Abstract:

The knowledge, attitudes, and practices (KAP) of the educated elite have serious implications for containing the spread of Covid-19 in Bangladesh. As opinion leaders, if they are negligent, they can influence others in their ambit with severe consequences. A study was designed to understand cognitive issues to help structure a public health response policy. Students, teachers, bankers, and other service holders were approached with 24 questions. More than 500 respondents from Bangladesh responded; 490 were ultimately used after data cleaning. As the threat of the virus continues to evolve, it is critical to conduct KAP analyses in significant sectors and devise a clear and consistent strategy to fight this invisible foe that has the power to devastate. Unless stopped with smart decisions, it will be unforgiving and relentless, thereby exacting a heavy price.

Background:

Life has come to a virtual standstill for many around the world due to the Corona Virus Disease-2019 or Covid-19 in short. Bangladesh has also been active in the global movement to contain the spread of the virus by urging people to stay at home and maintain the self-imposed quarantine. The country reported 183,795 confirmed cases of Covid-19 infection with 2,3521 deaths and 93,614 fully recovered [1]. Sadly, the numbers of the afflicted are increasing. The transmission classification is registered as ‘local’ [2]. The news media and social media updates have also become grimmer with each passing day. Due to a lack of testing, uncoordinated communication, the state of preventive care in public health, and logistical constraints, the reports on Covid-19 are ominous. The increasing numbers of deaths due to common cold and fever reported in many districts exacerbate this apprehension.

This study adopted a KAP [3] perspective intended to assess and guide social and health policy. As such, we focused on awareness/knowledge of the severity of the disease, its spread, and preventive measures. This was followed up by examining respondents’ attitudes to gain insight into how severely Covid-19 is likely to affect Bangladesh. The pandemic has already claimed 561,617 hundreds of thousands of lives and counting with 230,370 new cases worldwide [4]. WHO (World Health Organization) has classified the virus as high-risk. Hence, irrespective of the relatively low number of cases in Bangladesh, as presently reported, it is not a time to be complacent.

When the H1N1 pandemic jolted the world in 2009, WHO Director-General expressed concern that misinformation caused confusion and spread fear [and complacency], which hampered the ability of a national health system to control the outbreak. According to him, “Misinformation on the coronavirus might be the most contagious thing about it” [6]. Hence, a comprehensive communication strategy is essential to guide public health response to tackle this pandemic.

Keeping the phenomenon of MERS and SARS in perspective, it is vitally important that public health officials recognize time as a critical variable in controlling severe outbreaks [7]. With the free flow of quality information,  attention to data accessibility, targeted intervention, and behavior control, the spread of the outbreak – popularly termed as flattening the curve – may be easier to manage.

Methods

Data were collected using a self-administered questionnaire on Google Form in order to obtain responses efficiently. The study was modeled on a study by Qian, Wu, Wu, Hou, Liang, Cowling, and Yu (2020) that addressed psychological responses, behavioral changes, and public perceptions of the Covid-19 outbreak in China [8]. Our study focused on a particular group in Bangladesh: mainly the higher social strata in terms of education and income. This choice was predicated on the belief that this group represents opinion leaders who have influence and whose behaviors are generally emulated. Participants were asked not to identify themselves; they were also assured that the information collected would remain anonymous.

Since the target respondents were the educated elite in Bangladesh, well-versed in the English language, the survey instrument was also in the same language. After the questionnaire was reviewed by three university faculty members to give their opinions regarding its objective and content, it was followed by a pilot study to test the clarity of the wording and flow of the instrument. The data of the pilot analysis was not included in the final sample of the study.

Given multiple constraints – time, resources, financial support, lists, and finding investigators to gather data – the survey was sent out on March 22nd. By March 28th, we received over 500 responses. After cleaning blank and repetitive responses, we finally obtained 490 responses to work with. The respondents were mainly students (64.49%) and the actively employed community:  they are economically active with educational backgrounds beyond higher secondary education (30.61%), with a sizeable proportion having graduate and post-graduate degrees (60%). While we had a mixed-income group, this variable tended to lean towards middle and upper incomes. A significant number (59.84%) mentioned having a family member over the age of 65 living with them.  It was deemed useful to study the educated elite because if their knowledge, attitudes, and practices reflected shortcomings, the general population’s response to Covid-19 without similar advantages of education, jobs, and incomes could be less promising, with marked consequences.

Findings

Because this is a descriptive study, the analysis focused mainly on the distribution of the responses. 

