1. Background
Coronavirus disease 2019 (COVID-19) is an infectious disease affecting the respiratory system caused by a novel coronavirus (1, 2). In Pakistan, COVID-19 has infected over 1.17 million individuals and caused an estimated 26,000 deaths (3). Over 219 million individuals across the globe have been infected with the virus, which continues to rise exponentially every day. Having a high mortality index, COVID-19 has been declared a worldwide emergency due to its high burden of deaths across the globe (3, 4).
Since it is a viral disease, most patients are given palliative treatment, including pain relievers, antipyretics, cough medication, and fluid intake. Although COVID-19 is a self-limiting disease, it can cause severe respiratory illness, especially among children and the elderly (5, 6). Researchers suggest that other preventive interventions may also be required apart from proactive measures to contain COVID-19 (7). The strongest and most effective strategy we can employ as a society is preventive measures against COVID-19 infection. Evidence suggests that by raising awareness and educating the masses about COVID-19, self-imposed preventive measures like mask-wearing and social distancing can be stimulated (8). To date, there have been only limited studies conducted to evaluate the knowledge and awareness about COVID-19 and the practice of hygiene measures to prevent the spread of coronavirus disease in a developing country like Pakistan.
2. Objectives
The present study assessed the knowledge, awareness, and general hygiene practices among the Pakistani population.
3. Methods
A prospective observational study was conducted in Sindh, Pakistan, from March 01 to March 25, 2020. A non-probability consecutive sampling technique was used to enroll the participants. Using the Select Statistics sample size calculator, a confidence interval of 99.9%, a margin of error of 1.57%, and a COVID-19 prevalence in Pakistani population to be 2.3%, a sample size of 978 was obtained (9). The following formula was used for sample size calculation:
The authors used previous literature and developed a questionnaire to determine the knowledge and prevention measures against COVID-19. The consultants of infectious diseases and public health approved the questionnaire. Moreover, a pilot study was performed to test the reliability and consistency of the questionnaire. The questionnaire was developed using Google Forms. The questionnaire was developed using the updated guidelines on COVID-19 by the National Health Service (NHS) (10). The data were analyzed with Statistical Package for Social Sciences (SPSS) version 24. All results were presented in tabular forms.
4. Results
The mean age ± SD of the study population was 29.11 ± 7.8. Of 980 participants, 198 (34.2%) were males, and 382 (65.8%) were females. The demographic characteristics of the study population are given in Table 1.
Table 1.Demographics of Study Population (n = 980)
| Variables | No. (%) |
|---|---|
| Age (y) | |
| 18 to 24 | 602 (61.4) |
| 25 to 29 | 245 (25.0) |
| 30 to 44 | 51 (8.8) |
| 45 or older | 47 (4.8) |
| Gender | |
| Male | 333 (34.2) |
| Female | 647 (65.8) |
| Marital status | |
| Unmarried | 578 (59.0) |
| Married | 390 (39.8) |
| Divorced/separated | 12 (1.2) |
| Educational status | |
| Grade tenth or lower | 29 (3.0) |
| Higher secondary school or grade twelfth | 186 (19.0) |
| University level | 735 (75.0) |
| Postgraduate level or higher | 30 (3.1) |
| Profession | |
| Medicine | 470 (47.9) |
| Engineering | 284 (29.0) |
| Business/commerce | 176 (18.0) |
| Other | 50 (5.1) |
| Employment status | |
| Government sector | 411 (38.1) |
| Private sector | 306 (31.3) |
| Business owner or self-employed | 78 (8.0) |
| Student | 146 (14.9) |
| Unemployed or retired | 75 (7.7) |
4.1. Knowledge about Coronavirus Disease (COVID-19)
The study participants were well-informed about COVID-19; nevertheless, most participants did not know that patients with COVID-19 can also manifest gastrointestinal and neurological diseases. Table 2 shows details.
