A Cross-sectional Study of Knowledge, Attitudes, and Practices toward COVID-19 in Mongolia
1Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Department of Biological Sciences, College of Life Sciences, Inner Mongolia University, Hohhot, China
Corresponding Author: Batbold Batsaikhan, Department of Internal Medicine, Institute of Medical Sciences, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia, Phone: +97699153010, e-mail: email@example.com
Background: Currently, 6.3 million people have been infected with severe acute respiratory syndrome (SARS)—CoV-2 and the pandemic has spread to 216 countries. To date of 6th June 2020, 383,262 deaths were confirmed.
Objective: We aimed to evaluate the knowledge, attitudes, and practices (KAP) toward COVID-19 among the population.
Materials and methods: This cross-sectional study was conducted in 614 residents of Ulaanbaatar city by online survey. The Ethics Committee of Institute of Medical Sciences, Mongolian National University of Medical Sciences, Mongolia, approved our study protocol, procedures, information sheet, and consent statement (№2020/D-11). The questionnaire consists of 45 questions, including general information, KAP. The KAP were evaluated by 20, 14, and 9 scores, respectively.
Results: The mean scores of participants were determined and ranked into levels of good, average, and poor. Appropriate statistical methods were performed. The mean age of participants were 32.14 ± 10.82 (12–86) years and 70% were women. The mean score of knowledge questionnaire was 13.73 ± 2.7 (13.7 ± 2.3 in male, 13.8 ± 2.6 in female, p = 0.221) which refers that 72.5% (445) of participants had a mean score of knowledge. Furthermore, the mean score of attitude was 13.2 ± 2.7 (13.7 ± 2.3 in male, 13.8 ± 2.6 in female, p = 0.221) and the mean score of practice was 6.9 ± 1.6 (6.3 ± 1.7 in male, 7.1 ± 1.6 in female).
Conclusion: The population has a relatively good level of KAP toward COVID-19.
How to cite this article: Badamjav T, Dondov G, Batbaatar B, et al. A Cross-sectional Study of Knowledge, Attitudes, and Practices toward COVID-19 in Mongolia. J Postgrad Med Edu Res 2022;56(2):70-74.
Source of support: Nil
Conflict of interest: None
Keywords: Attitude, COVID-19, Knowledge, Mongolia, Practice
The outbreaks of SARS and Middle East Respiratory Syndrome have occurred in 2002 and 2012, respectively as an endemic and a pandemic. In December 2019, a novel coronavirus cluster of infection spread out in Wuhan, Hubei Province, China, the causative virus was temporarily named as a 2019-nCoV. On 11th February 2020, International Committee on Taxonomy of Viruses officially announced that the virus renamed is SARS-CoV-2. This name was taken because of the genome sequencing similarity of SARS-CoV which utilizes the angiotensin-converting enzyme 2 as a cell receptor to invade human cells.1-3 Therefore, the World Health Organization declared a name for the novel coronavirus disease: COVID-19. As of 4th June 2020, a total of 6.3 million people among 216 different countries have been infected with the new SARS-CoV-2, 383,262 people have died.4 Our country has become one of the few countries in which the COVID-19 has not spread out among the population as a result of prompt and effective implementation of quarantine, social distancing, information, and publicity by the Government and the Ministry of Health since January 2020. A knowledge, attitude, and practice (KAP) survey of any communicable disease is a suitable way to evaluate existing programs and to identify effective strategies for behavioral change in society.5,6 Thus, our survey was conducted to evaluate the level of KAP about COVID-19 among the population. A cross-sectional online survey of 614 Mongolian residents was conducted between 19th May and 28th May 2020.
We aimed to evaluate the KAP toward COVID-19 among the population.
To assess the level of knowledge of the population on the COVID-19 diagnosis, treatment, prevention, and transmission risk factors.
To assess the level of attitude and practice of the population on the COVID-19 diagnosis, treatment, prevention, and transmission risk factors.
MATERIALS AND METHODS
We enrolled 614 subjects in this cross-sectional study. Data collection was performed online using the Google Form platform. The call for participation was made on social media. Physicians, healthcare workers, and medical students were not included in this survey. Because it was not feasible to do a population-based survey during the lockdown, we conducted an online-based survey. The Ethics Committee of Institute of Medical Sciences, Mongolian National University of Medical Sciences, Mongolia approved our study protocol, procedures, information sheet, and consent statement (№2020/D-11). Participants who gave consent to willingly participate in the survey would click the “Continue” button and would then be directed to complete the self-administered questionnaire. The survey consisted a total of 45 questions and divided into four main parts including general information, knowledge, practice, and attitude. The knowledge, attitude, and practice sections had 20, 14, and 9 questions, respectively and each question was answered “yes,” “no,” and “I don’t know.” Correct answers scored 1 and other answers scored 0. The mean scores of subjects were determined and ranked into levels of good, average, and poor. The participant’s knowledge, attitude, and practice were compared with age, gender, education level, and employment. Statistical analysis was performed using SPSS 21 (version 21.0, SPSS Inc., Chicago, IL, USA) software. Knowledge, attitudes, and practices of different persons according to demographic characteristics were compared with independent-samples t-test, one-way analysis of variance, or Chi-square test as appropriate. The correlation between subjects’ knowledge, attitude, and practice was determined by linear regression analysis. For all statistical analyses, a two-tailed p-value of <0.05 was considered statistically significant.
