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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 14-20

Knowledge overload versus actual practices: Knowledge and awareness about COVID-19 infection among patients attending the emergency services of a tertiary care hospital during the COVID “lockdown” period


1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission14-Jun-2020
Date of Decision18-Jun-2020
Date of Acceptance21-Jun-2020
Date of Web Publication7-Oct-2020

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_57_20

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  Abstract 


Background: It is essential to assess the knowledge and awareness about COVID-19 infection among people utilizing the emergency health-care services. Aim: This study aimed to evaluate the knowledge and awareness about COVID-19 infection and the practices followed by the patients and their caregivers with respect to prevention of spread of COVID-19. Methodology: A cross-sectional exploratory study was conducted in the emergency outpatient services of a tertiary care center using a brief self-designed questionnaire. Results: More than half of the participants considered that touch and coming in contact with a person with cough/cold were the most common mode of spread of the infection, but many others had several misinformations regarding the exact mode of transmission. Three-fourth of the participants thought that wearing a mask is required to protect oneself from getting infected, while handwashing and social distancing as important precautionary measures were reported by only half and one-fourth of the participants respectively. Only half of the participants used masks during traveling to the hospital and one-third reported of sanitizing hands during travel and only half of the participants reported of having knowledge about using surgical masks and sanitizers in emergency premises, and only two-fifths thought social distancing to be a precautionary measure to follow in the emergency setting. Conclusions: The study findings highlight the need to improve awareness programs so as to improve the knowledge and practices of medically ill patients and their caregivers attending the emergency services.

Keywords: COVID-19, emergency, knowledge, practices


How to cite this article:
Sahoo S, Mehra A, Jagota G, Suman A, Kumari S, Dhibar DP, Sharma N, Kumari S, Grover S. Knowledge overload versus actual practices: Knowledge and awareness about COVID-19 infection among patients attending the emergency services of a tertiary care hospital during the COVID “lockdown” period. J Mental Health Hum Behav 2020;25:14-20

How to cite this URL:
Sahoo S, Mehra A, Jagota G, Suman A, Kumari S, Dhibar DP, Sharma N, Kumari S, Grover S. Knowledge overload versus actual practices: Knowledge and awareness about COVID-19 infection among patients attending the emergency services of a tertiary care hospital during the COVID “lockdown” period. J Mental Health Hum Behav [serial online] 2020 [cited 2020 Dec 1];25:14-20. Available from: https://www.jmhhb.org/text.asp?2020/25/1/14/297421




  Introduction Top


The COVID-19 outbreak since December 2019 and its subsequent transformation into a Pandemic had resulted in several challenges to humanity and the health-care system across the World. As per the recent World Health Organization (WHO) Statistics (as on April 18, 2020), COVID-19 has infected more than 22 lakh individuals in 213 countries with more than 1.5 lakh deaths worldwide.[1] The WHO and national authorities of every country have been using various strategies to tackle the COVID-19 infection and minimize the associated mortality. To tackle with the increasing spread of the infection across the country, in India, a nationwide “lockdown” was announced since the midnight of March 24, 2020.[2] Lockdown strategy implies prevention of free movements of the public in an area/locality. In this scenario, all educational institutions, shopping arcades, factories, offices, local markets, transport vehicles, airports, railways, metros, buses, etc., are completely shut down except hospitals, police stations, emergency services such as fire station, petrol pumps, and grocery shops, etc. In addition to it, time and again since the beginning of COVID-19 cases in India, there has been promotion of various infection control measures such as frequent practice of hand hygiene measures, creating awareness about COVID-19 infection over mobile caller tunes/telecommunication/social media platforms/radio, social distancing, using masks while going out from home, precautions during coughing/sneezing and frequent monitoring of passengers by thermal scanners, etc.[3],[4] However, it is not clear, how much this has percolated to the level of the general public and to what extent these strategies are being followed.

