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   Table of Contents      
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 90-96

Public Perspective and Adherence to Government Directives in the Face of COVID-19 Situation in India


1 Consultant, Community Processes/Comprehensive Primary Health Care division, National Health Systems Resource Centre, New Delhi, India
2 D.N.B., Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission20-May-2020
Date of Decision07-Jul-2020
Date of Acceptance18-Jul-2020
Date of Web Publication29-Aug-2020

Correspondence Address:
Dr. Bratati Banerjee
Professor, Room no. 328, Department of Community Medicine, Maulana Azad Medical College, 2, Bahadur Shah Zafar Marg, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_43_20

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  Abstract 


Background: Coronavirus disease-19 (COVID -19) is an acute respiratory illness which spread rapidly to many countries including India. The Government of India took several measures to control the spread of the disease including issuing advisories and awareness materials for the public along with nationwide lockdown. Aims: To assess the public perspective of the disease, their behaviour during lockdown and adherence to government directives for its prevention. Materials and Method: A cross-sectional study was conducted among adult population residing in India during the lockdown, using a self-administered online-circulated questionnaire. Snowball sampling technique was followed. Data were collected on awareness regarding the disease and adherence to advisories issued by the government during the lockdown. Results: A total of 404 subjects sent their responses, of whom 73.76% were aged less than 50 years and 51.24% were females. More than 85% knew about the modes of spread of the disease and 97.5% knew its symptoms. Most participants were aware that they had to call the COVID-19 helpline number or visit a doctor/hospital immediately in case they came in contact with an infected person or developed symptoms themselves. Around 79% reported that they went out of their house during lockdown, mostly to buy essential supplies, of whom 8.7% went outside almost every day. More than 90% followed correct handwash practices but approximately 6% of those who went out didn’t use a mask regularly and 2% never used a mask. Conclusion: Majority of the participants across India were aware regarding COVID-19 and were following Government directives.

Keywords: Adherence, coronavirus disease, COVID-19, government directives, pandemic, public awareness


How to cite this article:
Banerjee R, Banerjee B. Public Perspective and Adherence to Government Directives in the Face of COVID-19 Situation in India. MAMC J Med Sci 2020;6:90-6

How to cite this URL:
Banerjee R, Banerjee B. Public Perspective and Adherence to Government Directives in the Face of COVID-19 Situation in India. MAMC J Med Sci [serial online] 2020 [cited 2020 Nov 23];6:90-6. Available from: https://www.mamcjms.in/text.asp?2020/6/2/90/293887



Key messages: The control of the COVID-19 pandemic in India depends majorly on the extent to which the citizens follow precautions for infection prevention and adhere to the government directives. The present study found that adults across the country were aware regarding COVID-19 and were following government advisories.


  Introduction Top


Coronavirus disease-19 (COVID-19), caused by the novel Coronavirus (SARS-CoV-2), is an acute respiratory illness which started in China in December 2019 and spread rapidly to many countries in the world. On 11th March 2020, WHO declared the disease as a pandemic.[1] The first case of COVID-19 in India was reported on 30th January 2020.[2] The first few weeks of the disease in the country showed imported cases, i.e. cases who had travelled to India from affected countries, after which local transmission began. In order to slow the transmission and flatten the curve of the disease, a nation-wide lockdown was implemented by the Government of India for 3 weeks starting on 24th March 2020, which was further extended initially till 3rd May 2020 and then beyond. The Government also issued various advisories and awareness materials for the public, regarding personal protective measures to be followed in order to prevent the spread of the disease.

Although the lockdown resulted in slowing of the outbreak in the country, cases of the disease have been reported from 32 states and the total number of cases were 39,980 including 1,301 deaths at the end of the second phase of lockdown (as on 3rd May 2020).[3] The Government has taken several measures to contain the disease including testing and isolation of cases, contact tracing and quarantine, sealing of hotspots and social distancing in the form of extended lockdown. With eventual ease in restrictions, it is the peoples’ responsibility to keep following precautions for infection prevention. It is therefore, pertinent to assess the extent to which they have been following the current directives. With this background, the present study was conducted to assess the public perspective regarding the disease, their behaviour during lockdown and their adherence to government directives for its prevention.


