Knowledge, attitudes, and practices of chronic disease patients in Bojanala towards COVID-19

Background COVID-19 is an acute respiratory disease. Its morbidity and mortality in patients with comorbidities have been established. This study evaluated the knowledge, attitude and practices regarding COVID-19 of patients with comorbidities attending primary health care services. Methods An analytical cross-sectional study was conducted, with data collected from patients using a self-administered questionnaire. Knowledge, attitude and practice scores were calculated. Descriptive and inferential statistical analyses were used, and the level of significance was set at 5%. Results This study enrolled 469 participants aged 18–84 years, and the majority were women. The mean knowledge score was 7.09 ± 1.73 out of 9, the mean attitude score was 2.33 ± 0.86 out of 3, and the mean practices score was 3.79 ± 0.56 out of 4. There was a positive linear relationship between knowledge and attitude scores and between attitude and practices scores; as one score increased, the other also increased significantly. Conclusion The level of knowledge was good in general, with optimistic attitudes and good practices by the patients. Those aged 70 years and above need special attention because older persons have poorer knowledge of and practices towards COVID-19, which could lead to higher hospitalisation and mortality rates. Contribution This study found that patients with chronic diseases had good COVID-19 knowledge, attitudes and practices, while interventions targeting patients aged 70 years and above are needed to improve their COVID-19 awareness and practices.


Introduction
COVID-19 is a respiratory disease caused by the novel coronavirus first discovered in Wuhan.The World Health Organization (WHO) declared the official name as COVID-19 in February 2020, 1 and on 11 March 2020, declared the COVID-19 outbreak a pandemic. 2The overall mortality rate varies from 0.7% to 10.8%. 1,3with close to 200 million confirmed cases and 4 million deaths worldwide.Elderly patients and people with comorbidities suffer severe disease and have a poor prognosis with COVID-19. 3

Study population and sampling strategy
The population of the Bojanala health district is estimated at 1 779 141, with an incidence of 3.04 COVID-19 cases per 100 000 (district health information system).Participants were patients with chronic diseases attending primary health care services during the period of study.We used a single population proportion formula to determine the sample size.The assumptions were a 5% margin of error, a 95% confidence interval (CI) and a 50% prevalence for KAP.
A total of 469 respondents were selected for the study.This sample was proportionally divided into five to represent the five subdistricts.The systematic random sampling method was used, with every third client after a random start being selected for the study.

Data collection
Data were collected from patients with comorbidities using a self-administered questionnaire; where this was not possible, a research assistant (professional nurse) assisted the patients in completing the questionnaire.
The questionnaire was developed by authors using the Risk Communication and Community Engagement (RCCE) tool 17,18 and articles published on knowledge, attitude, practice and associated factors related to COVID-19 before conducting this study.
The final structured questionnaire was piloted using 12 participants in three clinics to assess the adequacy of its contents, participants' comprehension and potential difficulties.
The demographics include age in years, gender, marital status, education level and employment status.
The chronic medical conditions were hypertension, diabetes mellitus, asthma, human immunodeficiency virus (HIV) disease, chronic obstructive pulmonary disease, hypercholesterolaemia, epilepsy and mental health condition.The COVID-19 KAP section consisted of nine questions pertaining to knowledge regarding COVID-19 disease, three questions addressing attitudes towards the disease, and four questions covering patients' practices towards COVID-19.The Cronbach's alpha coefficient of the knowledge questionnaire was 0.73, indicating satisfactory internal consistency. 19

Data analysis
The data were captured in Microsoft Excel, and data management and analyses were performed using Stata 17. Mean (standard deviation [s.d.]) was used to report continuous variables, while frequencies and percentages were used to summarise categorical variables.The KAP item responses were summarised using frequencies and percentages.Cronbach's alpha was used to assess the reliability of the KAP items.Knowledge, attitude and practices scores were calculated for each patient with chronic comorbidities by adding their correct answers.A correct answer was scored 1, while an incorrect answer was scored 0. The knowledge score ranged from 0 to 9, the attitude score ranged from 0 to 3, and the practice score ranged from 0 to 4. The scores were summarised using mean (s.d.) and the Pearson correlation test was used to assess the linear relationship between the KAP scores.The scores were further categorised into binary outcomes using the mean as the mid-point for each score.The knowledge score was categorised into good (≥ 7) and poor (< 7); attitude was categorised into positive (≥ 2) and negative (< 2); and the practice score was categorised into good (≥ 4) and poor (< 4).The results for the categorised scores were summarised as frequencies and percentages.The Pearson Chi-square test assessed associations between the KAP binary variables, sociodemographic variables and comorbidity variables.Adjusted logistic regression was used to determine the factors associated with good knowledge, a positive attitude and good practices.The level of significance was set at 5%.

Ethical considerations
The research protocol was submitted to Sefako Makgatho University Research Ethics Committee (SMUREC), and ethics approval was granted (reference number: SMUREC/ M/307/2020:IR).Permission to conduct the study was given by the Bojanala District Health Services.Study participants gave informed consent before they were enrolled.Their identities were kept confidential, thereby ensuring anonymity and confidentiality.

