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Brazilians’ level of knowledge, attitudes and practices towards COVID-19: a cross-sectional study

ABSTRACT

BACKGROUND:

Brazil is facing increasing cycles of numbers of infected people and deaths resulting from coronavirus disease 2019 (COVID-19). This situation involves a series of factors, including the behavior of the population, that can be decisive for controlling the disease.

OBJECTIVE:

To determine the knowledge, attitudes and practices of the Brazilian population regarding COVID-19.

DESIGN AND SETTING:

Cross-sectional survey-type study, conducted using a population sample from different Brazilian states.

METHODS:

A quantitative, descriptive and analytical approach was used. Sampling was done according to convenience and via snowballing. The data collection instrument was a knowledge, attitudes and practices system.

RESULTS:

1,655 people from all over Brazil participated in the survey; 80% were living in the southern region and 70.15% were female. More than 90% had knowledge and good attitudes relating to the means of transmission, preventive care and symptoms associated with COVID-19, although their knowledge and attitudes were not fully reflected in daily practices, for which there was lower adherence (80%). Greater knowledge was correlated with older participants, larger number of children, female sex and marital status; better attitude, with female sex and complete higher education; and better practices, with greater age, larger number of children and female sex.

CONCLUSION:

A large part of the population has general knowledge about COVID-19, but not all knowledge was applied in practice. Older people, females and university graduates stood out as the best informed and most committed to controlling the disease.

KEY WORDS (MeSH terms):
Behavior; Public health; COVID-19; SARS-CoV-2

AUTHORS’ KEY WORDS:
Information; Conduct; 2019 novel coronavirus

INTRODUCTION

Through the etiological agent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), coronavirus disease 2019 (COVID-19) has become responsible for causing respiratory11. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470-3. PMID: 31986257; https://doi.org/10.1016/S0140-6736(20)30185-9.
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,22. Huang Q, Wu X, Zheng X, et al. Targeting inflammation and cytokine storm in COVID-19. Pharmacol Res. 2020;159:105051. PMID: 32603772; https://doi.org/10.1016/j.phrs.2020.105051.
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and systemic33. Bezerra TC, Vieira KABDC, Abreu, JMF, et al. Covid-19 e suas manifestações sistêmicas/Covid-19 and its systemic manifestations. Braz J Hea Rev. 2020;3(5):14633-43. https://doi.org/10.34119/bjhrv3n5-258.
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disorders among many thousands of people around the world, including severe expressions. These conditions are related to individuals’ intense and disordered multisystemic inflammatory response to the disease.11. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470-3. PMID: 31986257; https://doi.org/10.1016/S0140-6736(20)30185-9.
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,22. Huang Q, Wu X, Zheng X, et al. Targeting inflammation and cytokine storm in COVID-19. Pharmacol Res. 2020;159:105051. PMID: 32603772; https://doi.org/10.1016/j.phrs.2020.105051.
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COVID-19 has already infected more than 178,927,817 people and has led to the death of at least 3,875,915 people worldwide. In South America, about 500,000 people have lost their lives to this disease in Brazil alone. In the first half of 2021, Brazil was experiencing its worst time regarding the numbers of cases/deaths since the beginning of the pandemic.44. Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (Johns Hopkins University). COVID-19. Available from: https://coronavirus.jhu.edu/map.html. Accessed in 2021 (Jun 12).
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Therefore, despite the advances in vaccines against SARS-CoV-2, the classic methods of non-pharmacological prevention and control, such as proper hand hygiene with alcohol gel and use of masks, need to be continued and encouraged,55. Leslie AR, Zhou SS, Macinga RD. Inactivation of SARS-CoV-2 by commercially available alcohol-based hand sanitizers. Am J Infect Control. 2021;49(3):401-2. PMID: 32818578; https://doi.org/10.1016/j.ajic.2020.08.020.
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along with social distancing, especially for high-risk groups.66. Brandén M, Aradhya S, Kolk M, et al. Residential context and COVID-19 mortality among adults aged 70 years and older in Stockholm: a population-based, observational study using individual-level data. Lancet Healthy Longev. 2020;1(2):e80-e88. PMID: 33521770; https://doi.org/10.1016/S2666-7568(20)30016-7.
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Studies have confirmed that the speed with which new cases of COVID-19 occur reduces as social isolation increases.77. Silva FCD, Zamprogna KM, Souza SS, Silva DH, Sell D. Social isolation and the speed of covid-19 cases: measures to prevent transmission. Rev Gaucha Enferm. 2021;42(spe):E20200238. PMID: 33787728; https://doi.org/10.1590/1983-1447.2021.20200238.
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It is likely that adherence to non-pharmacological prevention measures and the success or failure of such actions are closely influenced by the population’s awareness of the subject,88. Pal R, Yadav U, Grove S, et al. Knowledge, attitudes and practices towards COVID-19 among young adults with Type 1 Diabetes Mellitus amid the nationwide lockdown in India: A cross-sectional survey. Diabetes Res Clin Pract. 2020;166:108344. PMID: 32710997; https://doi.org/10.1016/j.diabres.2020.108344.
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which is endorsed by the theory of knowledge, attitudes and practices. This theory, which was first put forward in the 1960s, assumes that suitable health-related behavior is divided into three continual processes, “the acquisition of knowledge, the generation of attitudes and the change in behavior itself”.99. Kim TR, Ross JA, Smith DP. Korea-trends in four National Kap Surveys, 1964-67. Studies in Family Planning. 1969;1(43):6-11. https://doi.org/10.2307/1965090.
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From this perspective, knowledge is the determining factor for a change in behavior, while beliefs and attitudes are the “driving force” of this change.99. Kim TR, Ross JA, Smith DP. Korea-trends in four National Kap Surveys, 1964-67. Studies in Family Planning. 1969;1(43):6-11. https://doi.org/10.2307/1965090.
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,1010. Fan Y, Zhang S, Li Y, et al. Development and psychometric testing of the Knowledge, Attitudes and Practices (KAP) questionnaire among student Tuberculosis (TB) Patients (STBP-KAPQ) in China. BMC Infect Dis. 2018;1(213):1-10. PMID: 29739363; https://doi.org/10.1186/s12879-018-3122-9.
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This theory builds on the foundations of another concept that was created in 1950, “the health belief model”, which argues that belief is essential for people to adopt healthy behavior, based on preventive pillars.1111. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs. 1974;2(4):328-332. https://doi.org/10.1177%2F109019817400200403.
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Through the media and official health agencies, information about COVID-19 has been intensively disseminated. However, given the continuing debate and scientific advances relating to preventive care, diagnostic criteria and treatment, this knowledge does not remain static.1212. Araujo-Filho JAB, Sawamura MVY, Costa AN, Cerri GG, Nomura CH. COVID-19 pneumonia: what is the role of imaging in diagnosis? J Bras Pneumol. 2020;46(2):e20200114. PMID: 32236303; https://doi.org/10.36416/1806-3756/e20200114.
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Nonetheless, it needs to be asked whether there is any process of acquisition of knowledge and adherence to attitudes/practices regarding preventive measures against COVID-19 among people in Brazil.