Source of Information

Fig. 1: Information sources

Information search is typical human nature. When people are confronted with a dire situation, they will be thirsting to learn more about it in all its dimensions. The six most used sources of information mentioned by the respondents were television, social media, radio, newspaper, friends, and family. Though the broadcast media is non-personal, it has the broadest possible reach in disseminating information to a large audience [9]. As shown in Figure 1, the most popular source of information was social media (Facebook) used by most of the respondents. Family and friends generally influence the type of news that the users are exposed to in this format. Similarly, another personal source was television. Usually, the respondents watch television to reconfirm what they picked up from social media posts. Newspapers served as another information conduit, providing a vital service in times of a pandemic.

While various mass media sources generally serve a beneficial purpose, one must be careful of their role. Media studies forewarn that some sources can play a manipulative role (suppressing information, providing biased messages, and serving particular interests).  Social media can also be troubling with its reputation of providing mal-information and misinformation (e.g., suggesting strange concoctions to be ingested or partaking in community chants to thwart the virus). At a time like this, the media must play a trustworthy role; if their credibility is diminished, public confidence can be shattered.

Knowledge of the virus

KAP surveys are popular and there has been widespread interest in their findings. A practical and creative public health information strategy can be designed by gathering and analyzing information on knowledge, attitudes, and practices of the general population [4]. Knowledge about Covid-19 (see figure 2) can reflect the confusion that may need to be corrected via appropriate interventions. For this study, the respondents’ knowledge levels were classified as comprehensive, partial and minimal on three key issues: i) How does the virus spread; ii) How long does it take for symptoms of infection to appear and iii) How to prevent infection from occurring.

There are two main mechanisms of virus transmission – person to person (P2P) (respiratory droplets) and from affected surfaces (the virus can remain active for different periods on different surfaces). In the responses received, P2P showed up more prominently among the educated elite (i.e., transmission via respiratory droplets, coming in close contact with a virus-infected person; by air, touch, and sneeze). Few identified possible transmissions from the surfaces where the virus can also survive for some length of time.

According to expert [2] guidelines, the knowledge that symptoms of infection will start showing up within “1-14” days was categorized as “comprehensive.” As showed in the graph, around 26% of respondents had this comprehensive understanding. When the response was “14 days”, it was labeled as “partial understanding”; most of the responses (65%) fell into this category. Respondents saying 3-4 days, or some such variant, were placed in the “minimal knowledge” category. The finding suggested that the majority of the respondents were aware of the duration to some extent. Hence, health interventions seem to be necessary to make the representative group better identify the mechanism through which the virus manifests itself.

Fig.2 Respondents knowledge on ways Coronavirus spreads, time for symptoms of infection, and methods of preventing Covid-19

While we are still learning about the virus, a few necessary preventive measures can save one from getting infected and stop further transmission. Again, knowledge of prevention was classified as comprehensive, partial, or minimal. Comprehensive knowledge was reflected in statements such as: “Wash hands for 20 seconds; avoid touching eyes, mouth, and hand; cover mouth and nose during a cough or sneeze; maintain social distance; avoid large crowds, and do not go out unless necessary. Partial knowledge was reflected in “Wash hands, stay away from sick people, and do not go to large gatherings.” Minimal knowledge as indicated by “Wash hands and the bare limbs regularly” or “Stay away from any person by at least 3 feet.” The findings show that around 37.8% of the educated elite group had partial knowledge and highlighted social distancing more than hygiene factors.

Attitudes

Fig. 3 Respondents’ attitude on nine statements on Covid-19.

Nine statements were formed to measure the respondent’s attitude by scoring them on a scale of 1 to 7 (combined into three categories in Figure 3). On the statement ‘Covid-19 is affecting my job/earning,’ 69 % of the respondents agreed. This may be due to the large demographic group of university students who generally have a side income. Another group is the service holders in small and medium enterprises (SMEs) affected by the widespread lockdown. Service holders in larger and established organizations generally have an uninterrupted month-end salary. They are the neutral group or the disagreeing group, somewhat indifferent to the shut-down or lockdown. Eventually, if the lockdown continues indefinitely, everyone will be affected by the anticipated economic meltdown, and significant sectors may be forced to shut down; labor-intensive sectors will take the most significant blow.

When asked about minimizing contact with others, 82% agreed, and 8% disagreed, showing a widespread understanding of the need for “Social-Physical Distancing.” With ongoing news of the virus’s spread and the growing number of deaths being recorded worldwide, people seem to have associated the cause of infection with human exposure. What is of some consternation is the 18% remained neutral or disagreed with the need to minimize social distancing.