Results
In this study, 469 patients with chronic comorbidities (chronic patients) responded to the survey.The mean ± s.d.age of these chronic patients was 47.6 ± 15.2 years, ranging from 18 years to 84 years.Most chronic patients fell into the 30-49 year age group (43.28%, n = 203), as shown in Table 1.The majority of the chronic patients were women (n = 295, 62.9%) and had attained secondary education (60.77%, n = 285).There were more single chronic patients in this study (45.84%, n = 215), and a few were smokers (17.06%, n = 80).
The knowledge about COVID-19 responses is shown in Table 3.Most of the chronic patients were knowledgeable about COVID-19, because more than 70% of them selected the 'correct' responses for the knowledge items, except for the mixed responses linked to the treatment of COVID-19, which 44.56% (n = 209) said is not available.The average scale reliability for the knowledge items was 0.7286.
The responses regarding COVID-19 practices and attitude are shown in Table 4.Most of the chronic patients indicated good practices about COVID-19, because more than 89% of them selected the 'correct' responses for the practice items.However, the average scale reliability for the knowledge items was 0.46.Regarding attitude, most of the chronic patients indicated a positive attitude about COVID-19, because more than 65% of them selected the 'correct' responses for the attitude items.However, the average scale reliability for the knowledge items was 0.48.
In general, the mean ± s.d.knowledge score was 7.09 ± 1.73 and ranged from 0 to 9. The mean ± s.d.attitude score was 2.33 ± 0.86 and ranged from 0 to 3. The mean ± s.d.practice score was 3.79 ± 0.56 and ranged from 0 to 4. Table 5 shows the correlation analysis of KAP scores.There was a significant positive linear relationship between the knowledge and attitude scores (r = 0.1725, p = 0.0002), knowledge and practice scores (r = 0.2986, p < 0.0001) and attitude and practice scores (r = 0.2591, p < 0.0001).As one score increases, the other also increases significantly.Associations between KAP categorical variables and sociodemographic and comorbidity variables were assessed using the Chi-square test (Table 6).There was a significant association between knowledge about COVID-19 and age group, as chronic patients aged 70 years and above did not have good knowledge (58.97%, p < 0.0001); employment status, as those who were unemployed had good knowledge (77.51%, p = 0.02); educational level, as those with tertiary education had good knowledge (79.07%, p < 0.0001); being hypertensive, as those who were not hypertensive had good knowledge (76.23%, p = 0.017); and HIV status, as those who were HIV-positive had good knowledge (78.23%, p < 0.0001).
There was a significant association between a positive attitude towards COVID-19 and being hypertensive, as those who were hypertensive had a positive attitude (62.6%, p = 0.002); and HIV status, as those who were HIV-negative had a positive attitude (63.8%, p = 0.001).There was a significant association between good practices for COVID-19 and employment status, as those who were unemployed had good practices (90.53%, p = 0.006); and educational level, as those with secondary education had good practices (88.42%, p < 0.0001).

Discussion
Of the participants in this study, 70% displayed good knowledge of COVID-19, 20,21 and this knowledge translated into positive attitudes and practices towards the disease.A few studies carried out respectively in Egypt, India and Iran showed similar findings. 3,6,13,22ntrary to our findings, some studies in Africa found that a significant number of chronic disease patients had poor knowledge of and practices towards COVID-19. 2,23his difference in knowledge is perhaps because after the fourth wave of COVID-19, at the time of this study in South Africa, most of the population had more information on COVID-19 than in other countries.
This study found a significant association between knowledge about COVID-19 and the younger age group.Chronic patients aged 70 years and above had poor knowledge of the disease, with poor attitude and practices.It has been established that older patients, particularly those older than 65 years, or patients with comorbidities, had a high rate of admission to hospital (including the intensive care unit) and a high mortality rate. 24,25,26,27,28,29,30The poor KAP observed in this age range is of concern.Supporting this category of patients will alter the admission and mortality rate.The severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) vaccine is the most recommended preventative measure.
In this study, level of education was associated with good knowledge of and good practices towards COVID-19.As expected, having a tertiary level of education correlated with better knowledge.These findings are consistent with those observed elsewhere. 6,31,32is study found that non-hypertensive and HIV-positive patients had a good knowledge of COVID-19 compared to hypertensive patients and those who did not have HIV.This knowledge translated into a more positive attitude towards COVID-19 among HIV-positive patients than in HIV-negative patients.This may be due to the fact that patients with comorbidities perceived themselves as at risk of COVID-19, and not only seek knowledge but improve their attitudes and practices to protect themselves.as the risk associated with COVID-19 in hypertensive patients has been widely described. 29,33man immunodeficiency virus was the second most common chronic condition associated with COVID-19, and the KAP towards the disease among HIV patients was commendable.This finding is consistent with those of other studies. 34e study's strength lies in its emphasis on the need for patients aged 70 and above, who may require special attention due to their poor KAPs towards COVID-19.
Although it is the largest in the North West province, this study depicts just one health district.Additionally, the crosssectional nature of the study did not allow us to show the cause-effect relationship.Moreover, because the KAP was self-reported, this may not be what is actually the case.For these reasons, further study is warranted.
The study found that the level of knowledge about COVID-19 was generally good among the participants, which translated into a positive attitude and practices towards the disease.However, older patients had poorer knowledge of and practices towards the disease, which could lead to higher hospitalisation and mortality rates.A tertiary level of education was associated with better knowledge of and practices towards COVID-19.
The study suggests that improving knowledge of and attitudes towards COVID-19, particularly among older patients and those with comorbidities, could be beneficial in reducing hospitalisation and mortality rates.

TABLE 1 :
Sociodemographic characteristics of the chronic patients.

TABLE 2 :
Comorbidities of the chronic patients.
HIV, human immunodeficiency virus.

Table 7
shows the adjusted logistic results to determine factors associated with good knowledge, a positive attitude and good practices.Level of education was the only variable associated with good knowledge in this analysis.The higher

TABLE 4 :
Response to COVID-19 practice and attitude items.

TABLE 5 :
Correlation matrix of knowledge, attitude and practice scores.

TABLE 6 :
Associations between participants' characteristics and knowledge, attitude and practices.

TABLE 7 :
Regression results to predict good knowledge, a positive attitude and good practices.