  Methodology Top


The study was approved by the Institutional Ethics Committee of Maulana Azad Medical College and wasexempted from review. A cross-sectional study was conducted during the month of May 2020, i.e., two months after the onset of the epidemic in the country. The study subjects were adults aged ≥ 18 years, who were able to take online survey using circulated English questionnaire and were located anywhere in India at the time of data collection. Even though online surveys are associated with various limitations, Indian Council of Medical Research (ICMR) has approved this as an acceptable method of data collection for public health and socio-behavioral research since “social distancing norms may not facilitate conventional methods of data collection” during the pandemic.[4] Health care workers were excluded from the study, since it could skew the results in favour of good awareness and behaviour. In absence of previous similar studies with composite awareness, and assuming the level of adherence to be 50%, we considered the sample size to be 400, at 5% level of significance and 10% relative precision.[5] The data were collected by snowball sampling technique, in which the researchers initially recruit subjects to take part in a study and these initial subjects then recruit additional subjects into the study. Accordingly, the questionnaire along with informed consent form was incorporated into Google forms and circulated through online platforms viz. Email and WhatsApp, to all available contacts meeting the eligibility criteria. The participants were encouraged to forward the survey form further, using online platforms. As the desired sample size was reached, the survey was closed.

Data collection tool was a pre-tested, semi-structured, anonymous, self-administered, online questionnaire which collected information on age, gender, state of location at the time of survey and included nine items on awareness about COVID-19 and adherence to Government advisories.

The data received was entered in Microsoft Excel and analysed using statistical package for social sciences (SPSS)-25. Qualitative data were expressed as frequency and percentage. For all questions asked, each positive response was given a score of 1 and negative response was scored 0. Maximum attainable score was 13. A comprehensive score was calculated for each participant, which included their correct awareness and adherence to government directives, higher scores being more favourable.

The participants were divided into two groups based on the degree to which the state they were located in at the time of survey was affected by COVID-19. The group of more affected states was taken as Category 1 comprising those which had reported 1000 or more cases as on 3rd May 2020 (Andhra Pradesh, Delhi, Gujarat, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu, Telangana, and Uttar Pradesh) and the remaining States were taken as Category 2, which were the States with case load of less than 1000. The mean score obtained by the participants was calculated for these two groups based on state category and compared using student t-test.

Data collection questionnaire was anonymous, without any identifier linked to the individual and no personal or sensitive information was asked. Those voluntarily returning the filled up questionnaire were included in the study and no reminders were sent to those who did not revert.


  Results Top


A total of 404 responses were received during the period of data collection, all of which were included in the study. Nearly three-fourth of participants (73.76%) were less than 50 years of age and more than half the participants were females (51.24%) [Table 1].
Table 1 Distribution of study participants according to demographic variables

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Data regarding the state/UT where the participant was located during the period of lockdown was collected. The participants belonged to 24 states and union territories (UT). Majority were located in metropolitan cities of which 20.79% were from Karnataka, followed by Delhi (16.58%), Maharashtra (13.61%) and West Bengal (13.36%). Other states with relatively greater representation were Uttar Pradesh, Kerala, Haryana, Tamil Nadu, Telangana, Gujarat, Meghalaya and Madhya Pradesh [Table 2].
Table 2 Distribution of study participants according to the state of current location

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The participants were further divided based on the Category of the States they were located in at the time of the study. In the total group of participants, 196 were located in Category 1 states and the remaining 208 were located in Category 2 states.

Awareness of the participants was assessed regarding the presence of dedicated helpline numbers for COVID-19, the modes of spread and symptoms of the disease. Only 84% of the participants were aware that there is an existing dedicated helpline number for COVID-19 in their respective States. Majority of the participants (>85%) knew about the various modes of spread of the disease and almost all the participants (97.5%) correctly knew fever, cough and difficulty in breathing to be the symptoms of the disease [Table 3].
Table 3 Awareness of study participants regarding COVID-19 according to the category of states

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We also assessed the participants for commonly prevalent misconceptions regarding the disease. A third of the participants (31.4%) stated that gargling with warm water can cure the disease and/or prevent getting infected, and 7.2% stated that taking antibiotics can prevent and/or cure the disease. Some participants (13.4%) answered that asymptomatic cases of COVID-19 cannot spread the disease to others [Table 3].

