considers that all people suspected of being sick of COVID-19 must be isolated in the hospital. The public has not been able to differentiate between ways to increase immunity and how to prevent COVID-19 transmission. The incomplete public understanding of COVID-19 has resulted in a lack of vigilance in controlling transmission and early detection or excessive panic due to misunderstanding of COVID-19 transmission. This condition can trigger stress and anxiety which have an impact on decreasing the immune system [26]. Besides, they highlighted that major gaps in disease knowledge could result in uncertainties and non-stringent control measures [19].
Female have better knowledge of COVID-19 than men, according to the results of research conducted in Tanzania and Chinese [27,28]. This can be caused by female show higher levels of concern about the effect the COVID-19 pandemic is having on their lives than men. The office for national statistics (ONS) has posted showing eight in ten women (79%) in Great Britain are worried about how the outbreak has impacted them [29]. The same study also shows that female are also more likely to say they are following Government guidance to avoid leaving their homes during lockdown [29]. This is inversely proportional to data showing that men are more at risk of experiencing COVID-19 because of this in a recent study, women contain more antibodies which comparatively boost their immune system relative compare men [30]. Meanwhile, smoking as well as alcohol addicts in men, this puts them a higher risk of lung cancer and other cardio vascular diseases, as it is known that SARS-CoV-2 potentially attacks the lungs, hence, the mortality rate up [31,32].
The knowledge score about COVID-19 in the labor group is the lowest compared to other group of occupation. This might indicate limited access to credible and accurate information about this virus. Variations in this level of knowledge might reflect the current COVID-19 information landscape in the country. Although health authorities have consistently disseminating COVID-19 information since the disease was first detected in Indonesia, there has also been a surge of incorrect and hoaxes information [33]. Information overload may cause confusion and difficulty verifying information. The knowledge score about COVID-19 based on age group showed no significant differences, because a lot of information about COVID-19 can be accessed through various social media. This is consistent with research conducted in America on all age groups say that there are many everyday interaction and search for information have be do be done online because of recommended limits on social contact during corona virus outbreak [34].

Attitude
Respondents were given three topic statements related to their attitude to control COVID-19 in the community. The first topic is a community attitude that consistently increases immunity so it is not susceptible to COVID-19 transmission as shown in Figure 1. The second topic are community attitudes in those who come in contact with COVID-19 patients, people returning from the epicenter area of COVID-19 and people showing symptoms of COVID-19 as shown in Table 4. Third topic about their belief in the leadership and resources the region had to fight COVID-19 as shown in Figure 1.
Most people do not agree that the behavior of not smoking or stopping smoking is one way to increase body immunity so that they are not susceptible to COVID-19. People only understand that sunbathing in the morning is the only way to increase body immunity. Community attitudes about patients suspected COVID-19, namely 1) use separate toiletries and cutlery; 2) help distribute food and logistics; and 3) self-isolated are shown in Table 4.  Community attitudes are good about people who are suspected of having COVID-19 symptoms or carrying corona virus. This is shown from the attitude of those who agree to separate the equipment used if there are family members suspected of being COVID-19. The community agreed to the rule requiring people from areas with local transmission to be self-isolated and agreed to help distribute food and logistical needs for these people. The results of this study also show about Community attitude about belief in the leadership and resources the region to fight COVID-19 as shown in Figure 2.
The community has a positive belief that the government will succeed in controlling and managing a health crisis. However, some of them are also unsure and distrustful of the ability of the government and regional leaders to control this. The difference in scores of community attitudes towards COVID-19 based on demographic characteristic and knowledge characteristics are shown in Table 5.
Scores of community attitudes against Covid-19 in women were better than men and statistically showed significant differences because the p-value <0.05. Attitude scores based on age groups showed no significant difference between the ages of adolescents, adults and elderly because of the p-value> 0.05. The attitude score based on occupational groups shows that labors have the lowest score compared to other occupational groups and statistically this difference is stated to be significant because the p-value< 0.05. Community knowledge above the mean value has a better attitude score against COVID-19 compared to community knowledge below the mean value and based on a p-value< 0.05, the difference is significant.  The present study found that a large majority of participants not agree that the behavior of not smoking or stopping smoking is one way to increase body immunity. This attitude is contrary to reports from WHO that tobacco smokers (cigarettes, water pipes, bidis, cigars, heated tobacco products) may be more vulnerable to contracting COVID-19, as the act of smoking involves contact of fingers (and possibly contaminated cigarettes) with the lips, which increases the possibility of transmission of viruses from hand to mouth [35]. There are a variety of recommendations from various literatures that can improve the body's resistance to respiratory infections, one of them stopped smoking. Smoking decreases the protective function of airway epithelium, alveolar macrophages, dendritic cells, natural killer cell (NK cells), and the adaptive immune system. Smoking can also increase microbial virulence and antibiotic resistance [36].
The community has a positive belief that the government will succeed in controlling and managing a health crisis. This condition is in accordance with research in China which shows that the positive attitude of the people due to drastic actions taken by the Chinese government to reduce the spread of the virus. In Indonesia, the government took swift action with large-scale social restrictions. The restrictions are: Work from Home, School from Home, restrict religious activities, restrict activities in public places or facilities, restrict social and cultural activities, restrict travel by various means of transportation and restrict other activities specifically related to security, prohibition of back to hometown and guard the border area between the district and province [9]. However, eighteen percent of them are also unsure and distrustful of the ability of the government and regional leaders to control this because it is significantly related to their level of knowledge and gender. The results of research in the UK show that women more concerned about the risk Coronavirus to the country [29].
Knowledge is the consciousness that humans get directly from life. Individual knowledge comes from teaching and training that is influenced by the level of education of individuals or their communities and the media designed to provide information to the public [37]. Individuals who have information will be able to determine how to make decisions and react when facing problems [38]. Epidemiological studies with various models have shown that knowledge of social distance can reduce the number of cases of respiratory infections in cases such as influenza [38].