Understanding these attitudes, or lack of them, during the pandemic can show up any bottlenecks that may exist and the reasons for failure, in situations relating to the great present challenge of ensuring the safety and effective protection of the population.1313. Adalja AA, Toner E, Inglesby TV. Priorities for the US health community responding to COVID-19. JAMA. 2020;323(14):1343-4. PMID: 32125355; https://doi.org/10.1001/jama.2020.3413.
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OBJECTIVE

Thus, the aim of this study was to assess the level of knowledge, attitudes and practices of the Brazilian population towards COVID-19, in relation to its sociodemographic characteristics, through using a method for ascertaining knowledge, attitudes and practices.

METHODS

The present study received prior approval from the National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa, CONEP) on April 3, 2020, under the number 3.982.636, as provided for in Resolution 466/2012 of the National Health Council. The research that was developed was of survey type, with a quantitative descriptive-analytical approach. The sampling used was obtained according to convenience and through snowballing, given the possible ignorance of the study participants. This method enabled identification and integration of the sample through third-party references.1414. Biernacki P, Waldorf D. Snowball Sampling: Problems and Techniques of Chain Referral Sampling. Sociological Methods & Research. 1981;10:(2):141-63. https://doi.org/10.1177/004912418101000205.
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We spread word of this study among our existing contacts through the instant messaging application WhatsApp. Participants thus recruited were asked to send invitations randomly to their telephone contacts, to try to also enroll them as participants in this research. We aimed to reach the largest number of people and different audiences possible, and to enable participation and responses from all Brazilian states.