One aspect of their potential adherence to Government advisories was assessed by asking the participants what they would do first in case they showed symptoms of the disease and in case they came in contact with a confirmed case. They were given four options to each situation: stay in home quarantine for 14 days, call the COVID-19 helpline number, visit a doctor/hospital immediately, take self-medication for fever/cough. In response to the first action they would take in case of exhibiting symptoms of COVID-19, 80% of participants stated that they would call the dedicated COVID-19 helpline number or visit a doctor. In response to what they would first do in case they came in direct contact with a confirmed case of COVID-19, only 65% of participants stated that they would call the helpline number or visit a doctor. Some of the participants stated they would stay in home quarantine in case of symptoms (17%) or in case of contact (35%). About one to two percent of participants even stated they would take self-medication for fever/cough [Table 4].
Table 4 Actions to be taken in COVID-19 related situations as perceived by the study participants according to the category of states

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The participants were asked whether and how frequently they went out of their house during the period of lockdown and the reasons for going out. More than three-quarters of the participants (319, 78.9%) reported that they went out of their house during the lockdown period, of whom 35 (8.7%) went outside almost every day. About 12% of total participants enrolled in the study reported to be engaged in essential services, which comprised of 15% of the people who had gone outside during the lockdown. More than 90% of those who went outside reported that they did so to buy goods like groceries and other essential supplies and the remaining went outside to walk or walk their pets, throw garbage, feed stray dogs and attend to medical needs. One male respondent aged less than 50 years from Tamil Nadu answered that he went out frequently, one of the reasons of going out being to meet friends. However, he stated using mask always while going out. Almost a quarter (24%) of the participants had ordered home delivery of cooked food in the past one month [Table 5].
Table 5 Behaviour of study participants during the lockdown according to the category of states

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We also collected data on personal protective measures like following hand hygiene and using masks while going out of the house. More than half of the participants (51.9%) answered that in the last two months they sometimes used alcohol-based hand sanitizer to clean their hands while at other times they practised handwashing with soap and water. Another 40% stated that they always used soap and water. Very few participants (1.5%) mostly used alcohol-based hand sanitizer. However, 26 (6.4%) participants answered that they sometimes washed their hands with only water [Table 6].
Table 6 Personal protective measures followed by the study participants according to the category of states

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Out of the people who reported that they had gone outside during the lockdown period, approximately six percent did not use a mask regularly and two percent never used a mask, although half of them reported having gone outside frequently or almost every day. One response received from a female participant in the age group 51–60 years from Punjab, stated going out every day for a walk but never using a mask [Table 6].

We also calculated the mean of the comprehensive score obtained by participants on awareness and adherence reported by them. The mean (SD) score computed for total group was 10.94 (±1.41), which was 84.15% of maximum attainable score of 13. On comparing the mean comprehensive awareness and adherence scores of the participants according to the two Categories of the States they were located in at the time of the study, the difference was not found to be statistically significant at P < 0.05.


  Discussion Top


An epidemic is always an emergency and all actions including research need to be carried out at the earliest. In the current COVID-19 situation, it is important to know the understanding and behaviour of the population in adhering to the directives issued by the Government for containing the epidemic in the country, as people’s participation is the crux of success of any programme. The present study was conducted in the earlier phase of the pandemic when the epidemic curve in India was beginning to rise. Even though the epidemic has rapidly evolved since then, the documentation of people’s behaviour at that time will help to enable further research on the same.

Electronic survey or E-survey is currently emerging as an important and useful technique for rapid collection of data at a low cost.[6] This technique of data collection, which has been approved by the ICMR in the current epidemic situation,[4] was used in the present study to assess the awareness of people across the country and their level of adherence to directives issued by the Government.

More than half of the participants of the present study were women and nearly three-fourth of the population was of less than 50 years of age. The participants belonged to 24 States and UTs of India, representing all COVID-19 affected States/UTs where the total number of reported cases had exceeded 300 as on 3rd May 2020.

Adherence to control measures regarding COVID-19 is affected by an individual’s knowledge, attitude, and practices (KAP) towards the disease. An online survey conducted in China reported that the COVID-19 knowledge score was significantly associated with a lower likelihood of negative attitudes and preventive practices towards COVID-2019.[7] Hence, assessing the awareness of people is of prime importance to gauge their practice and adherence to advisories regarding control measures.

