Knowledge, attitude and practices among the inhabitants of Lahore, Pakistan towards the COVID-19 pandemic: an immediate online based cross-sectional survey while people are under the lockdown

Background: COVID-19 is an emerging infectious disease and has reached a status of global health emergency. It is widespread in Pakistan causing morbidity and mortality amongst masses. Objectives: Undertaken study aims at investigating knowledge, attitude and practices of the people residing in Lahore, Pakistan whilst the global crisis with sparse data available previously. Methodology: Following lockdown announcement, an immediate online cross sectional study was conducted from the 31st March to 6 April 2020. Data was analyzed by using SPSS IBM version 22. 00. Results: A total of 316 responses were received. Our study has shown that people 95.80% were well familiar with COVID-19, informed via news channels 46.2%. 91.7% believed the virus is contagious, 95.8% reported that the virus is spread by the respiratory droplets, 89.2% believed that all ages are at risk while 62.3% believed it risky for geriatrics only. 60.4% believed in its prevention with 91.7% respondents agreeably quarantined themselves while 6.6% didn’t. 99.7% participants were aware of social/physical distancing and 75.6% found it affecting mental health i.e. cause anxiety, depression etc. 59.2% of respondents were optimistic expecting it to end soon while 32.3% were uncertain. 49.1% said they have diagnostic facility and 89.6% acknowledged efforts of researchers/healthcare providers (doctors, pharmacist, nurses, allied health professionals and paramedical staff) for the society. 94.3% believed that there is need of awareness regarding COVID-19. Conclusion: An ever increasing need of awareness amongst the local population regarding COVID-19 is needed. It will lend hands in preventing spread of COVID-19 with minimal secondary transmission. It is recommended that extensive survey studies are required that can provide supportive data in developing and implementing public health policies regarding COVID-19 pandemic. It would further control and arrest the spread of COVID-19 in country.


Introduction
A walk down through history, brings to our notice a gigantic number of outbreak of diseases, affecting masses all around the globe. Epidemic or pandemic, has tremendously affected people in terms of morbidity and mortality, overall affecting the lives, economy and lifestyles in the worst possible way. The history of pandemic has been well known to the public, with its first ever encounter through a viral outbreak reported in 1918. This was renowned as Spanish flu with H1N1 influenza virus being the causative agent. The viral outbreak affected as many as 500 million people across the world with a massive rise in death toll shooting from 17 to 50 million. A similar situation was faced on the face of the globe in 2009 by the spread H1N1 Swine flu during the time frame of 2009-2010. This contributed to an enormous feat rate inflicting around 6.8 billion people while killing nearly 5 million people of the world population 1 . In recent times, COVID-19 outbreak is accounted as a global issue with a health emergency like situation. This has been closely associated with unprecedented outburst of pneumonia with an etiology previously not known well. The viral outbreak was first reported in Wuhan City, lying within Hubei province in the last month of year 2019. Following the findings of this disease, a novel virus that is corona virus was identified as the sole agent. Later named by the WHO (World Health Organization) as COVID- 19. This has shown close association with previous outbreaks reported under, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [2][3] . Structurally, coronaviruses are described as enveloped, singlestranded positive large RNA virus that is known for its zoonotic feature. Morphologically, it appears as spherical virions composed of a core shell fitted with surface projections akin to a solar corona. This is how the name was established from Latin word corona, meaning crown. Apparently, SARS-CoV-2 transferred from animals to humans via its oral consumption as food, finding its display in the Huanan sea food market in Wuhan, China 4 . The symptoms seen in patients infected with COVID-19 indicated a higher leukocyte count with high levels of plasma pro-inflammatory cytokines followed with abnormal respiratory findings. To understand better, a case with COVID-19 was reported with the 5 days of recurring fever with body's temperature affixed at 39.0 °C. Patient also had a cough presenting sounds of coarse breathing. Through clinical investigations, the sputum of the subject revealed positive realtime polymerase chain reaction (PCR) confirming COVID-19 infection 5 . In order to better understand the transmission and risk factors, a consistent data of epidemiological information must be obtained. This would rather explain, course and magnitude of geographic spread, infection related risks, transmission routes and to better plan to reduce this global burden via epidemiological models enabling prioritized surveillance post collection of real time data 6 . The current healthcare system of Pakistan does not promise a thorough service to the entire population. Thus, the only option feasible in times remains restriction of spreads, in turn less active cases. The number may decrease with timely testing of masses, quarantining active patients, imparting isolation and social distancing practices amongst public to break the chain of spread. Also passive counseling of public with communication between designated health authorities is the need of hour 7 . In addition to this, with rising threat of COVID-19 improving the technical skills and knowledge of healthcare workers is also of paramount importance. Improvement in knowledge and global updates is a must to combat this pandemic disease 8 . The spread of this disease has taken the entire world alike, people's knowledge, adherence to control measures, precautions and overall attitude is important to be learnt in best interest of public health 9, 10 . The underlying study aims at investigating the knowledge, attitude and practices of the people residing in Lahore, Pakistan on this global crisis, as previously no such study was found through extensive literature review.