The messages sent out provided a link to access an electronic form that we developed on Google Forms. This containing the informed consent statement, guidelines for resolution, and study questions to be answered by people aged 18 years and over. For people who agreed to participate in the study, but who because of limitations indicated that they were unable to provide responses through the form (this was especially the case among elderly participants), the form was applied via telephone, in accordance with the ethical guidance of Resolution No. 510/2016 of the National Health Council.1515. Brasil. Diário Oficial da União. Resolução nº 510, de 7 de abril de 2016. https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22917581. Accessed in 2021 (Apr 27).
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Data collection took place from July to December 2020. The sample size was calculated using a scale based on the items/subject ratio and at least five participants per item, as proposed by Pasquali.1616. Pasquali, L. Psicometria Teoria dos testes na psicologia e na Educação. 5a ed. Petrópolis: Vozes, 2013. In this study, approximately 71 participants were used per item, with the highest possible number of members. This was a decisive factor with regard to the internal consistency of the scale.1616. Pasquali, L. Psicometria Teoria dos testes na psicologia e na Educação. 5a ed. Petrópolis: Vozes, 2013.

Individuals from 23 Brazilian states took part in the study. The only states from which there were no responses were Roraima, Amapá and Amazonas. Participants answered a questionnaire containing 23 questions with three choices: a) true; b) false; and c) I don’t know. These questions sought to recognize clinical and epidemiological knowledge;1515. Brasil. Diário Oficial da União. Resolução nº 510, de 7 de abril de 2016. https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/22917581. Accessed in 2021 (Apr 27).
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attitudes and practices in relation to COVID-19;1717. World Health Organization. Advice on the use of masks in the context of COVID-19. Available from: https://apps.who.int/iris/bitstream/handle/10665/331693/WHO-2019-nCov-IPC_Masks-2020.3-eng.pdf?sequence=1&isAllowed=y2020. Accessed in 2021 (Mar 22).
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and sociodemographic characteristics (age, sex, marital status, education, state of origin, profession and children).1818. World Health Organization. Conselhos sobre doença coronavírus (COVID-19) para o público. Available from: https://www.who.int/pt/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Accessed in 2021 (Aug 23).
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This was adapted from a previously published knowledge, attitudes and practices system.99. Kim TR, Ross JA, Smith DP. Korea-trends in four National Kap Surveys, 1964-67. Studies in Family Planning. 1969;1(43):6-11. https://doi.org/10.2307/1965090.
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The questions in this instrument addressed information and concepts set forth by the World Health Organization,1818. World Health Organization. Conselhos sobre doença coronavírus (COVID-19) para o público. Available from: https://www.who.int/pt/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Accessed in 2021 (Aug 23).
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regarding etiological agents, transmission routes, protection routes, signs and symptoms, the most vulnerable populations, care and related beliefs. The instrument was built for use in a general population in which people might be unfamiliar with the subject. Therefore, easily understood questions were recommended: these were evaluated from the semantic, conceptual and cultural points of view by three consultants, who were specialists in the field of infectious diseases and in the methodology of this study.

The responses to all the questions were organized to enable association analysis and were counted in a scoring system. Each item in the knowledge, attitudes and practices system consisted of a statement with three alternatives: a) true; b) false; and c) I don’t know. The alternatives “false” and “I don’t know” were subsequently condensed into a single “false” alternative1919. Lee M, Kang BA, You M. Knowledge, attitudes, and practices (KAP) toward COVID-19: a cross-sectional study in South Korea. BMC Public Health. 2021;21(295):1-10. PMID: 33546644; https://doi.org/10.1186/s12889-021-10285-y.
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because of the small number of statements of the type “I don’t know”.

The assertions were graded as correct or incorrect, and scores were calculated from the sum of these responses. Continuous/numerical variables were then subjected to descriptive analysis (mean, median and standard deviation); and categorical/qualitative variables were subjected to absolute and relative frequency analysis.

Regarding the scores per domain, the maximum score for knowledge was 13, while for practices and attitudes it was five points. Initially, the data were subjected to a normality test (Kolmogorov-Smirnov). Because the data were found not to adhere to normal distribution, nonparametric tests were used for quantitative numerical correlations (age and number of children) and Spearman’s correlation coefficient was calculated. For comparative analysis on nominal qualitative variables, the Mann-Whitney test was used for sex and the Kruskal-Wallis test with Tukey’s multiple comparisons was used for marital status and educational level. Variables for which the correlations were significant (P < 0.05) were integrated with the multiple regression analysis for each score, which was performed by using the stepwise method, in the SPSS for Windows software, version 19.0.0 (SPSS, São Paulo, Brazil).