The Ministry of Health and Family Welfare has published a document on frequently asked questions (FAQs) regarding COVID-19 for the public which is freely accessible on their website,[8] and these messages have been disseminated far and wide through media and other modalities. It is, therefore, expected that people of the country have made themselves familiar regarding the disease, its spread, its prevention and other facts, which have been mentioned in the document. In our study, majority of the participants had correct knowledge regarding the existence of a dedicated helpline number for COVID-19, the modes of spread of the disease and its symptoms, although some misconceptions regarding treatment modalities were also prevalent among them. Other online studies conducted in India also reported that study participants had fairly good knowledge of the disease and its prevention.[9],[10],[11],[12],[13] However, a considerable fraction of participants has also been reported to harbour false beliefs towards the transmission of the novel coronavirus, and its prevention and treatment.[9]

Our study participants were aware that they had to call the COVID-19 helpline number or visit a doctor/hospital immediately in case they came in contact with an infected person or developed symptoms suggestive of COVID-19 themselves. This implies that people are aware about the first action that needs to be taken in case they experience such situations. Yet the alarming point is that about a third of the participants stated they would stay in home quarantine or take self-medication for fever/cough, which implies that in case such individuals actually come in contact with a case or develop symptoms and exhibit this kind of behaviour, the health system will not be able to trace them.

Nearly four-fifth of our study population had gone out of their house during the lockdown period, some of whom were engaged in delivering essential services. Majority had gone out about once a week, mainly to buy essential supplies, indicating they were adhering to the Government directive regarding staying at home during lockdown.[14] Another online survey reported that the attitude towards COVID-19 showed people were willing to follow government guidelines on quarantine and social distancing.[10] One study reported that majority of the subjects had even taken precautions on their own before the government announced the lockdown.[12] This is an encouraging scenario that ensures people’s cooperation in combating the disease.

Almost a quarter of our study participants had ordered home delivery of cooked food in the past one month. Although it has not been documented that COVID-19 can spread through food, we included this aspect in our survey because transmission through close contact with infected food handler or delivery person has been documented.[15] The recent incident of a food delivery executive testing positive for COVID-19 and the subsequent quarantining of all the households he had delivered food to impresses upon the fact that this is a potential mode of transmission of infection and, therefore, caution should be exercised in this regard.[16]With increase in awareness, various preventive measures are currently being practiced by the population. Our study found that more than half of the participants practised cleaning their hands sometimes with alcohol-based hand sanitizer and sometimes washing them with soap and water, and another 40% always washed their hands with soap and water. More than 90% of our study population reported wearing a mask while going outside the house. Another pan-India online survey reported 75% of study population had started washing hands more frequently and 76% used face mask.[11]

The difference in the mean comprehensive awareness and adherence scores of the participants belonging to Category 1 and Category 2 states was not statistically significant. This implies that the difference in magnitude of disease in various States might not be dependent solely on public awareness and behaviour and there may be other factors in play, which affect the burden of the disease.

Our study had some limitations. Firstly, the study subjects were restricted to the English speaking and computer literate population since the data collection tool was designed in English and circulated through online platforms. Since the study was carried out during the period of lockdown and restricted movement, the only possible method to obtain data from a large number of people from across the country was through an online survey. Even though online studies have many limitations, it has been approved by ICMR in the light of the current scenario. Secondly, snowball sampling technique was followed in this study which is a non-probability sampling technique. Thirdly, an epidemic is a dynamic phenomenon, which is best captured by longitudinal studies and it is ideal to study changing behaviour over time as the epidemic progresses. Moreover, any epidemic evolves so rapidly that research findings become obsolete by the time they are published and disseminated. In our study, we have studied individual behaviour, and made comparisons according to the severity of the epidemic in the States where they were located at the time of data collection. The inferences drawn in this regard may be biased due to reductionist fallacy.

In spite of some limitations, our study was strong in many aspects. We were able to achieve national representation and collect data from all age groups even during the time of lockdown, owing to our methodology of online data collection. We were also able to achieve our statistically calculated sample size. Since it was a self-administered questionnaire, there was no interviewer bias. For the same reason as well as the questionnaire being anonymous and researchers being unknown to majority of the study subjects, social desirability bias was also unlikely to have happened.