Table 2.Knowledge and Awareness of COVID-19 Among Study Population
| Item | No. (%) |
|---|---|
| Knowledge about COVID-19 | |
| Coronavirus disease is caused by? | |
| Virus | 933 (95.2) |
| Immunodeficiency | 33 (3.4) |
| Inherited | 11 (1.1) |
| Bacteria | 3 (0.3) |
| The disease is transmitted through? | |
| Droplets after sneezing | 866 (88.4) |
| Touching and shaking hands with an infected person | 816 (83.3) |
| The use of objects used by an infected person | 642 (65.6) |
| Sexual route | 99 (10.1) |
| Signs and symptoms of the disease? | |
| Same as seasonal flu | 934 (95.8) |
| Diarrhea | 277 (28.3) |
| Shortness of breath | 780 (79.6) |
| Nausea and Vomiting | 194 (19.8) |
| Inability to smell | 265 (27.0) |
| How is the disease diagnosed? | |
| Blood test | 274 (28.0) |
| Nasopharyngeal swab test | 575 (58.7) |
| Polymerase chain reaction | 585 (59.7) |
| Treatment of COVID-19? | |
| No treatment; the disease is self-limiting | 819 (83.6) |
| Paracetamol | 223 (22.8) |
| Broad spectrum antibiotics | 44 (4.5) |
| Anti-malarial; Hydroxychloroquine | 260 (26.5) |
| Awareness about COVID-19 | |
| Route of Transmission and Spread | |
| Airborne route | |
| Yes | 564 (57.4) |
| No | 232 (23.7) |
| Not sure | 185 (18.9) |
| Can COVID-19 be caught from a person who has no symptoms? | |
| Yes | 835 (85.3) |
| No | 69 (7.0) |
| Not sure | 76 (7.7) |
| Can I catch COVID-19 from the feces of someone with the disease? | |
| Yes | 247 (25.2) |
| No | 380 (38.8) |
| Not sure | 353 (36.0) |
| Can humans become infected with COVID-19 from an animal source? | |
| Yes | 615 (62.8) |
| No | 223 (22.8) |
| Not sure | 142 (14.4) |
| Can the new coronavirus be transmitted through mosquito bites? | |
| Yes | 21 (2.1) |
| No | 830 (84.7) |
| Not sure | 139 (14.2) |
| Measures Effective Against the Spread of COVID-19 | |
| Are antibiotics effective in preventing or treating COVID-19? | |
| Yes | 60 (6.1) |
| No | 730 (74.4) |
| Not sure | 191 (19.5) |
| Are there any medicines or therapies that can prevent or cure COVID-19? | |
| Yes | 137 (14.0) |
| No | 628 (64.1) |
| Not sure | 215 (21.9) |
| Is there a medicine that can treat COVID-19? | |
| Yes | 362 (36.9) |
| No | 567 (57.9) |
| Not sure | 51 (5.2) |
| Does smoking help in preventing the disease? | |
| Yes | 106 (2.1) |
| No | 819 (83.6) |
| Not sure | 140 (14.3) |
| Can cold weather and snow kill the new coronavirus? | |
| Yes | 161 (16.4) |
| No | 600 (61.2) |
| Not sure | 220 (22.4) |
| Can hot weather kill the new coronavirus? | |
| Yes | 228 (23.3) |
| No | 488 (49.8) |
| Not sure | 264 (26.9) |
| Can "taking a hot bath" prevent the new coronavirus disease? | |
| Yes | 417 (42.6) |
| No | 543 (55.3) |
| Not sure | 246 (25.1) |
| Are hand dryers effective in killing the new coronavirus? | |
| Yes | 77 (7.9) |
| No | 618 (63.0) |
| Not sure | 285 (29.1) |
| Can an ultraviolet disinfection lamp kill the new coronavirus? | |
| Yes | 116 (11.9) |
| No | 365 (37.2) |
| Not sure | 499 (50.9) |
| Can spraying alcohol or chlorine all over your body kill the new coronavirus (that has already entered your body)? | |
| Yes | 77 (7.9) |
| No | 807 (82.3) |
| Not sure | 96 (9.8) |
| Do vaccines against pneumonia protect you against the new coronavirus? | |
| Yes | 29 (3.0) |
| No | 716 (73.0) |
| Not sure | 235 (24.0) |
| Can regularly rinsing your nose with saline help prevent infection with the new coronavirus? | |
| Yes | 352 (35.8) |
| No | 346 (35.3) |
| Not sure | 283 (28.9) |
| Can "eating garlic" help prevent infection with the new coronavirus? | |
| Yes | 96 (9.8) |
| No | 738 (75.3) |
| Not sure | 146 (14.9) |
| General Awareness | |
| Who is at risk of developing severe illness? | |
| Older persons | 875 (89.3) |
| Persons with pre-existing medical conditions (such as high blood pressure, heart disease, lung disease, cancer, or diabetes) | 854 (87.2) |
| Infants or children under the age of 10 years | 629 (64.2) |
| Not sure | 41 (4.2) |
| Should I travel during the current pandemic? | |
| Yes | 25 (2.6) |
| No, not unless absolutely necessary | 882 (90.0) |
| Not sure | 73 (7.4) |
| Should I wear a mask to protect myself? | |
| Yes, all the time. | 404 (41.2) |
| No, because I am healthy. | 158 (16.3) |
| No, because I am not taking care of a patient who has COVID-19. | 265 (27) |
| No, because I am not in close contact with anyone who has COVID-19. | 356 (36.3) |
| Not unless I have COVID-19, because there is a global shortage of masks. | 368 (37.6) |
| Does wearing multiple masks give more protection? | |
| Yes | 134 (13.7) |
| No | 702 (71.6) |
| Not sure | 144 (14.7) |
| How long does the virus survive on surfaces? | |
| 10 to 60 minutes | 215 (22.1) |
| Several hours to several days | 720 (73.5) |
| It does not survive on surfaces. | 43 (4.4) |
| How long is the incubation period for COVID-19? | |
| 1 day | 9 (0.9) |
| 2 - 14 days | 873 (89.1) |
| Not sure | 98 (10.0) |
4.2. Awareness about Coronavirus Disease (COVID-19)
4.2.1. Route of Transmission
Only about half the study population, i.e., 562 (57.4%), were aware of the airborne transmission associated with COVID-19. Other sources of transmission, as claimed by the participants, included feces of an infected person with 245 (25.1%), animal sources with 615 (62.8%), and mosquito bites with 12 (1.2%) (Table 2).