Due to lockdown, at many places, the outpatient services have been suspended and the medical services at many places are limited to emergency services. All these are understandable as part of the preventive measures. Due to this, overcrowding in the outpatient areas has stopped, and the risk of transmission has been minimized. People requiring medical help are being provided services through the telemedicine facilities, although these are still in its nascent phase in many parts of the country.[5]

Despite all these, a small subgroup of patients are still being brought to the emergency services, either for acute medical-surgical emergencies or for management of relapse of their ongoing chronic illnesses.[6],[7] These people who are visiting the emergency services can be considered as a source of infection for the parts of hospital which are not being used for patients diagnosed with or suspected to have COVID-19 infection and at the same time can be considered as vulnerable to develop infection, if they do not follow the required precautions. Hence, it is important to understand their awareness with respect to various aspects of COVID-19 infection. Understanding their awareness and practices can help in evaluating the usefulness of the current awareness programs being circulated/shown in various telecommunication services/radio/social media platforms. This understanding will also possibly help in formulating further awareness programs, especially for the emergency setups in terms of distribution of pamphlets, having signboard, or providing information to people, etc., in the emergency setup to minimize the risk of transmission. In this background, this study aimed to evaluate the knowledge, awareness, and precautions being taken by the patients and their caregivers visiting the emergency services of the hospital, with regard to the COVID-19 infection. In addition, the study also evaluated the reasons for visiting the emergency medical outpatient services and the problems faced by them while approaching the emergency services.


  Methodology Top


It was a cross-sectional exploratory study conducted in the emergency outpatient services of a tertiary care center in North India. The study was approved by the ethics committee of the institute, and all the participants were recruited after obtaining written informed consent. The data was collected in the second week of April, 2020.

At our institute, all patients and caregivers undergo screening for COVID-19, before being provided services at the emergency.

The participants included patients (aged more than 18 years with any kind of medical illnesses visiting the emergency medical services) and their caregivers. The caregivers were also required to be aged more than 18 years of age. In addition, the patients were required to be medically stable enough to participate in the study.

The sociodemographic details in the form of age, gender, occupation, number of years of education, and distance from the hospital were recorded in a structured format. All the participants were assessed on a brief self-designed questionnaire which was specifically designed for the study to evaluate the knowledge about COVID-19 and the practices followed by the patients and their caregivers with respect to prevention of spread of COVID-19. The questionnaire covered the knowledge about mode of spread of COVID-19 infection, anxiety related to contracting infection and current precautions being taken to prevent contracting the infection, reasons for coming to hospital despite lockdown, problems faced during traveling, and precautions taken during traveling. The questionnaire took 8–10 min to administer. After the completion of the questionnaire, all the participants were explained about the mode of transmission of COVID-19 and the precautions to be followed. They were explained about the hygiene practices, the practice of social distancing, and the use of mask. The participants who expressed the desire for psychiatric help were also provided the same.

The data collected were analyzed using Statistical Package for Social Science (SPSS) 20.0 version (IBM Corp., Armonk, NY), and descriptive statistics was applied to derive the results.


  Results Top


The mean age of the study sample was 42.1 years (standard deviation [SD] – 16.4), and the mean number of year of education was 3.9 years (SD – 5.5). About two-third of the participants were male (60%) and were married (70%). Majority of the participants were patients (n = 64) and about one-third (n = 36) were caregivers of the patients. Majority had traveled beyond 10 km distance, suggesting that they did not belong to the city of Chandigarh. About one-sixth (15.0%) of the participants were suffering from carcinoma/malignancy and other chronic illnesses [Table 1].
Table 1: Sociodemographic profile

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More than half of the participants considered that touch and coming in contact with a person with cough/cold were the most common mode of spread of COVID-19 infection. The other common modes of spread reported by the participants were droplets, coming in contact with patients/persons with COVID-19, and crowd [Table 2]. Besides these, many participants also had misinformation about mode of spread, most common such a reason was dirt.
Table 2: Modes/methods of spreading COVID-19