Duration
Following the lockdown announcement of towns/ cities, immediately a week study was conducted from the 31 st March to 6th April, 2020. An online cross sectional study was done in order to obtain the data since physical interaction for questionnaire distribution and filling was not possible to have the community based survey.

Participants
For the purpose of sample collection, a form of two pages was generated by consulting the recent published studies 9, 11. Further, sample collection proforma was uploaded on the Google forms and links were shared on different platforms (WhatsApp, FaceBook, LinkedIn, Twitter etc). Authors have also sought help from their reliable connections to spread this sample collection form in order to get maximum response from the volunteers. Participants who were sixteen years of age or above were allocated for the data collection based on their understanding. No area was confined to allow maximum data collection throughout the region. Respondents had to respond either in no or yes in order to confirm their participation voluntarily. Once approval of voluntary participation was confirmed participants were navigated to the sample collection instrument. Sample collection instrument and statistical analysis The sample collection form was divided into the two parts. First section dealt with demographic information including: Name, age, gender, marital status, education and residence city/town. Second area broadly covered knowledge, attitude and practice analysis which included various questions provided with yes, no and may be options. Knowledge was analyzed through question 1 to 17 while questions from 18 to 25 assessed population attitude. However, questions from 25 to 29 were constructed to know the practices followed by the population in the current scenario. Following this, collected data was analyzed by using SPSS IBM version 22. 00. Option codes 0, 1, and 3 were assigned to maybe, yes and no respectively while entering the data in SPSS. Frequencies, percentages, standard deviation (SD), independent t-test and ANOVA were calculated to evaluate the received data. The value of p (statistical significance level) was kept less than 0.05 which considered significant for this study.

Results
A total of 316 responses were obtained. The socio demographic information (table 1) showed that the majority of the population belonged to an age group of 21-25. Among 316 respondents 169 (53.48%) were females while 147 (46.52%) were males and most of them had a graduation degree 120 (37.97%).   Figure 1. Knowledge, attitude and practices assessment of the respondents

Discussion
To the best of our knowledge it is the first study in Pakistan which is based on knowledge, attitudes and practices of the community towards the COVID-19.
Majority of the population in this study is educated and belongs to females. Current study indicates that the community is well informed and has sound knowledge about the COVID-19. News channels and social media have played a significant role in this regard, to make communities familiar with COVID-19 pandemic 9, 12 . However, this study has several limitations i.e. only literate people were accessible through online portals and to fill the form. English language must be understood by the respondents, participants needed to have an account to access the questionnaire and dissemination of the sampling instrument only through an online platform 10 15,16 . This survey indicates that more than fifty percent of the respondents admire government initiatives and practices in order to cope with the current situation while remaining are not satisfied. The present study has also highlighted that the public is facing troubles while getting basic necessities (food/rations etc). Further, Pakistan is already facing the economic crisis and it is quite difficult to sustain this lockdown for a longer period otherwise it is supposed that people may face issues to have basic necessities 17,18 . Many people residing in Pakistan also imply herbal medicines to treat various ailments with strong belief but for COVID-19 cure, many people are unconfident. An investigation has suggested that cure of H1NI and SARS through Chinese traditional medicine is well documented, based on human evidence and historical data and such medicine could be an alternative approach to prevent COVID-19 in high risk communities 19 . This study is also focused on the availability of diagnostic facilities to the public. Less than half of participants agreed on its availability while remaining claimed that it is not available or unsure. Earlier, Pakistan lacked the COVID-19 diagnostic facility and now Pakistan has received Primer from Japan and the rapid diagnostic kits from China. Now, Pakistan has the diagnostic facility at major centers and still there is need to establish more testing points to screen maximum population 20 . COVID-19 also poses challenges to the mental well-being and resilience of the societies. This current global health emergency has badly impacted the psychological health (i.e. depression, anxiety, boredom, frustration etc.) of the individuals.
To deal with it many people have adopted healthy activities which include exercise, yoga, playing indoor games, reading, writing, cooking etc. 21,22 further launching of many new free online courses in this duration of crisis is also an effective way to keep people (especially students) busy and has opened new doors of learning 23 . Worldwide frontline heroes including the health care providers (doctors, pharmacists, nurses, allied health care professionals and paramedical staff) and researchers are working tirelessly to fight against the COVID-19 by putting their lives at risk. People not only Pakistan, but globally acknowledge their efforts and struggle [24][25][26] .

Conclusion
Present study concludes that people are well informed about COVID-19 however still there is need of awareness amongst masses regarding COVID-19 to counteract the spread. People should rather quarantine themselves in order to prevent infection, catering this as a health emergency by keenly observing precautionary measures. However, to keep a mental and physical balance of health, people should adopt healthy activities during the lockdown. It is obvious from this study that the community also acknowledges the struggle and determination of the researchers and frontline healthcare providers for the well-being of their society.

Conflict of interest
The authors declare that there is no conflict of interest. Funding None Ethical clearance This cross sectional survey study has been conducted after obtaining suitable informed consent from volunteers. After approval from the participants data were collected and confidentiality of the information was secured.