RESULTS

One thousand six hundred and fifty-five people participated in the survey, of whom 1,161 (70.15%) were women, and 494 (29.84%) were men. The participants were aged between 18 and 92, with an average age of 35 (SD 14.55). Regarding marital status, 804 (48.55%) of the participants reported being married or in a stable relationship, and 754 (45.53%) were single. Approximately 50% had children. The predominant level of education among the participants was complete higher education (54.65%), followed by incomplete higher education (28.44%). The majority had some form of occupation at the time when they answered the questionnaire. Among the participants, 650 (39.27%) said that they had a job in companies, 226 (13.65%) worked in education and 189 (11.41%) were students. The other 590 individuals (35.67%) were distributed in other less frequent functions (Table 1).

Table 1.
Sociodemographic characteristics of the study participants

Among the interviewees, 1,334 (80%) were from the southern region, 218 (13.18%) from the southeast, 44 (2.66%) from the center-west, 43 (2.59%) from the north and 15 (0.90%) from the northeast. The participation of 1,041 individuals (62.90%) living in the state of Paraná can be highlighted: this was the state in which the distribution of the questionnaire began (Table 1).

In the system for evaluating the knowledge, attitudes and practices of the participants in relation to COVID-19, the highest score (percentage of correct answers) was in the knowledge domain (94.84%), followed by the score in the attitudes domain (92.20%). The lowest performance, i.e. the lowest number of correct responses from the participants (80.00%), was in relation to the questions in the practical domain (Table 2).

Table 2.
Frequency of correct responses, overall mean and percentage mean (%) of statements relating to the knowledge, attitudes and practices of the study participants towards coronavirus disease 2019 (COVID-19)

In the knowledge domain, about 98% of the participants showed that they knew that “COVID-19 has droplet transmission”, that “the flu vaccine does not prevent COVID-19”, that “they should avoid crowded places” and that “social isolation is effective for prevention of COVID-19.” Moreover, about 88% recognized that “younger people, elderly people and immunosuppressed children form a group that is more vulnerable to the disease”. When asked about preventive care, such as “rubbing one’s hands together for 20 seconds” during “hand washing with soap and water, and use of alcohol gel”, the average percentage of correct responses (knowledge among the participants) also decreased to 96.60% and 90.40%, respectively (Table 2).

It was found that 98.50% of the participants were aware that they “should seek the healthcare service in the event of fever and respiratory distress”, but on the contrary, almost 10% of them did not recognize that “COVID-19 can cause respiratory problems”, and another 15% did not recognize that “fever and cough are common in COVID-19”. In addition, almost half of the participants (46%) were unaware that symptoms such as “runny nose and sneezing are less common” among individuals infected with this disease (Table 2).

Regarding attitudes, approximately 6% of the study participants did not “believe in the effectiveness of the World Health Organization and Ministry of Health recommendations” and did not “follow them”. For some of them (3.02%), this was because they considered that “social isolation does not decrease contamination”; while for others (6.65%), this was because they did not believe in “the severity of the disease.” However, a higher percentage of participants (20%) considered that “the pandemic is non-transitory”, and 3.08% showed concern about the disease, through the belief that, directly or indirectly, “it is reflected in damage to health and employment” (Table 2).

Regarding the domain of the participants’ practices, almost 50% reported “having normally frequented public places”, even though 15.17% of them were “living with people in the high-risk group”. Although a large part of the population continued to attend public places, the majority (96.68%) claimed to carry out “hand washing” and “social distancing” in public places and had started to “greet people with gestures” (93.66%). However, in their routine, “sanitizing your belongings and objects” was not a practice for 26.40% of the participants.

Correlations between sociodemographic variables and the knowledge, attitudes and practices system showed differences with regard to knowledge, attitudes and practices (Tables 3, 4 and 5).

Table 3.
Average knowledge score versus demographic variables (age, number of children, sex, marital status and educational level of the participants)
Table 4.
Average score for attitudes versus demographic variables (sex and educational level of the participants)
Table 5.
Average score for practices versus demographic variables (age, number of children and sex of the participants)

The variables of age, number of children, sex, marital status and education were correlated with the knowledge domain (P = 0.001). Greater age, larger number of children and longer education correlated with greater knowledge. Females and married people had higher scores for this domain than males and single people (Table 3).

Regarding the attitudes domain, it was noted that females had higher scores (P = 0.034). There was also an association between education and the attitudes of the participants. The categories of complete high school and incomplete higher education did not differ from each other; however, they presented a lower score than complete higher education (Table 4).

Regarding practices, there was a correlation between age and the number of children of the participants. Older age and a larger number of children increased adherence to correct practices (P = 0.014 for age; and P = 0.028 for the number of children). As in the other domains, females also had a high mean score than males (P = 0.001) (Table 5).

