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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 31
| Issue : 2 | Page : 276-281 |
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Development and psychometric testing of the Knowledge, Attitude, and Practice Questionnaire to assess knowledge, attitude, and practices regarding COVID-19 among patients attending COVID screening outpatient department in a tertiary care hospital in North India
Nidhi Chauhan1, Ravi Rohilla2, Deepak Aggarwal3, Sumeesha Jaswal1, Abhayraj Singh1, Priti Arun1
1 Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
2 Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
3 Department of Pulmonary Medicine, Government Medical College and Hospital, Chandigarh, India
| Date of Submission | 09-Aug-2021 |
| Date of Acceptance | 06-Jan-2022 |
| Date of Web Publication | 08-Aug-2022 |
Correspondence Address:
Dr. Nidhi Chauhan
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ipj.ipj_177_21
 Abstract | | |
Background: COVID-19 pandemic has hit the world leading to major disruptions globally. Due to its highly contagious nature and associated mortality, a wide array of emotional and behavioral reactions were seen which indirectly reflected the knowledge, attitudes, and practices (KAP) of individuals. Understanding the KAP of individuals is fundamental when it comes to decreasing future COVID cases. Aim: The study aimed to develop a Knowledge, Attitude, and Practice Questionnaire regarding COVID-19 (COVID-KAPQ) among patients attending screening outpatient department (OPD) in a tertiary care hospital in North India and evaluate its psychometric properties. Materials and Methods: The study procedure consisted of step-wise procedure starting with item generation, expert evaluation for categorization of items into domains of KAP and testing for psychometric properties. The items were generated and evaluated by the Delphi method based on 8 experts. Reliability and validity were assessed using data from 200 patients attending COVID screening OPD. Content validity was evaluated using content validity index (CVI); construct validity was examined using exploratory factor analysis and Cronbach's alpha coefficient was computed for internal consistency. Results: The final COVID-KAPQ consisted of three domains and 29 items. Cronbach's alpha coefficient for the entire questionnaire was 0.734, 0.710 for knowledge domain, 0.614 for attitudes domain, and 0.759 for practice domain. CVI ranged from 0.86 to 1. Five factors each for knowledge and attitudes domain and two factors for practice domain were extracted by principal factor analysis and varimax rotation, with a cumulative contribution of 70.19%, 71.54%, and 66.77% variance in KAP domain. Conclusions: A questionnaire COVID-KAPQ (KAP regarding COVID-19) was developed. Psychometric testing indicated that it had adequate validity and reliability for use in COVID research in the general population. This questionnaire might help the public health researchers to map the level of KAP in the population and plan awareness and prevention strategies accordingly.
Keywords: Attitudes and practices, COVID, knowledge, psychometric testing, questionnaire development
How to cite this article:
Chauhan N, Rohilla R, Aggarwal D, Jaswal S, Singh A, Arun P. Development and psychometric testing of the Knowledge, Attitude, and Practice Questionnaire to assess knowledge, attitude, and practices regarding COVID-19 among patients attending COVID screening outpatient department in a tertiary care hospital in North India. Ind Psychiatry J 2022;31:276-81 |
How to cite this URL:
Chauhan N, Rohilla R, Aggarwal D, Jaswal S, Singh A, Arun P. Development and psychometric testing of the Knowledge, Attitude, and Practice Questionnaire to assess knowledge, attitude, and practices regarding COVID-19 among patients attending COVID screening outpatient department in a tertiary care hospital in North India. Ind Psychiatry J [serial online] 2022 [cited 2022 Dec 7];31:276-81. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/276/353552 |
COVID-19, as it is commonly called, caused by a novel SARS-CoV-2 virus, leads to a plethora of symptoms in essentially all organ systems but especially affecting the lungs (leading to severe acute respiratory syndrome in severe cases). It is a highly conatgious virus with no successful antiviral treatment or vaccine. It hit the world like a storm and it spread exponentially which led to major disruptions globally. The WHO declared it as a public health emergency of international concern, the highest level of alarm under international law. Nations worldwide sprang into action, applying different measures like nationwide lockdown, travel limitations, control on mass gatherings, screening international travelers, quarantining them, and contact tracing to control its spread. Governments worldwide held multiple campaigns to increase the knowledge of the general public regarding the disease and methods to be employed to prevent the spread of virus. Public health measures were advocated as of utmost importance for the control of spread such as social distancing, respiratory etiquettes, washing hands, and not touching the face. Numerous platforms were available to the public to seek information regarding COVID-19.