Demographic Characteristics of the Subjects
The average age of the subjects was 32.14 ± 10.82 (range 12–86), 30% (184) were men, and 70% (430) were women. Out of the total, 2% (12) had middle school education, 13.4% (82) had a high school education, 7.2% (44) had a college degree, and 77.4% (475) held a university degree or higher.
Assessment of Knowledge
The mean score of knowledge was 13.73 ± 2.7 (in male 13.7 ± 2.3, in female 13.8 ± 2.6, p = 0.221) and we graded 0–10, 11–16, and 17–20 scores as good, average, and poor, respectively. About 72.5% (445) of the subjects had an average level of knowledge about COVID-19. Majority of the subjects had an awareness rate of the transmission by cough (94.6%) and contact (89.1%). On the contrary, some had a wrong understanding of the transmission by unprotected sexual intercourse, contaminated blood (25.9%), and mother-to-child during delivery (21.2%). Residents answered correctly that flu-like symptoms develop in COVID-19 (89.4%) and nonsymptomatic patients can spread the infection (82.6%). About 17.6% of subjects answered wrong that all COVID-19 infected people carry the virus the rest of their life and the rates of reporting “I don’t know” was 36.5%. Besides, respondents reporting rates of “Agree,” “Disagree,” and “I don’t know” on spontaneous healing of COVID-19 were 25.9%, 47.2%, and 26.5%, respectively. A total of 92% of subjects answered that self-isolating is significant to prevent from COVID-19 and 93.6% subjects answered to consider social distancing (1–2 m) in public places. No difference of knowledge score was observed relating to participant’s age and gender but significantly differed across their education level and occupational status (Figs 1 and 2). Moreover, knowledge of 33% of subjects with middle school education was poor and 67% were average but there was not a respondent with good knowledge toward COVID-19. In contrast, 74% of subjects who held a bachelor’s degree or higher had average knowledge and 15% had good knowledge. (p < 0.0001). Also, there was no participant who had good knowledge among herders, welfare groups, and students but 13–19% of officials and employees had good knowledge according to the questionnaire (p < 0.0001).
Assessment of Attitudes
The mean score of attitude was 10.7 ± 2.5 (for male 10.3 ± 2.8, for female 11 ± 2.4, p = 0.001). From the finding of the study, 20.5% (126), 53.6% (329), and 25.9% (159) were poor, average, and good attitude level, respectively. Almost all subjects worried about COVID-19 (99.3%), considered screening test is important (97.5%), and believed they can protect themselves from infection (88.1%). Moreover, 93.8% of subjects have thought the decisions of the State Special Commission and Ministry of Health were effective and 96.6% have followed the regulation and recommendation. Attitudes toward COVID-19 were significantly different by gender and level of education. Especially in males, 26.1% had poor and 21.2% had a good attitude, while in females 18.1% had poor and 27.9% had a good attitude (p = 0.044). On the contrary, there was no significant difference between attitude and age, level of education, and employment.
Assessment of Practices
A mean score of practice was 6.9 ± 1.6 (for men 6.3 ± 1.7, for women 7.1 ± 1.6, p < 0.0001) and we graded 0–2, 3–5, and 6–8 scores as good, average, and poor, respectively. From the finding of the study 7.7% (47), 75.6% (464), and 16.8% (103) were poor, average, and good practice level, respectively. To assess the practice of the subjects, 90.9% of the subjects responded that they regularly put masks on when they needed to go outside, 95.9% have washed their hands regularly, 97.1% have regularly interchanged their home air, 86.0% have periodically cleaned their home with disinfectants, and 33.1% have worn gloves when going out. However, 30.8% of the subjects answered that they have regularly visited public places when it was not necessary, 11.2% have taken their children out at least once, 27.9% were smokers, and 21.5% of the subjects’ children played on the outdoor playground during high-level of preparedness and response period for COVID-19 infection. The levels of the practice toward COVID-19 were not statistically significant in gender, level of education, and employment. Preventing practice for COVID-19 infection was higher in women than in men (p < 0.0001). Particularly, 20.5% and 8.2% subjects had good practice in women and men, respectively.