Univariate analyses in the multiple regression model also showed differences within the knowledge, attitudes and practices system in relation to demographic variables (Table 6). Females and individuals with higher education had a better relationship with the knowledge domain (Beta = 0.302 for sex; and Beta = 0.233 for education) and also with the attitudes domain (Beta = 0.100 for sex; and Beta = 0.128 for education). Furthermore, female sex also had a greater association with practice scores (Beta = 0.134).

Table 6.
Multiple regression analysis: knowledge, attitudes and practices in the study population

DISCUSSION

The overall results from this study revealed issues relating to knowledge, attitudes and practices regarding COVID-19 in Brazil. These have been undergoing extensive discussion and continual updating through the media, government bodies and the scientific community since the beginning of the pandemic.

Importantly, the method for evaluating knowledge, attitudes and practices has been adapted, built and used in other studies in different countries, depending on the cultural context and local reality.88. Pal R, Yadav U, Grove S, et al. Knowledge, attitudes and practices towards COVID-19 among young adults with Type 1 Diabetes Mellitus amid the nationwide lockdown in India: A cross-sectional survey. Diabetes Res Clin Pract. 2020;166:108344. PMID: 32710997; https://doi.org/10.1016/j.diabres.2020.108344.
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,2020. Rios-Gonzalez CM. Conocimientos, actitudes y prácticas hacia COVID-19 en paraguayos el periodo de brote: una encuesta rápida en línea. Rev Salud Publica Parag. 2020;10(2):1-20. http://doi.org/10.18004/rspp.2020.diciembre.17.
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,2121. Zhong BL, Luo W, Li HM, 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(10):1745-52. PMID: 32226294; http://doi.org/10.7150/ijbs.45221.
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As shown in Table 1, most of the population assessed had completed higher education (54.65%), similar to what was shown in other studies.2020. Rios-Gonzalez CM. Conocimientos, actitudes y prácticas hacia COVID-19 en paraguayos el periodo de brote: una encuesta rápida en línea. Rev Salud Publica Parag. 2020;10(2):1-20. http://doi.org/10.18004/rspp.2020.diciembre.17.
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2222. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8(217):1-10. PMID: 32574300; http://doi.org/10.3389/fpubh.2020.00217.
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The high scores observed for the knowledge domain generally demonstrated that the Brazilian population has knowledge about COVID-19, especially regarding the means of transmission of SARS-CoV-2 and the care required for avoiding this (96%).

Knowledge about COVID-19 in different parts of the world is quite high, but it varies depending on the region.2323. Wake AD. Knowledge, Attitude, Practice, and Associated Factors Regarding the Novel Coronavirus Disease 2019 (COVID-19) Pandemic. Infect Drug Resist. 2020;13:3817-32. PMID: 33149627; http://doi.org/10.2147/IDR.S275689.
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Surveys from two countries on different continents illustrate the differences in subjects’ levels of knowledge: the levels ranged from 62% in Paraguay2020. Rios-Gonzalez CM. Conocimientos, actitudes y prácticas hacia COVID-19 en paraguayos el periodo de brote: una encuesta rápida en línea. Rev Salud Publica Parag. 2020;10(2):1-20. http://doi.org/10.18004/rspp.2020.diciembre.17.
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to 90% in China.2121. Zhong BL, Luo W, Li HM, 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(10):1745-52. PMID: 32226294; http://doi.org/10.7150/ijbs.45221.
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The latter percentage was similar to what was found in the present study (94.84%) (Table 2).

The level of knowledge among participants in the present survey showed a relationship with their level of education. Individuals who had completed higher education had higher knowledge scores than those with incomplete elementary school, complete high school and incomplete higher education (Table 3).

