Knowledge, Attitude and Practices Towards COVID-19 Among Grass-Root Level Workers of Bengaluru District - A Cross-Sectional Study

Introduction

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the seventh human Coronavirus, was discovered in Wuhan, Hubei province, China, during the recent epidemic of pneumonia in January 2020.¹ Since then, the virus has spread all over the world, and as of April 2024, it has infected 45,035,393 people, and caused 533,570 deaths in India.² In India, under NRHM (National Rural Health Mission) 2005, the goal of “Health for all by 2000 AD” was gradually implemented, targeting the improvement of health facilities and health needs of the community.³

The Coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the most significant global health crises in recent history, compelling governments and health organizations to adapt their strategies for disease prevention and health promotion. In India, a unique cadre of community health workers known as ‘Accredited Social Health Activists (ASHA)’ has been instrumental in managing public health initiatives, particularly in rural and underserved areas. An ASHA is usually a woman who is married or widowed or divorced, preferably in the age group of 25 to 45 years, and with a minimum formal education of 10th standard. She is a health activist in the community who would create awareness on health and its social determinants and mobilize the community towards local health planning, increased utilization, and accountability of the existing health services.⁴ Their undisputed role in the management of COVID-19 has been indispensable.

These workers serve as vital links between the community and the healthcare system, promoting health awareness, facilitating access to healthcare services, and educating the public on various health issues, including the prevention and management of COVID-19. Understanding the knowledge, attitudes, and practices (KAP) of ASHA workers towards COVID-19 is very crucial for evaluating their effectiveness and identifying gaps for capacity building.

As per government directives, ASHAs were tasked with conducting a survey for COVID-19 in their respective areas, and in Karnataka, nearly 42,000 ASHAs participated in this task.⁵ In the process, they played a pivotal role in disseminating awareness and ensuring preventive measures against the disease in the community. It has been observed that ASHAs tend to face problems in the field of duty, such as psychological stigma, discrimination, exposure to risk of infection, and inability to answer the various disease-related queries raised by the community.⁶ Lack of awareness can lead to a negative attitude, poor practices, and an unwillingness to perform one’s duties. Hence, this study was conducted to assess the knowledge, attitudes, and practices of ASHAs towards COVID-19 infection.

Materials and Methods

Study design and setting

A cross-sectional study was conducted among Accredited Social Health Activists (ASHA) workers in primary health centers (PHCs) in North Bengaluru between January 2020 and January 2021.

Study participants and sampling technique

A total of 503 community health workers, ASHAs, were selected from the PHCs of North Bengaluru using a universal sampling technique. Individuals who did not respond to the data collection were excluded from the study.

Study tool

A semi-structured questionnaire comprising 23 questions was developed to assess the knowledge, attitude, and practice (KAP) of ASHA workers regarding the control and prevention of COVID-19.

Knowledge

The knowledge domain included nine questions focused on the etiology, pathogenesis, prevention, and control of COVID-19. Each correct response was awarded one mark.

Attitude

The attitude domain consisted of six questions assessing perceptions of COVID-19 fatality, adherence to social distancing, cough etiquette, mask-wearing, hand hygiene, and the mental well-being of individuals diagnosed with COVID-19. Responses were scored using a Likert scale, with four being the highest score and one being the lowest.

Practice

The practice domain included eight questions designed to evaluate the actions of ASHA workers regarding COVID-19. These questions focused on field-based screening, reporting cases to government officials, and implementing preventive measures against COVID-19. Responses were scored on a 3-point Likert scale, with two as the highest score and 0 as the lowest.

Method of data collection

Data were collected using a semi-structured questionnaire developed using online Google forms. The questionnaire was designed and translated to local language after obtaining linguistic validation of the tool for easy understanding by ASHA workers.

Validation of the study tool

The content validation of the tool was done by three external subject experts. The tool was translated into the local language, and linguistic validation was conducted by two government school teachers. It was then pilot tested before the study was conducted.

Statistical analysis

Data were coded, entered in an Excel sheet and analyzed using SPSS ver. 20. Categorical variables were summarized using frequency and proportions. The study has been approved by the Institutional Ethics Committee, SIMS & RC, Bangalore. Verbal informed consent was obtained from the Taluka Health Officers of North Bangalore, before the study was conducted.

Results

Out of 503 ASHA workers, 62.2% ASHAs belonged to Bangalore Urban and 37.8% of them belonged to Bangalore Rural district. Out of these, 235 had an experience of five years.

On assessing the knowledge about COVID-19 among ASHA workers, it was found that 490 (97.4%) had knowledge regarding COVID-19 being a viral infection, 499 (99.2%) were aware of the major symptoms of COVID-19, 491 (97.6%) viewed quarantine and isolation as best measures to control COVID-19, 501 (99.6%) opined wearing mask as a compulsory measure, 500 (99.4%) agreed on the usefulness of hand sanitation & social distancing in controlling the disease and 502 (99.8%) were aware of investigations being available to diagnose COVID-19 (Table 1).

On evaluating the attitude towards COVID-19 among ASHA workers, it was found that 293 (58.3%) agreed that getting temperature checked once a day was enough, 228 (45.4%) completely agreed that avoiding crowded areas would help reduce the spread of COVID-19. Furthermore, 37 (7.3%) disagreed and 156 (31%) completely disagreed with the statement that using N95 masks was not a necessary requirement for them when visiting the community (Table 2).