4.2.2. Measures Effective Against Prevention of the Spread of COVID-19
Most participants knew the virus could survive in both hot and cold temperatures (Table 2).
4.2.3. General Awareness
Of the participants, 875 (89.3%) responded that the elderly, 857 (87.2%) claimed that individuals with pre-existing conditions like diabetes, and 629 (64.2%) replied that infants and young children were at risk of developing a critical illness.
4.3. Practice Measures to Prevent the Spread of Coronavirus Disease
The study participants observed apt practices of hygienic and self-imposed preventive measures. Also, 670 (68.4%) participants claimed that they maintained social distance, while 94.1% practiced proper respiratory etiquette. Higher education status and the medical profession were associated with the better practice of preventive measures (Tables 3 and 4).
Table 3.Practice Measures to Prevent the Spread of Coronavirus Disease (n = 430)
| Practice of Self-imposed Preventive Measures | No. (%) |
|---|---|
| Wash your hands frequently. | |
| Yes | 951 (97.1) |
| No | 29 (2.9) |
| Maintain social distancing. | |
| Yes | 670 (68.4) |
| No | 310 (31.6) |
| Maintain at least one meter or three feet distance between yourself and anyone who is coughing or sneezing | |
| Yes | 791 (80.7) |
| No | 189 (19.3) |
| Avoid touching eyes, nose, and mouth | |
| Yes | 893 (91.1) |
| No | 87 (8.9) |
| Cover your mouth and nose with your bent elbow or tissue when you cough or sneeze | |
| Yes | 922 (94.1) |
| No | 58 (5.9) |
| Stay home when you are sick, except to get medical care. | |
| Yes | 882 (90.0) |
| No | 98 (10.0) |
| Clean frequently touched surfaces and objects regularly. | |
| Yes | 914 (93.3) |
| No | 66 (6.7) |
| Wash your hands often with soap and water for at least 20 seconds. | |
| Yes | 884 (90.2) |
| No | 96 (9.8) |
| Have a room in your home that is being used to separate sick household members from those who are healthy. | |
| Yes | 776 (79.2) |
| No | 204 (20.8) |
| If soap and water are not available, use a hand sanitizer to cleanse your hand. | |
| Yes | 897 (91.6) |
| No | 83 (8.4) |
| Use the separate room and bathroom you prepared for sick household members. | |
| Yes | 743 (75.9) |
| No | 237 (24.1) |
| Do not share utensils, towels, or toiletries with a sick person. | |
| Yes | 822 (83.9) |
| No | 158 (16.1) |
| Discourage children and teens from gathering in other public places. | |
| Yes | 893 (91.1) |
| No | 87 (8.9) |
| Take care of the emotional health of your household members. | |
| Yes | 828 (84.5) |
| No | 152 (15.5) |
| Comply with the lockdown/quarantine. | |
| Yes | 526 (53.7) |
| No | 454 (45.3) |
Table 4.Practices Towards COVID-19 by Demographic Variables
| Demographic Characteristics | Self-imposed Preventive Measures Taken by Study Participants | ||
|---|---|---|---|
| Maintain Social Distancing | Maintain at Least One Meter or Three Feet Distance Between Yourself and Anyone Who Is Coughing or Sneezing | Wash Your Hands Often with Soap and Water for at Least 20 Seconds | |
| Age group | |||
| 18 - 24 | 514 (80.6) | 490 (76.9) | 618 (97.6) |
| 25 - 29 | 77 (31.4) | 208 (84.8) | 189 (77.1) |
| 30 - 44 | 39 (76.4) | 46 (90.2) | 41 (80.3) |
| 45 and older | 40 (85) | 47 (100.0) | 38 (79) |
| Gender | |||
| Male | 244 (73.2) | 291 (87.3) | 301 (90.3) |
| Female | 426 (65.8) | 500 (77.2) | 585 (90.4) |
| Profession | |||
| Medicine | 345 (73.4) | 427 (90.9) | 448 (95.5) |
| Engineering | 184 (64.8) | 174 (61.3) | 232 (81.8) |
| Business/commerce | 101 (57.4) | 148 (84.4) | 166 (94.3) |
| Other | 40 (90) | 42 (84.0) | 40 (80) |
5. Discussion
The sheer volume of emerging information coinciding with sensationalized media tends to render much of the general populace unable to delineate between actual data and conjecture, especially in developing regions, which can ultimately lead to misconceptions that may have a drastic impact on the health crisis. Knowledge of these perceptions may help institutions take better measures to inform the local public (11).