Knowledge, attitude, and practice (KAP) research is considered to be the primary educational intervention for mitigation of communicable diseases for decades.[1] Ample research is present to demonstrate that level of KAP in individuals is linked to efficient management of illness, response to management and promotion of one's health.[2],[3] Lower KAP levels, on the other hand, is associated with poor health outcomes, poor health-care resource utilization, and maladaptive disease preventive behaviors.[4],[5] The knowledge gained determines the attitude toward the disease and modifies the behavior. The general public had been taken aback by the rapid deterioration of health caused by viruses which created confusion, fear, and anxiety, giving rise to harmful stereotypes, a lot of it being attributed to misinformation. WHO issued guidelines and developed online courses and training to fight the stigma as it can drive people to hide their illness and discourage them from adopting healthy behaviors.[6] Incorrect attitudes and practices directly increase the risk of infection. The battle against COVID-19 is still continuing. To guarantee success, public's adherence to control strategies is quintessential which are dictated by their KAP.
To the best of our knowledge, there is no structured tool to assess the KAP regarding COVID-19. The article aims to prepare a questionnaire for the survey to assess KAP of the population toward combating the pandemic and to examine its psychometric properties with the background understanding that despite widely circulated information from many governmental and nongovernmental sources COVID-19 cases are increasing. Thus, the tool developed as a part of this study will capture the factors having the highest weightage in KAP of population through appropriate statistical analysis. A KAP survey is a suitable way to identify effective strategies for behavioral change in society, thus having an overall health implication.
| Materials and Methods | |  |
The standardized methodology was followed in the process of development and validation of the questionnaire that included steps such as literature review, expert evaluation, pilot study, validation of the questionnaire, etc.
Item generation
Items were prepared by listing items related to COVID-19 with respect to what is known about COVID-19 and the general attitude people hold for the illness and related domains based upon the awareness material regarding COVID-19 provided by the Ministry of Health and Family Welfare, Government of India. In addition, some items were generated upon the common reactions observed in people in regard to COVID-19.
Expert evaluation
The list so prepared was subjected to expert evaluation by a team of 8 experts (that included consultant psychiatrists, clinical psychologists and pulmonogists). The experts were requested to provide critical appraisal and to label each item as knowledge/attitude/practice. They were also requested to rate whether each item is relevant or not on a 0-4 likert scale; 0- not relevant and 4- very relevant). The percentage concurrence for each item on the three domains of knowledge, attitude, or practice for all responders was computed and items scoring maximum concurrence were grouped under one domain. Items with selection rate of <90% were deleted.[7] To ascertain the feasibility of the instrument, it was piloted on a small group (30 subjects which were not included in the final sample) after which it was further modified and shaped in its present version.
Participants and survey procedure
After the entire exercise, the questionnaire was administered on a population of 200 participants to examine the construct validity and internal consistency of the questionnaire. The final questionnaire obtained was applied to participants who understood Hindi and English, were above 18 years of age, and were visiting the COVID-19 screening outpatient department (OPD) at a tertiary care teaching hospital in North India. Verbal informed consent was obtained from all participants in which they were informed regarding the purpose and objectives of study, voluntary participation, declaration of confidentiality, and anonymity; care was taken to maintain social distancing and no pen-paper was used for obtaining consent to minimize risk of transmission of COVID infection to one another. The questionnaire was administered by a mental health professional. Content validity and face validity were established by expert evaluation.
Ethical approval
The study was approved by the Institutional Ethics Committee and all the participants gave verbal informed consent with due maintenance of physical distancing before their participation. Written informed consent was not sought as a precautionary measure attempting to prevent the spread of COVID-19.