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Three-fourth of participants (75.0%) considered that wearing a mask was required to avoid contracting or avoiding coming in contact with patients with COVID-19 infection. Half of the participants considered washing hands as a protective method to avoid contracting infection. The other commonly reported methods reported to avoid contracting the COVID-19 infection were staying back at home, using sanitizer, maintaining social distancing, and using gloves [Table 3].
Table 3: Precautions required to avoid contracting COVID-19 infections

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When asked to rate their fear, with respect to developing the infection, the mean score on the Likert scale (0–10) of fear of getting infected with COVID-19 was 3.6 (SD: 3.1).

In terms of practice of precautions, about half (54%) of the study participants used masks while traveling. The sanitization was the second most common precaution, and this was followed by the use of gloves and maintaining social distancing [Table 4]. About one-third (32%) did not consult any local doctor, before traveling to the tertiary care center.
Table 4: Precautions taken to avoid COVID-19 while traveling

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Further, in terms of practice, when asked about the practices for avoiding infection, while being in the emergency, majority of the participants (n = 91) reported that they were using the precautions to avoid COVID-19 infections in emergency. The most commonly used precautions were using masks (n = 91%), followed by the use of sanitizers (51%), social distancing (40%), and the use of gloves (18%) [Table 5]. However, among those who were using the masks, more than two-third (70.3%) were using the same for more than 6 h, without changing or washing it.
Table 5: Precautions taken in emergency to avoid COVID-19 infections

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  Discussion Top


COVID-19 pandemic is a harsh reality, and it is requiring the most stringent protocol to be followed such as complete shutdown in many areas declared as “hotspots” and sealing off of a particular locality, strict restrictions on free movements of the public, and many others.[8] The WHO and the National Health Authority of India (Ministry of Health and Family Welfare) are trying every possible effort to reduce the number of cases, i.e., reducing the chances of spread of the extremely contagious infection. Although every information related to the mode of transmission and the general precautions to follow to limit spread of infection as well as to protect self from getting infection (hand hygiene, social distancing, avoid unnecessary traveling out of home, etc.) are being transmitted by several means (telecommunication/radio/newspapers/mobile caller tunes/television advertisements by film celebrities in the form of dialogs, short documentaries, songs/animated stories for educating children/COVID related comics for children, etc.), yet there is every probability that a section of the public may not be aware of the exact modes of transmission of the virus and thereby may not be following adequate precautions to prevent themselves from getting infection. However, little is known about the practice being followed, especially in high risk areas.

The current study evaluated the knowledge and awareness of patients and their caregivers who were attending the emergency services of a tertiary care hospital in a city of North India during the “lockdown” period. Ideally, it is expected that this section of people should be more aware and educated about the modes of transmission of COVID-19 as they were stepping out of their homes despite strict lockdown protocol due to emergency medical issues to the hospitals, many of which are in the COVID-19 containment and treatment zones.

The study findings revealed that majority of the patients and caregivers had low education and most of them were unemployed or unskilled workers. The mean distance from the hospital was 52 km, ranging from 1 to 300 km, and about 71% of the hospital attendees were outsiders. Further, about one-third of them did not seek consultation from their local doctors before traveling so far to the city. This reflects that despite the available awareness programs being run by the health ministry a section of the public belonging with low educational background and low socioeconomic status (unemployed, low literacy, and poor income) did not practice the advisory to seek local consultation before traveling outside their locality even for emergency medical conditions. Therefore, this section of the public should be made aware about when to and when not to travel by the local health authorities in a more simpler way as many of them may not be having access to the telecommunication and internet services.