Correlation between Knowledge, Attitude, and Practice
A linear regression analysis has revealed a weak positive correlation between knowledge and practice (r = 0.049, p < 0.0001) (Fig. 3A), between knowledge and attitudes (r = 0.03, p < 0.0001) (Fig. 3B), and between attitude and practice (r = 0.076, p < 0.0001) (Fig. 3C). In other words, the subjects’ ability to protect themselves from COVID-19 infection depends on their level of knowledge and attitude toward the infection.
In our study, the majority of the subjects were aged 20–40 years which belongs to the working age. Our study indicates that the population of our country have a relatively good level of KAP toward COVID-19 infection.
Compared to our previous study which evaluates KAP toward hepatitis B and C virus infections among the population of Dornod province, the knowledge score of the current study was lower but the attitude and practices were relatively higher.7 Mongolian population are well-informed about hepatitis B and C virus infections but the wrong attitude and practices are stabilized in our life. Both studies proved that the knowledge and attitude toward hepatitis B and C virus infections and the knowledge toward COVID-19 infection were significantly associated with education level and occupational status of subjects.7 Therefore, providing the target groups with education, publicity, and information about those infections is highly required. There are several KAP studies toward COVID-19 in countries which have high morbidity and mortality rates. Particularly, 6,919 residents from Wuhan, China where the infection caused by SARS-CoV-2 first detected in December 2019 participated in KAP study toward COVID-19. This was the first survey which studied KAP of COVID-19 infection in China and the correct answer rates of the 12 questions on the COVID-19 knowledge were 70.2–98.6%. The mean knowledge score of COVID-19 infection was 10.8, implying an overall 90% (10.8/12 × 100) correct rate on this knowledge test. Furthermore, knowledge scores were significantly different by age groups, categories of marital status, education levels, and hometown (p < 0.001). Male gender, age-group of 16–29 years, marital status of “never married,” education of bachelor’s degree or lower, and occupations of unemployment and students had lower knowledge score.8 Another study of KAP toward COVID-19 infection among residents of Anhui, China, showed that the residents took various actions to prevent and control the epidemic. These actions include “no gathering and less going out” 97.4% (n = 3,913), “putting masks on when going out” 93.6% (n = 3,758), and “do not go to crowded and closed places”.9 Azlan et al. conducted a survey of KAP toward COVID-19 infection using social networks in adults of Malaysia. The survey consists of 13 questions and the average knowledge score of Malaysians in regard to COVID-19 infection was moderate at 10.5 ± 1.4 with an overall correct rate of 80.5%. However, correct rates of COVID-19 knowledge ranged widely indicating that while some subjects had high levels of knowledge on the disease, others did not.10 For instance, Malaysians above the age of 50 held higher knowledge scores, possibly due to a higher risk intuition of contraction and complications from the disease.11 There was another KAP study toward COVID-19 infection among healthcare workers of District 2 Hospital, Ho Chi Minh, Vietnam. The mean age of subjects was 30.1 ± 6.1, most of them were female (74.0%), the highest percentage of subjects were nurses (70.9%), and the majority of them had less than 5 years of experience (62.9%). About 98.2% of subjects knew the COVID-19 outbreak and the main sources of COVID-19 information were social media and the Ministry of Health website 91.1% and 82.6%, respectively. The percentage of the subjects who knew that COVID-19 is a virus were 99.1%, and who knew how to prevent transmission between humans were 98.2%, and the subjects who knew that infected cases could result in death were 98.8%.12
Our results showed that people adopted practices of wearing masks and washing hands to prevent from COVID-19 in a short time despite COVID-19 being a recent incident. This indicates that the State Emergency Commission and Ministry of Health provide people with COVID-19 information, education, and publicity through every possible media intensively. Because of the well-organized safety program from the government and KAP of the residents of Ulaanbaatar city, Mongolia became one of the countries who has lowest infectious rate of COVID-19 in the world. This is the first study to evaluate the knowledge, attitude, and practices of COVID-19 infection in Mongolia. We included some health and medical related participants in this study and there were not few studies which evaluated the knowledge, attitude, and practices of medical or pharmaceutical workers in some infectious and noncommunicable diseases in other countries.13,14
The population has a relatively good level of KAP toward COVID-19 in Mongolia. The knowledge of subjects correlates with their attitude and practices. Thus, intensifying the educational and advertisement work of COVID-19 is significant to elevate knowledge of COVID-19 risk and to form the right practices and attitudes among people.
We thank our colleagues from the Department of Internal Medicine of Institute of Medical Sciences, Mongolian National University of Medical Sciences who provided insight and expertise that greatly assisted for the research.
Tegshjargal Badamjav https://orcid.org/0000-0001-9982-949X
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