Statistical analysis
Data were analyzed using SYSTAT (Systat Software, Inc., San Jose California, USA) software version 13.2 for Windows. Construct validity was obtained by exploratory factor analysis with varimax rotation to test the hypothesized domain structure and internal consistency evaluated by calculating the Cronbach's alpha coefficient. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett's test of sphericity was applied prior to factor analysis to see appropriateness of data for factor analysis. The factor analysis was based on the following criteria: (a) a bigger KMO value: KMO value should be between 0 and 1, the greater its value, the better factor analysis results. If KMO value is <0.5, it is unsuitable for factor analysis. (b) Significant Bartlett ball test (P < 0.05), which was used to examine whether the factor was independent. The first criterion of a candidate variable to be considered suitable for entering in a particular factor is when it has a factor loading of >0.50. The second criterion was for maximizing of the Cronbach's alpha (>50%).
| Results | | |
The mean age of males and females was 40.90 (13.28) and 40.08 (14.19) years, with an overall mean age of 40.61 (13.58) years. Demographic characteristics of the participants are given in [Table 1].
Development of the questionnaire
A list of 45 items was generated which consisted of questions on knowledge, attitude and practice related to COVID-19. The questionnaire was subjected to expert evaluation for evaluation of content validity and face validity. The percentage concurrence of experts for each item under KAP domain was computed. Those items with maximum concurrence (~90%) under the respective domain were considered for that particular domain. All items for which concurrence was low were again subjected to modification and expert evaluation till ~90% concurrence was achieved for each item in a particular domain. Items with selection rate <90% were deleted.[7]
Validation of questionnaire
Content validity index (I-CVI) for each item was computed as the number of experts providing a score of 3 or 4 divided by the total number of experts.[8] With more than 5 experts, the I-CVI should not be lower than 0.78.[9] The I-CVI for most items was in the range of 0.86–1; 4 items had I-CVI of <0.78, and therefore, these items were deleted from the questionnaire.
Thereafter, the questionnaire consisted of 41 items, 31 items had a yes/no/not sure response whereas, the rest were multiple answers correct type responses; items 1–21 (21 items) pertained to knowledge regarding the novel coronavirus disease (COVID-19), 22–35 (14 items) pertaining to attitude toward COVID-19, and 36–41 (6 items) pertaining to practice/behaviors regarding COVID-19. The items dealt with clinical presentation, transmission, preventive measures, attitudes, and practices. A separate section for recording the sociodemographic details was also included.
Result of internal consistency
The overall Cronbach's alpha coefficient for the entire questionnaire was 0.734 (0.679–0.785). The Cronbach's alpha coefficient for individual domains of knowledge was 0.710 (0.648–0.766), attitude domain 0.614 (0.529–0.688), and practice domain was 0.759 (0.703–0.807).
Result of construct validity
Exploratory factor analysis was used to explore the appropriate construct of COVID KAP questionnaire. In the index study, the KMO value was 0.632 (KMO value for knowledge domain = 0.631, attitude domain = 0.570, and practice domain = 0.696), Bartlett's test of sphericity was found to be significant (2 = 3561.12, P < 0.001). Therefore, the exploratory factor analysis could be conducted on this study.
Principal component analysis with biggest variance orthogonal rotation was applied to determine the underlying factor structure of 41 items. The factor loading of all questionnaire items were not present cross, and the factor loading values were more than 0.5, ranging from 0.521–0.959, highlighted in [Table 2]. Since eigenvalues were more than 1, five meaningful factors were extracted for the knowledge domain and attitude domain. Two meaningful factors were extracted for the practice domain. The factors explained 70.19% variance of knowledge domain, 71.54% of variance of attitude domain, and 66.77% variance of practice domain, as shown in [Table 3].
Out of 41 items, items 1 and 2 are constant, items 7, 8, 9, 20, 21, 33, 34, and 35 were multiple-choice questions (do not follow the Likert scale), items 11 and 37 did not qualify (with factor loading <0.5) and thus were excluded from the final questionnaire. The final 29 item questionnaire included 13 items in the knowledge domain (items 1–13), 11 items in the attitude domain (items 14–24). and 5 items in the practice domain (items 25–29) (attached in the Supplementary Files). The scoring of the questionnaire is also attached in the Supplementary File.
| Discussion | | |
In the index study, we developed and validated a 29-item questionnaire knowledge, attitudes, and practices questionnaire regarding COVID-19 (COVID-KAPQ) and result findings reveal that COVID-KAPQ is fairly consistent, reliable, and a valid questionnaire. To the best of our knowledge, this is the first reliable and validated tool to measure KAP of the general population regarding COVID-19. A similar study of developing questionnaire to assess KAP of students in Indonesia was conducted which included 36 items based on confirmatory factor analysis and Rasch analysis.[10]
The Cronbach's alpha coefficient reflects internal consistency of the questionnaire. Cronbach's alpha coefficient value between 0.65 and 0.70 is the minimum acceptable value, 0.70–0.80 is rather good, and 0.80–0.90 is the best. Our results showed that the Cronbach's alpha coefficient of the questionnaire was 0.734, revealing that COVID-KAPQ has good internal consistency. The test–retest reliability of COVID-KAPQ could not be evaluated because to the best of our knowledge, there is no reliable and valid tool assessing KAP in COVID.