On the other hand, in Nepal, for example, where 45.50% of the people had not had higher education, the average knowledge score was 60.00%.2424. Sah GS, Shrestha G, Dhakal A, et al. Knowledge, Attitudes, and Practices of Cancer Patients Towards COVID-19: A Cross-Sectional Study in Central Nepal. Cancer Manag Res. 2020;12:10173-80. PMID: 33116872; http://doi.org/10.2147/CMAR.S271910.
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Regarding preventive measures, which were evaluated in relation to part of the population (10.00%), this knowledge was found to be limited. For example, there is misinformation about the use of soap and water as an efficient alternative to use of alcohol gel for hand hygiene, or in the case of absence of alcohol gel. Similarly, in India, the majority of “educated” people and healthcare professionals were aware of how infection occurs and what the preventive measures are. Even so, about 57.00% of the people did not recognize the disease as highly contagious, and almost 10.00% did not realize the importance of hand hygiene and social isolation.2525. Roy D, Tripathy S, Kar SK, et al. Study of knowledge, attitude, anxiety and perceived mental health needs in the population during the COVID-19 pandemic. Asian J Psychiatry. 2020;51:102083. https://doi.org/10.1016/j.ajp.2020.102083.
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Along the same lines, a study carried out in the United States showed that the participants had good knowledge about the forms of transmission and symptoms. However, these individuals also showed some misconceptions: for example only 37.80% believed that use of an ordinary surgical mask was highly effective for preventing from COVID-19, and 25.60% thought that it was wise to avoid Chinese restaurants.2626. Li ZH, Zhang XR, Zhong WF, et al. Knowledge, attitudes, and practices related to Coronavirus disease 2019 during the outbreak among workers in China: A large cross-sectional study. PLoS Negl Trop Dis. 2020;14(9):e0008584. PMID: 32941447; https://doi.org/10.1371/journal.pntd.0008584.
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In Pakistan, 54.70% of the subjects reported not knowing that physical contact was the main means for spreading the infection.2727. Afzal MS, Khan A, Qureshi UUR, et al. Community-Based Assessment of Knowledge, Attitude, Practices and Risk Factors Regarding COVID-19 Among Pakistanis Residents During a Recent Outbreak: A Cross-Sectional Survey. J Community Health 2020;46(3):476-86. PMID: 32661860; https://doi.org/10.1007/s10900-020-00875-z.
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Contrary to this, in the present study, 97.76% of the participants knew that droplets are the main means of infection transmission.

Appropriation of knowledge relating to preventive care and its updates among the entire population has become essential for controlling COVID-19. Understanding of simple measures that can be applied to indoor environments in situations of limited resources, which is the reality for many Brazilian households, can be highlighted.

Regarding symptoms, 45.98% of the participants in the present study mistakenly said that a runny nose and sneezing were common in COVID-19 (Table 3). However, these do not correspond to the classic signs and symptoms of the disease,2828. World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. Accessed in 2021 (Aug 23).
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which are mainly fever (around 90%), dry cough (67.7%-86%), fatigue (38.1%) and dyspnea (18.6%-80%).1818. World Health Organization. Conselhos sobre doença coronavírus (COVID-19) para o público. Available from: https://www.who.int/pt/emergencies/diseases/novel-coronavirus-2019/advice-for-public. Accessed in 2021 (Aug 23).
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In the Philippines, a considerable proportion (89.5%) of the sample was able to point out coughing and sneezing as transmission routes.2323. Wake AD. Knowledge, Attitude, Practice, and Associated Factors Regarding the Novel Coronavirus Disease 2019 (COVID-19) Pandemic. Infect Drug Resist. 2020;13:3817-32. PMID: 33149627; http://doi.org/10.2147/IDR.S275689.
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In Brazil, 15% of the participants did not correlate some of these symptoms with COVID-19. However, recognition of typical signs and symptoms of the disease and the degree of concern that these represent, given the clinical condition manifested, directs possibly infected people to seek medical and/or hospital care at the proper time.

Regarding attitudes, the mean score identified in this study was high, thus confirming the findings from recent studies conducted elsewhere.2323. Wake AD. Knowledge, Attitude, Practice, and Associated Factors Regarding the Novel Coronavirus Disease 2019 (COVID-19) Pandemic. Infect Drug Resist. 2020;13:3817-32. PMID: 33149627; http://doi.org/10.2147/IDR.S275689.
https://doi.org/http://doi.org/10.2147/I...
In this regard, although 20% of the participants noticed that the COVID-19 pandemic was not a temporary phenomenon, 7% still refused to accept and/or follow instructions from official bodies such as the World Health Organization and the Ministry of Health (mask use, hand-cleaning with 70% alcohol or soap and water, avoidance of personal contact and avoidance of situations of crowding, among others).1717. World Health Organization. Advice on the use of masks in the context of COVID-19. Available from: https://apps.who.int/iris/bitstream/handle/10665/331693/WHO-2019-nCov-IPC_Masks-2020.3-eng.pdf?sequence=1&isAllowed=y2020. Accessed in 2021 (Mar 22).
https://apps.who.int/iris/bitstream/hand...