The medical conditions requiring an emergency hospital visit were mostly malignancy and exacerbation of previous chronic physical illness. This had been highlighted in various newspapers that immediate lockdown has resulted in widespread chaos and has created a major hurdle for those with chronic and severe medical illnesses such as malignancies and HIV/AIDS.[7],[9] These findings suggest that there is a need to allay the fear and anxiety of the patients with chronic medical illnesses and adequate planning to treat the severely medical ill persons during the COVID-19 pandemic at the local level. In this regard, designated hospitals/centers specifically treating chronic medical illness (cancer/HIV) in the local areas or nearest possible hospital could be considered for medical help to avoid these vulnerable patients of getting infected by COVID-19 by attending general hospitals catering to COVID cases. Moreover, the nearest possible hospital health-care workers (doctors and nursing staff) can contact parent health-care facilities through teleconsultation facilities and start/guide treatment and avoid unnecessary travel of the medically ill patients.[10]

When the knowledge about spread of COVID-19 infection was assessed among the patients and caregivers, it was found that although two-thirds of the participants were able to identify more than one correct modes of transmission of COVID-19, yet there were participants who lacked sufficient information about the modes of transmission and reported reasons of transmission such as exposure to dirt. There are several myths and rumors attached to the spread of COVID-19 infection (such as temperature can affect transmission rate, taking a hot bath can prevent infection, drinking alcohol can cure COVID-19, nonvegetarian food consumption can lead to infection, holding breath for 10 s acts as a test for COVID-19, garlic boosts immunity, blood donation can result in COVID-19 transmission, and many others).[11] Despite all the public awareness measures being taken by the government, these findings suggest that there is mismatch between the public's viewpoint of spread of the infection and health department's viewpoint. Therefore, the local health authorities should be given responsibilities to do periodic public awareness programs in the community level following all the principles of social distancing for the benefit of the public.

Similarly, when assessed about precautions required to avoid contracting COVID-19 infection, three-fourth of the participants were found to be well aware of correct infection control and protective measures to avoid disease transmission. However, only 8% of the participants were aware of at least 5 correct ways of disease prevention. Majority of the participants reported using masks to avoid contracting infection, yet the more well evidence-based precautions of frequent washing hands (50%), staying at home (47%), sanitizing hands (30%), and social distancing (26%) were followed less than expected. It has been seen that the general public is more keen on using masks as a means to protect themselves from getting infected, whereas maintaining hand hygiene, maintaining social distancing and covering face while sneezing/coughing were given less importance. Moreover, there is a huge rush to buy and stockpile masks which creates further chaos in the public. In this regard, the WHO had mentioned advisory on the use of masks[12] and Indian Health Ministry had provided methods of making own masks at home,[13] yet all these has to be more popularized and followed in public awareness programs. Another, fact, which emerged from the study was the fact that, although, majority were using the mask as a protective gear, but were using the same mask for more than 6 h continously, which may not be actually effective in protecting a person from infection in the vicinity, especially in a hospital setting. This inappropriate use may give a false sense of security, which can be dangerous in hospital setting.

The study findings also reflect a small proportion of participants believed in using indigenous methods such as using ayurvedic oil, and some believed that they would not get infection. This further reflects the prevailing rumors/myths about the treatment of COVID-19 such as drinking cow's urine and taking turmeric powder[14] as well as complete denial in some groups of population about the vulnerability to get infected such as younger age is not affected and those doing daily exercise have better immunity and cannot be infected.[15] The anxiety reported about contracting COVID-19 infection was low, which is possibly a reflection of poor awareness of the participants too.