Upon assessing the actions taken by ASHA workers to mitigate or prevent COVID-19, it was noted that 487 (96.8%) workers consistently practiced social distancing, 477 (94.8%) washed their hands after contact, and 466 (92.7%) replaced their masks daily. Only 17 (3.3%) cases were rarely referred to PHC. Most ASHA workers (69.4%) reported that their temperature was checked sometimes, 26.6% reported it was always checked, and 4% said it was rarely checked (Table 3).

Discussion

In a study involving 503 ASHA workers, a significant majority (62.2%) were from Bangalore Urban, while 37.8% were from Bangalore Rural. The age distribution showed that most ASHAs were between 21 and 30 years old, and 235 of them had five years of experience in their roles. This demographic profile indicates a relatively young workforce that is crucial for community health initiatives.

The knowledge of ASHA workers regarding COVID-19 was notably high. The majority of them, 490 (97.4%), recognized COVID-19 as a viral infection, and 99.2% were aware of the major symptoms associated with COVID-19. Out of 503 ASHAs, 491 (97.6%) viewed quarantine and isolation as effective control measures, 99.6% considered wearing masks an essential component and 99.4% acknowledged the usefulness of COVID-19 tests for diagnosis. This highlights that ASHA workers possess a strong understanding of both the nature of the virus and the recommended health practices to mitigate its spread. When compared to other studies, the knowledge levels among ASHA workers in this assessment were higher than those reported in similar studies across different regions. In Tripura, only 10% of ASHAs demonstrated adequate knowledge about COVID-19, which contrasts with the higher awareness levels found in Bangalore.^6,7 Previous studies have indicated lower awareness rates among community health workers in countries such as Uganda and Nepal compared to India’s grassroots-level workers. This discrepancy may stem from targeted training programs and ongoing support provided to ASHA workers throughout the pandemic.

A notable 58.3% of ASHA workers agreed that having their temperature checked once a day was sufficient for monitoring COVID-19 symptoms. Additionally, 45.4% completely agreed that avoiding crowded areas would help decrease the spread of COVID-19. Some of them did not express complete agreement, suggesting a potential gap in understanding or adherence to these preventive measures.

The attitude towards mask usage also revealed significant insights. Only 7.4% disagreed that visiting the community without an N95 mask was unnecessary, while 31% completely disagreed with this notion. This could have stemmed from various factors, including limited access to N95 masks or a lack of training regarding their importance in preventing virus transmission. The psychological impact of working in high-risk environments may also contribute to these attitudes, as many ASHAs have reported fears about contracting COVID-19 while serving their communities.^8,9

The findings from various studies highlight a concerning correlation between knowledge, attitude, and practice among ASHA workers. For instance, only 10% were found to have adequate knowledge about COVID-19, while 30.9% exhibited a positive attitude towards preventive measures. This suggests that enhancing knowledge through targeted training could significantly improve attitudes and practices related to COVID-19 prevention.

The data indicates that ASHA workers have consistently adhered to key preventive measures during the pandemic. A significant majority adhered to the protocols, with 96.8% of ASHA workers understanding the importance of practicing social distancing in curbing the infection. Similarly, 477 workers (94.8%) practiced hand washing after contact with surfaces or individuals, and 466 workers (92.7%) replaced their masks daily.

Despite their proactive measures, only 58.9% reported the importance of referring positive cases to their respective primary health centers (PHCs). This may suggest either a lack of cases requiring referral or potential barriers in the referral process that need further investigation.^8-10   ASHA workers sometimes had their temperatures checked, but not routinely. The reasons for these can be gauged from other similar studies that reported insufficient access to thermometers and personal protective equipment (PPE) for ASHAs, forcing them to purchase masks and gloves on their own, resulting in out-of-pocket expenses during the pandemic. This situation not only jeopardized their safety but also posed risks to their families, encountering stigma from communities due to their high-risk status as COVID-19 contacts. Reports of violence against them and their families highlighted the social repercussions of their work. Inadequate compensation, lack of training, and poor resource allocation were also cited as contributing factors.^11,12

Conclusion

The study highlights that ASHA workers in Bangalore possess a strong understanding of COVID-19, with the vast majority being aware of its viral nature, symptoms, and key preventive measures, including quarantine, isolation, mask usage, and the importance of diagnostic investigations. Their attitudes towards prevention were generally positive, although some inconsistencies were noted, particularly regarding temperature checks and the necessity of the use of N95 masks in the community. In terms of practices followed, most ASHA workers adhered to recommended preventive practices such as social distancing, hand washing, and daily mask replacement. However, a small portion demonstrated lapses and gaps in referring cases to primary health centers and undergoing routine temperature checks. These findings suggest that while ASHA workers are well-informed and largely compliant with COVID-19 preventive measures, targeted interventions could address areas of inconsistent practices to further improve their role in mitigating future pandemics.

Conflict of interest

None declared

Source of funding

Nil

Acknowledgements

We would like to thank all the study participants for their cooperation and participation rendered during the data collection process and at last we thank our THOs of Bengaluru North for permitting us to conduct this study.