The CVI of COVID-KAPQ items was in the range of 0.86–1, consistent with the requirement of a CVI of at least 0.8, suggesting that the items could reflect the KAP condition in the general population regarding COVID-19. It is reported that if the cumulative contribution rate is above 40%, and if each item on the corresponding factor owns enough loading (>0.4), the factor is acceptable and the relationship between the item and factor is meaningful.[11] The index study adopted the principal component factor analysis method, and five factors each for knowledge and attitude domain and two factors for practice domain were extracted. The cumulative contribution rate for KAP domain was 70.19%, 71.54%, and 66.77% and the corresponding factor loading of each item was >0.5, revealing that each item in the common factor distribution conformed to the theoretical construction of the questionnaire. These results displayed that the COVID-KAPQ has reasonable construct validity.
Despite all this, the index study has certain limitations in the form of a study sample consisting of subjects from urban backgrounds of a particular geographical area attending the screening OPD at a tertiary care hospital. The KAP of subjects from the rural background, various other geographical regions may be different which can be an area of further research. Furthermore, the index study was cross-sectional in nature and results may change with time.
| Conclusions | | |
An instrument which may be useful as an easy-to-use self-report measure of general population KAP toward COVID was developed and tested in the index study. The analyses of reliability and validity demonstrated strong psychometric properties of COVID-KAPQ. The COVID-KAPQ is an augmentation in the COVID research with a validated and reliable questionnaire to assess KAP of the general population toward COVID-19. Public health professionals can use COVID-KAPQ to tap KAP level among the general population, and data thus obtained may be used as the basis to improve awareness and prevention strategies and control.
Acknowledgment
The authors want to acknowledge the contribution of Dr. B.S Chavan who was the motivating force behind the initiation of this work. His constant encouragement gave the impetus to complete this work. However, as destiny would have it, he left for his heavenly abode on December 4, 2020, and is not among us to share the joy of watching the work getting published.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Supplementary Files
Survey on Persons Coming to COVID-19 Screening OPD at GMCH
Consent Statement
Hello,
We are working on knowledge, attitude, and practices of persons who are concerned because of coronavirus and are coming to screening OPD for testing. We are conducting this study to find out community readiness for the prevention of COVID-19 infection. The information from this study will help us to educate our community for effective prevention of COVID-19 transmission from infected persons to persons around them. All of the information provided by you will not be shared with anyone and will be kept confidential. Your participation in this study is voluntary. There are no right or wrong responses. Therefore, we encourage you to be honest and truthful in your responses so that we can accurately understand the on-the-ground situation.
By signing below, I attest that I have read the above statement and willing to participate in the study on my own without any coercion.
Signature of the participant...............................
Date:-__________
Questionnaire to tap knowledge, attitude, and practices toward COVID-19 infection
Sociodemographic Characteristics
Gender: Male/Female Age: __________ years
What is your highest level of education?
- No formal education
- Primary (up to 5th)
- Completed 8th class
- Completed 10th class
- Completed12th class
- Completed Diploma/Bachelors
- Completed Masters
- Professional degree
What is your religion?
- Hindu
- Sikh
- Islam
- Christianity
- Other______________________
- I don't hold any religious beliefs
What is your occupation?
- Health professional
- Non health professional (teacher, engineer, banking, govt. employee)
- Farmer, laborer, vendor
- Religious preacher
Interpretation:
Knowledge domain: Items 1–13
Attitude domain: 14–24
Practice domain: 25–29
Scoring: 0- No/disagree/no risk
1- Unsure/low risk
2- Yes/agree/high risk
*Items 11, 18, 19, 24 to be coded in reverse manner.
For item 11 – scoring Yes/unsure/disagree to be replaced by high risk/low risk/no risk.
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[Table 1], [Table 2], [Table 3]
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