  Conclusion Top


Our study, conducted on adults across the country, revealed that the study subjects had good level of awareness regarding the modes of spread and symptoms of COVID-19 and about the first action that needs to be taken in case they come in contact with a confirmed case of the disease or develop symptoms themselves. Majority of the study participants reported washing hands properly, staying at home during lockdown and wearing a mask while going out for mainly essential needs. With eventual ease in restrictions imposed by the Government, it is imperative that the people of the country continue to follow precautions so as to prevent the spread of the disease. Thus, based on the observations from our study, majority of the participants across India were aware regarding COVID-19 and were following Government directives to combat the disease in the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Coronavirus disease2019 (COVID-19) Situation Report − 51 [Internet]. World Health Organization, Geneva; 2020 [cited 2020 May 03]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10  Back to cited text no. 1
    
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WHO India. Novel Coronavirus (2019-nCoV) Situation Report 1 [Internet]. World Health Organization, New Delhi; 2020 [cited 2020 May 03]. Available from: https://www.who.int/docs/default-source/wrindia/india-situation-report-1.pdf?sfvrsn=5ca2a672_0  Back to cited text no. 2
    
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MOHFW. COVID-19 India. Ministry of Health and Family Welfare, New Delhi;2020 [cited 2020 May 03]. Available from: https://www.mohfw.gov.in/#  Back to cited text no. 3
    
4.
ICMR. National guidelines for ethics committees reviewing biomedical and health research during COVID-19 pandemic [Internet]. Indian Council of Medical Research, New Delhi; 2020 [cited 2020 July 07]. Available from: https://www.icmr.gov.in/pdf/covid/techdoc/EC_Guidance_COVID19_06052020.pdf  Back to cited text no. 4
    
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Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual [Internet]. Geneva: World Health Organization 1991.  Back to cited text no. 5
    
6.
Skarupova K. Technical report: computer-assisted and online data collection in general population surveys [Internet]. European Monitoring Centre for Drugs and Drug Addiction; 2014 [cited 2020 May 03]. Available from: http://www.emcdda.europa.eu/system/files/publications/808/Technical_report_Computer_assisted_and_online_data_collection_in_GPS_480810.pdf  Back to cited text no. 6
    
7.
Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci 2020;16:1745-52.  Back to cited text no. 7
    
8.
Government of Karnataka. Detail question and answers on COVID-19 for public [Internet]. Ministry of Health and Family Welfare;2020 [cited 2020 May 03]. Available from: https://www.mohfw.gov.in/#  Back to cited text no. 8
    
9.
Krishna PR, Undela K, Palaksha S, Gupta BS. Knowledge and beliefs of general public of India on COVID-19: a web based cross-sectional survey. medRxiv [Internet]. [cited2020 May 03]. Available from: https://www.medrxiv.org/content/10.1101/2020.04.22.20075267v1.full.pdf+html doi: https://doi.org/10.1101/2020.04.22.20075267  Back to cited text no. 9
    
10.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.  Back to cited text no. 10
    
11.
Nazli T, Heena XX, Raheem A, Kishore J. Perceptions and practices of the adult population in response to SARS-CoV-2 pandemic in India. Epidem Int 2020;5:10-6.  Back to cited text no. 11
    
12.
Annamuthu P, Shenbagavadivu T, Arthi S. A study on the perception and precautionary measures taken by the general public amidst COVID-19. Int J Modern Trends Sci Technol 2020;6:169-74.  Back to cited text no. 12
    
13.
Ranjan R, Ranjan GK. Knowledge regarding prevention of novel Coronavirus (COVID-19): an electronic cross-sectional survey among selected rural community. Int J Trend Sci Res Dev 2020;4:422-6.  Back to cited text no. 13
    
14.
MOHFW. Advisory on Social Distancing Measure in view of spread of COVID-19 disease [Internet]. Ministry of Health and Family Welfare; 2020 [cited 2020 May 03]. Available from: https://www.mohfw.gov.in/pdf/SocialDistancingAdvisorybyMOHFW.pdf  Back to cited text no. 14
    
15.
FSSAI. Food hygiene and safety guidelines for food business during Coronavirus disease (COVID-19) pandemic [Internet]. Food Safety and Standards Authority of India; 2020 [cited 2020 May 03]. Available from: https://fssai.gov.in/upload/uploadfiles/files/Guidance_Note_COVID_15_04_2020.pdf  Back to cited text no. 15
    
16.
Shrivastava A. Delivery boy tests positive for Covid-19 in south Delhi, families that ordered put in quarantine. The Economic Times: Politics and Nation [Internet]. 2020 Apr 16 [cited 2020 May 03]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/families-in-south-delhi-isolated-after-delivery-boy-tests-positive/articleshow/75175022.cms  Back to cited text no. 16
    



 
 
    Tables

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



 

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