We observed that attitudes were not necessarily reflected in practice, considering that 26% of the participants reported that they did not clean their belongings and objects, 50% continued to go to public places and 15% were living with high-risk people. Thus, although people may believe the recommendations of official bodies for controlling the COVID-19 pandemic, in practice these recommendations are not put into effect. A large part of the population continues to have contact with many people in their daily routine, perhaps because of work needs or the mistaken feeling that only people with comorbidities (whether respiratory, cardiac or multifactorial) are likely to have a worsened prognosis when affected by COVID-19.2929. Yang J, Zheng Y, Gou X, et al. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. International Journal of Infectious Diseases. 2020;94:91-95. PMID: 32173574; http://doi.org/10.1016/j.ijid.2020.03.017.
https://doi.org/http://doi.org/10.1016/j...
However, the real reason why people were going to public places was not investigated, which thus generates a limitation to our study. Nonetheless, it can be assumed that people were doing this in relation to work needs, as shown in a study carried out in Pakistan, where 59.3% of the subjects continued to attend mosques to pray, amid the pandemic.2727. Afzal MS, Khan A, Qureshi UUR, et al. Community-Based Assessment of Knowledge, Attitude, Practices and Risk Factors Regarding COVID-19 Among Pakistanis Residents During a Recent Outbreak: A Cross-Sectional Survey. J Community Health 2020;46(3):476-86. PMID: 32661860; https://doi.org/10.1007/s10900-020-00875-z.
https://doi.org/https://doi.org/10.1007/...

From correlations and multiple regression analyses, females stood out as having the highest scores in all domains, like in other recent studies that observed higher mean scores for knowledge among women.2020. Rios-Gonzalez CM. Conocimientos, actitudes y prácticas hacia COVID-19 en paraguayos el periodo de brote: una encuesta rápida en línea. Rev Salud Publica Parag. 2020;10(2):1-20. http://doi.org/10.18004/rspp.2020.diciembre.17.
https://doi.org/http://doi.org/10.18004/...
,2222. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8(217):1-10. PMID: 32574300; http://doi.org/10.3389/fpubh.2020.00217.
https://doi.org/http://doi.org/10.3389/f...
,3030. Peng Y, Pei C, Zheng Y, et al. A cross-sectional survey of knowledge, attitude and practice associated with COVID-19 among undergraduate students in China. BMC Public Health. 2020;20:1292. PMID: 32847554; http://doi.org/10.1186/s12889-020-09392-z.
https://doi.org/http://doi.org/10.1186/s...
Different studies on infectious diseases have also show that females had greater knowledge of the subject than males.3131. Park JH, Cheong HK, Son DY, Kim SU, Ha CM. Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean university students during the peak pandemic period. BMC Infect Dis. 2010;10:222. PMID: 20663229; http://doi.org/10.1186/1471-2334-10-222.
https://doi.org/http://doi.org/10.1186/1...
,3232. Tang CS, Wong CY. Factors influencing the wearing of face masks to prevent the severe acute respiratory syndrome among Chinese in Hong Kong. Prev Med. 2004;39(6):1187-93. PMID: 15539054; http://doi.org/10.1016/j.ypmed.2004.04.032.
https://doi.org/http://doi.org/10.1016/j...

With increasing age and larger numbers of children, higher knowledge scores were observed among our Brazilian population. This was put into practice by this population, in combating the COVID-19 pandemic. These results corroborate the findings of most previous studies that investigated these socioeconomic characteristics.2020. Rios-Gonzalez CM. Conocimientos, actitudes y prácticas hacia COVID-19 en paraguayos el periodo de brote: una encuesta rápida en línea. Rev Salud Publica Parag. 2020;10(2):1-20. http://doi.org/10.18004/rspp.2020.diciembre.17.
https://doi.org/http://doi.org/10.18004/...
,2222. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8(217):1-10. PMID: 32574300; http://doi.org/10.3389/fpubh.2020.00217.
https://doi.org/http://doi.org/10.3389/f...
,2323. Wake AD. Knowledge, Attitude, Practice, and Associated Factors Regarding the Novel Coronavirus Disease 2019 (COVID-19) Pandemic. Infect Drug Resist. 2020;13:3817-32. PMID: 33149627; http://doi.org/10.2147/IDR.S275689.
https://doi.org/http://doi.org/10.2147/I...
,3333. Sun J, Xu Y, Qu Q, Luo W. Knowledge of and attitudes toward COVID-19 among parents of child dental patients during the outbreak. Braz Oral Res. 2020;8(34):e066. PMID: 32520076; http://doi.org/10.1590/1807-3107BOR-2020.vol34.0066.
https://doi.org/http://doi.org/10.1590/1...
,3434. Rahman A, Sathi NJ. Knowledge, Attitude, and Preventive Practices toward COVID-19 among Bangladeshi Internet Users. Electron J Gen Med. 2020;17(5) e245. https://doi.org/10.29333/ejgm/8223.
https://doi.org/https://doi.org/10.29333...
On the other hand, in a study carried out in central Nepal, younger people showed more substantial knowledge, according to the authors.2424. Sah GS, Shrestha G, Dhakal A, et al. Knowledge, Attitudes, and Practices of Cancer Patients Towards COVID-19: A Cross-Sectional Study in Central Nepal. Cancer Manag Res. 2020;12:10173-80. PMID: 33116872; http://doi.org/10.2147/CMAR.S271910.
https://doi.org/http://doi.org/10.2147/C...