Another area of concern is the response to the statement- ‘Know where to go for help if infected.’ To both the researcher and the responders the term ‘help’ was interpreted as the role of medical facilities and personnel providing emergency services. Only 42% indicated knowing where to go for help – a dismal number concerning people’s ability to get help and save lives. The remaining 58% either disagreed or were in a neutral position. They do not seem to realize the severity of the situation; they must know about the medical service centers that have been identified by the Government. The uncertainty of locating the designated Covid-19 testing or facilities can be mitigated by the Health Ministry and the media, working in concert, to promote community-level awareness.

Concerning the two statements on ‘information,’ respondents seemed to agree on the need for more information (72%) and inadequacy (72%) of current information on Covid-19 in Bangladesh. Furthermore, this results in 79%, agreeing that “the media should do more.” These responses suggest the need for a better, consistent, and more comprehensive communication strategy to reach widely.

The fear of Covid-19 is also revealing: When asked whether they were afraid of the disease, 89% agreed with the statement. This provides a trigger to help change behaviors. Fear of being infected also made 92% realize that it is not safe to go out. Italy, Spain, and the USA had very marginal spread and a low number of deaths in early March [11]. However, misunderstanding the importance of social distancing and lack of practicing good hygiene caused massive harm that continues to be reported each day. [12]

The right attitude of both public and private groups must be cultivated and sustained to be most instrumental in defying the odds. After all, the first line of defense is the public itself and its knowledge and attitudes concerning the virus. Besides, the right health interventions by an entire health system on alert must be ensured. The media should also regularly update the public about all aspects of the disease. Incentives for health professionals must also be built into an integrated plan to keep them motivated to serve in their frontline positions. Authentic media broadcasts through the right channel will also play a substantive role. Income subsidy for those whose income and livelihood are affected by the outbreak must receive serious consideration at a broader level.

Conclusion:

Our  findings based on the educated elite, who are often opinion-leaders and emulated widely, engender cause for concern. Attention to a few fundamental human traits – knowledge, attitudes, and associated behaviors – can change history. Our research suggests that there are serious knowledge gaps among the educated elite concerning Covid-19. Their attitudes and perceptions about several critical issues are also ominous, as are their behaviors that do not elicit confidence. This callous disregard for the unseen dangers lurking in every handshake, every hand-wash, every sneeze, and every hug has been responsible for the pandemic that is now raging through the world and taking precious lives.

While the numbers in our study may reflect that inadequate/partial knowledge, cavalier attitudes and inappropriate behaviors among the educated elite are few, the fact is “the few” can cause severe damage. It must be kept in purview that the spread of the virus began from one epicenter, Wuhan, and rapidly spread throughout the globe because of the few negligent people who went about their regular routines. In Bangladesh, as probably elsewhere, there is a severe need to mobilize resources to inform, educate and motivate the general public about the notoriety of the Covid-19 virus and the need to adopt measures to stop it.

At this time of heightened ambiguity and uncertainty, information, education, and communication (IEC) is paramount to alleviating fear and stem irrational behavior (e.g., mass migration in hordes). Communicators from all walks must come forward to influence desired behaviors. The use of role models, demonstration effects, expert voices, and celebrity endorsements are essential at this moment. It is vital to coordinate and align the communication strategies of the leaders, the government, health organizations, news organizations, and the medical community to provide a clear and consistent message. Research has consistently shown that IEC/SBCC (social and behavioral change communication) programs can “increase knowledge, shift attitudes and cultural norms, and produce changes in a wide variety of behaviors.” This is not being practiced as vigorously as is necessary with potentially serious adverse consequences. Perhaps this apathy derives from a lack of deep understanding that research can provide. As our data show, media is seen as “not doing enough.” It must re-evaluate its role and responsibility in influencing desired behaviors by showcasing the virus in its destructive avatar. The use of various appeals (including fear appeals) and fact-sharing can help slow the spread of the virus until a cure or immunity is ensured. More importantly, SBCC programs must be immediately coordinated via “mass media, community-level activities, interpersonal communication, information and communication technologies, and new media.”

While communication is vital in this war against an invisible foe, the response system to make sure people are doing what they are supposed to do must also be strengthened so that the required behavior is enforced when needed. Covid-19 is a disease that can decimate entire populations. If the choice is left to individuals who do not seem to comprehend the sinister nature of the threat, enforcement via draconian measures is, unfortunately, the next best option.

References:

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Author:
Syed Saad Andaleeb, Ph.D., Distinguished Visiting Professor, Institute of Business Administration, University of Dhaka.
Mahreen Mamoon, Assistant Professor, BRAC Business School, BRAC University.