Regarding precautions taken during traveling to hospital, majority mentioned the use of masks and sanitization of hands, but very few participants reported maintaining social distancing while traveling. This could further reflect that principles of social distancing are not yet well understood by the lay public and more adherence to this precaution needs to be propagated and followed. This reflects the need to increase awareness in the public, with respect to precautions to be taken traveling, especially in ambulance. Simple measures such as playing recorded messages of infection control measures in the ambulance/vehicle, having placards, pamphlets, myth busters of COVID-19, and display boards can benefit the medically ill people while traveling in ambulance and in the hospital setting. Further, the ambulance driver can be a resource person who can be trained to provide basic information about infection control measures to the passengers which can be practiced in low resource settings like ours. Having display boards about modes of transmission of COVID-19, and precautions to be followed at regular intervals on the roads as signages and in the entrance of the hospital/emergency rooms/hospital corridors can be considered. Volunteers in the emergency setting can educate the persons about COVID-19 upon reaching the emergency. This can prove to be beneficial in improving the knowledge and awareness of the public attending hospitals [Table 6].
Table 6: Some of the recommendations/suggestions for creating awareness and improving knowledge during traveling and in emergency rooms for the medically ill patients and their caregivers

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Further, as emergency stting can be potential source of COVID-19 infection and usually immunocompromised patients are being attended due to exacerbation of preexisting medical conditions, more stringent precautions needs to be followed with respect to the use of surgical masks and social distancing. In the present study, only half of the study participants were aware of using surgical masks, but these were not used appropriately. Further, using sanitizers and maintaining social distancing were also reported by only half and two-fifths of the study participants, which is again an alarming. In this regard, brief awareness sessions need to be taken in the emergency premises by infection control staff to educate the patients and caregivers to maintain basic infection control measures to protect themselves.

Limitations

The study had some limitations as evidenced by its small sample size and majority of the participants belonging to the low socioeconomic strata; hence, the findings cannot be generalized to all the socioeconomic strata. Further, no standard questionnaire was used to assess knowledge. However, a simple questionnaire used showed several crucial findings and pitfalls in the awareness and knowledge of the study participants attending the emergency services during lockdown period.


  Conclusions and Implications of the Study Top


Currently, it is utmost important to educate the public in every possible way to reduce the spread of infection, and one such activity should include educating the medically ill patients and their caregivers on when to travel to hospitals, preferably visit the local facility before traveling to a far off hospital and precautions to be taken during travel and while in emergency setting [Table 6]. This can protect the medically ill patients at large from getting infected. Further, simple suggestions or recommendations [Table 6] can prove to be quite beneficial in improving the awareness and knowledge of the hospital attendees. The current study revealed that about 70% of the participants traveled from outside the city, 32% of the participants did not consult a local physician before attending the emergency, many had misinformation about modes of transmission of the infection, three-fourth thought that wearing a mask that is required to protect oneself from getting infected, while handwashing and social distancing as important precautionary measures were reported by half and one-fourth participants, only half of the participants used masks during traveling and one-third reported of sanitizing hands during travel and only half of the participants reported of having knowledge about using surgical masks and sanitizers in the emergency setting, and only two-fifths thought social distancing to be a precautionary measure to follow in the emergency setting. The study findings highlight the potential loopholes and measures to improve awareness programs so as to improve knowledge and practices of medically ill patients and their caregivers attending emergency services of a tertiary care center in North India.

In the upcoming days of “unlockdown” phase when gradually all the previously restricted activities and movements will resume back, then it is expected that the number of patients attending the emergency services and routine hospital services will increase exponentially owing to the extended phase of lockdown during which many needy patients might not have been able to avail the health-care services. Further, there will also be an increase in the number of patients presenting with trauma to the emergency trauma services too. As the infection rate is increasing at a faster rate in India, it is expected that many of these patients might be infected before attending the emergency and many can get infected during their emergency ward stay. Therefore, it is utmost important to create awareness among the patients and caregivers regarding infection control practices as well as to carry out infection control drills in the emergency service areas to identify pitfalls and loopholes so that infection spread can be controlled at the earliest. The government and health authorities should make standard operating procedures of referral of patients from one area to another to control the patient flow into different hospitals. In these aspects, the current study findings can be regarded as crucial to develop necessary strategies in the emergencies to educate the patient population attending the emergency service areas of the hospitals which can be regarded as a potential source of infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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