People with higher education or who were undergoing training tended to have scattered knowledge, as demonstrated by the present study. There were correlations with the level of education, both for knowledge (Table 3) and for attitudes (Table 4). This was confirmed through regression analyses (Table 6), such that people with higher education had more adequate knowledge and attitudes towards COVID-19. Lower levels of education can be considered to be a risk factor for the spread of viral infectious diseases and for disease progression to death.3535. Lemos DRQ, Neto RJP, Perdigão ACB, et al. Fatores de risco associados à gravidade e óbitos por influenza durante a Pandemia de Influenza A (H1N1) 2009 em região tropical/semi-árida do Brasil. J Health Biol Sci. 2015;3(2):77-85. http://dx.doi.org/10.12662/2317-3076jhbs.v3i2.165.p77-85.2015.
https://doi.org/http://dx.doi.org/10.126...

It is important to highlight that the average score for practices was lower (80.00%) than the scores for knowledge and attitudes (94.84 and 92.20%). In the light of this difference, it can be inferred that knowledge alone does not guarantee good practices, or their maintenance. As the pandemic advances, non-compliance with non-pharmacological practices to protect against SARS-CoV-2 infection may become more common.

It is worth remembering that the data in this study were collected in 2020, at a time when respondents were mostly aligned with preventive practices. However, it can be seen in everyday life that many of the measures that were adopted in the middle of the pandemic are not implemented with the same rigor today. Thus, within the Brazilian scenario of restrictions, psychological disturbances (stress and depression)11. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020;395(10223):470-3. PMID: 31986257; https://doi.org/10.1016/S0140-6736(20)30185-9.
https://doi.org/https://doi.org/10.1016/...
,3636. Maia BR, Dias PC. Ansiedade, depressão e estresse em estudantes universitários: o impacto da COVID-19. Estud Psicol. 2020;37:e200067. https://doi.org/10.1590/1982-0275202037e200067.
https://doi.org/https://doi.org/10.1590/...
and narrative wars between the various levels of government, the politicization of information may have affected not only knowledge, but also especially the beliefs of people in this country. These beliefs are reflected in their attitudes and practices, as described in the published knowledge, attitudes and practices system.99. Kim TR, Ross JA, Smith DP. Korea-trends in four National Kap Surveys, 1964-67. Studies in Family Planning. 1969;1(43):6-11. https://doi.org/10.2307/1965090.
https://doi.org/https://doi.org/10.2307/...
,1010. Fan Y, Zhang S, Li Y, et al. Development and psychometric testing of the Knowledge, Attitudes and Practices (KAP) questionnaire among student Tuberculosis (TB) Patients (STBP-KAPQ) in China. BMC Infect Dis. 2018;1(213):1-10. PMID: 29739363; https://doi.org/10.1186/s12879-018-3122-9.
https://doi.org/https://doi.org/10.1186/...
In addition, progressive weakening of preventive practices may already be a reality in 2021. This is very worrying and is one of the factors responsible for the successive waves of COVID-19.

Furthermore, limitations of the study relating to sample selection may have generated some sampling bias, given that the sample was concentrated in the southern region of the country and among people with higher education levels. Thus, based on this initiative, future applications of the knowledge, attitudes and practices system are suggested, in order to understand the population, considering the changes that are occurring with regard to the COVID-19 pandemic.

CONCLUSION

Through using this knowledge, attitudes and practices system, it was found in this Brazilian population that there was a high level of knowledge about COVID-19. However, there was less commitment to practical application of this knowledge.

Furthermore, some well-informed and active social groups, like older women with children and individuals with higher education levels were noted. These groups showed greater implementation of actions to combat COVID-19. This is an important finding that should be directed towards COVID-19 coping actions for less active groups.

REFERENCES

  • Centro Universitário de Pato Branco (UNIDEP), Pato Branco (PR), Brazil
  • Sources of funding: There are no funders to report for this submission

Publication Dates

  • Publication in this collection
    02 May 2022
  • Date of issue
    May-Jun 2022

History

  • Received
    22 June 2021
  • Reviewed
    22 June 2021
  • Accepted
    23 July 2021
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