The findings of this study convey that the participants were well-informed of the modes of transmission and general awareness but also expressed a large degree of uncertainty in the measures effective against the spread of COVID-19. This seems to coincide with a recent Stanford University survey conducted by Dr. Pascal Geldsetzer. In Dr. Geldsetzer's study, 43.5% of US participants and 36% of UK participants answered that at least one of the following would help prevent an infection with the novel virus: "using a hand dryer, regularly rinsing your nose with saline, taking antibiotics, and gargling mouthwash" (12). In a similar survey conducted in the UAE, discrepancies were found even among the knowledge of healthcare workers, approximately 20% of whom believed that the flu vaccine would suffice as protection from COVID-19 or that washing hands with soap and water would not help in the prevention (13). Zhong et al. revealed that most residents of high socioeconomic status had a fair amount of knowledge regarding COVID-19 (14).
In a survey published by Saqlain et al., healthcare workers had good knowledge regarding COVID-19 (15). Similarly, another study from Pakistan revealed that about one-half of the study participants had adequate awareness while the majority that is 72%, were following preventive measures against COVID-19 infection (16).
In these instances, the insufficiency of prevention knowledge may be attributable to widespread rhetoric from non-professionals and media misinformation. It is also interesting to note that, in previous studies, increased general knowledge about the virus was associated with a better outlook or a more "positive attitude" towards the pandemic (17). This may have interesting implications for the psychological well-being of individuals, particularly those experiencing adverse effects of prolonged quarantine.
When proposing certain practices for infection prevention, it is also important to highlight the demographic differences that may serve as factors limiting the frequency of these preventative measures. As illustrated in Table 4, there were many statistically significant instances where demographic factors influenced the practice of a specified preventative measure. Individuals from other professions were significantly less likely to maintain social distancing and wash their hands with soap and water. Although it is intuitive to infer that the latter result may simply be due to the lack of familiarity of other disciplines with standard medical practices, the factors contributing to the difference between practices by gender may be more challenging to quantify. A study from Saudi Arabia on the MERS epidemic showed that gender significantly affected the concern for the epidemic, whereas knowledge was the only factor predicting precaution and concern (17). The earlier surveys from China, by Zhong et al., demonstrated a similar trend of statistical deviation regarding preventative practices of different demographics on the basis of gender, marital status, and education level. For instance, it was shown that the male gender, occupation of “student,” and marital status of “other” were all significantly associated with “riskier” practices such as visitation of crowded places as well as decreased likelihood for mask-wearing (14). Thus, there seem to be inherent characteristics within each demographic which ultimately affect the preventative measures that are subsequently taken within that group. The previous studies suggest that targeting different demographic strata through alternative means geared towards those specific strata may be more effective in optimizing preventative measures.
One of the strengths of the study is that it is one of the earliest studies conducted in the region and so will act as the baseline against which all future studies will be compared. Since most of the participants were educated, the results cannot be generalized to a population of a lower socioeconomic status.
5.1. Limitations
Despite efforts to generalize the data, this study still poses many limitations regarding representing most of the Pakistani populace. This arises from the fact that the primary demographic of the sample came to be those who held a university-level education or higher and were thus more likely to be familiar with hygienic practices and modes of disease transmission as they are exposed to health education promotion programs on social media.
It is hoped that this study can catalyze more rigorous and prolonged assessments of knowledge of COVID-19 across diverse demographics so that each respective community can take a pragmatic course of action.
5.2. Conclusions
The present study indicated that the Pakistani population was well-informed of the modes of transmission and general awareness about the COVID-19 infection but also expressed a large degree of uncertainty in the measures effective against the spread of COVID-19. It is necessary to promote awareness about the pandemic and the effective ways to prevent the spread of the virus.