Practices
Practices toward COVID-19 were measured using five questions enquiring on: 1) behavior to prevent transmission; 2) behavior increases body immunity; 3) behavior after returning from traveling; 4) behavior towards confirmed people COVID-19; 5) disinfecting behavior at home. Community behaviors to prevent COVID-19 transmission are shown in Table 6. The difference in scores of community practice towards COVID-19 based on demographic characteristic and knowledge and attitude characteristics are shown in Table 7. Maintain a minimum physical distance of 1-2 meters b.
Do not use public transportation c.
Just stay at home d.
Work, worship, study at home e.
Wear a mask when outside the home f.
Wash hands with soap after the activity g.
Avoid crowds h.
Do not travel out of town / abroad i.
If it sick, don't visit other people / parents j.
Immediately change clothes / take a bath at home k.
Avoid physical interactions with people who have symptoms of pain l.
Clean Practice to avoid or prevent transmission and ways to increase body immunity in women it is better than men and statistically shows a significant difference because the p-value< 0.05. Community behavior in adolescents, adults and elderly shows no significant difference because of p-value> 0.05. Knowledge of people who have scores above the mean have better preventive behavior compared to people who have knowledge below the mean value and statistically this difference is stated significant because the p-value< 0.05. Health practice is influenced by internal factors, such as knowledge, perception, emotions, motivation and external factors such as the physical and non-physical environment. Cognitive knowledge is a very important domain for the formation of individual behavior. Knowledge of social distance will underlie attitudes to take preventive actions which then influence behavior [39]. In this study, most of the public stated that they had taken action to prevent transmission, such as physical distance, stay at home, wear a mask when outside the home, wash hands with soap, avoid crowds, and not back to hometown. They also carry out behaviors to increase immunity, such as: physical exercises, bask in the morning, and rest well. This shows that there is a desire from the community to change their behavior during the COVID-19 Pandemic in Indonesia. Nevertheless, there are several other behaviors that have not been carried out by the community to its full potential such as stopping smoking/prohibiting if there are family members who smoke. This is significantly influenced by: gender, type of work, public knowledge and attitude. They assume there is no correlation between smoking behaviors with the risk of COVID-19 transmission/susceptibility in the body.
The role of work in tobacco disparity is very complex, this can be influenced by the education and income associated with the occupational. On the other hand, occupational can also reflect other factors that can facilitate a person to smoke, such as work stress, access to tobacco, and social norms that can facilitate and inhibit the use of tobacco in the workplace [40]. The results of this study are also consistent with studies conducted in China which show that smokers and non-smokers differ in terms of knowledge, attitudes, participation in tobacco promotional, and sources of social pressure. Logistic regression model identified that sex, living cost, attitudes and the environmental constraints are significantly associated with smoking [41].
A report from WHO states that smoking behavior towards COVID-19 can increase the risk of transmission, as the act of smoking involves contact of fingers (and possibly contaminated cigarettes) with the lips, which increases the possibility of transmission of viruses from hand to mouth [35]. Smokers are also more susceptible to COVID-19 for smoking any kind of tobacco reduces lung capacity and increases the risk of many respiratory infections and can increase the severity of respiratory diseases and COVID-19 is an infectious disease that primarily attacks the lungs [35,42,43]. This pandemic can be a good moment for health authorities to reduce the number of smokers in Indonesia. While cigarette smoking is decreasing all over the world, Indonesia seemed to be bucking the trend. According to a survey on regular smokers in Indonesia in 2019, has one of the highest smoking rates in the world and is one of the biggest producers of tobacco worldwide [44].
The government together with all elements of both academics and NGOs must improve information and education to the public more comprehensively about the dangers of smoking to health, especially during the COVID-19 Pandemic. Health authorities must focus more on the consistency of proactively delivering information and health education through the media and being able to eliminate misinformation. Harness the flexibility and ubiquity of media technologies to increase the public's adherence to the safety measures suggested by global health organizations to combat the spread of COVID-19. Different media industries and channels for mass communication promote adaptive responses to foster positive health attitudes and adherence to preventive measures [45,46].

CONCLUSION
The results of this study can provide comprehensive information about Indonesian public knowledge, attitudes and practice towards COVID-19. This research shows that the Indonesian public has good knowledge to prevent COVID-19 transmission. Most have positive attitude towards the government in handling the COVID-19 pandemic in Indonesia and most have shown good practice to prevent transmission and increase immunity. However, if the knowledge, attitudes and behavior of the public towards the dangers of COVID-19 are not comprehensive, the risk of new cases and the speed of transmission will still arise. Therefore, consistent information and education from the health authorities and/or government to the community is the key to controlling COVID-19 transmission. In addition, public categories based on demographic characteristics need to be identified so that information and education are right on target.