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Enquiry Article

Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia

• Arina Anis Azlan,
• Mohammad Rezal Hamzah,
• Tham Jen Sern,
• Suffian Hadi Ayub,
• Emma Mohamad

x

• Published: May 21, 2020
• https://doi.org/10.1371/journal.pone.0233668

Figures

Abstract

In an effort to mitigate the outbreak of COVID-19, many countries have imposed drastic lockdown, motility control or shelter in identify orders on their residents. The effectiveness of these mitigation measures is highly dependent on cooperation and compliance of all members of gild. The noesis, attitudes and practices people hold toward the disease play an integral role in determining a gild's readiness to accept behavioural change measures from health authorities. The aim of this study was to determine the knowledge levels, attitudes and practices toward COVID-19 among the Malaysian public. A cross-sectional online survey of iv,850 Malaysian residents was conducted between 27^th March and three^rd April 2020. The survey instrument consisted of demographic characteristics, thirteen items on knowledge, 3 items on attitudes and 3 items on practices, modified from a previously published questionnaire on COVID-19. Descriptive statistics, chi-square tests, t-tests and one-style analysis of variance (ANOVA) were conducted. The overall correct rate of the knowledge questionnaire was 80.5%. Most participants held positive attitudes toward the successful control of COVID-19 (83.1%), the power of Malaysia to conquer the disease (95.ix%) and the mode the Malaysian government was treatment the crisis (89.ix%). Nigh participants were also taking precautions such every bit avoiding crowds (83.four%) and practising proper mitt hygiene (87.eight%) in the week before the movement control order started. However, the wearing of face masks was less common (51.ii%). This survey is among the first to appraise knowledge, attitudes and do in response to the COVID-xix pandemic in Malaysia. The results highlight the importance of consistent messaging from wellness regime and the authorities too as the need for tailored health instruction programs to improve levels of knowledge, attitudes and practices.

Citation: Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E (2020) Public knowledge, attitudes and practices towards COVID-19: A cross-exclusive report in Malaysia. PLoS I 15(5): e0233668. https://doi.org/10.1371/journal.pone.0233668

Editor: Wen-Jun Tu, Chinese Academy of Medical Sciences and Peking Union Medical College, CHINA

Received: Apr 21, 2020; Accustomed: May eleven, 2020; Published: May 21, 2020

Copyright: © 2020 Azlan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This research was supported by a grant from Universiti Kebangsaan Malaysia (Grant code: SK-2020-007) to EM. The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have alleged that no competing interests exist.

i. Introduction

The coronavirus disease 2019 (COVID-19) emerged in Wuhan, China at the end of 2019. Since then, it has spread to 200 countries and has been alleged a global pandemic by the World Health Organisation (WHO). To engagement, there are more than than 2.three million positive COVID-xix cases recorded with at least 150,000 deaths globally [1].

The showtime case of COVID-19 in Malaysia was detected on 25^th January 2020 involving 3 tourists from China [ii]. The number of cases steadily increased earlier the nation's first two deaths were recorded on 17^th March [3]. As of 20^th April 2020, Malaysia has recorded more 5300 positive cases involving 89 deaths. A majority of these cases were traced back to a religious gathering which has at present reached its 5th-generation infections [four]. The Malaysian Prime Government minister enforced a movement control social club (MCO) on 18^thursday March 2020 every bit a mitigation effort to reduce community spread and the overburdening of the country'due south health system. Similar to lockdowns in China and Italy, the MCO restricted virtually non-essential activity outside the home. Malaysians were only permitted to get out the house for bones activities such every bit ownership groceries and seeking medical treatment. The MCO also restricted Malaysians from leaving the land and all foreigners from entry. Non-essential sectors were ordered to close operations or allow employees to work from home.

Lockdown measures were perceived equally necessary to curb the spread of the virus as rapid human-to-human transmission occurred and much about the virus remained unknown [5]. Due to the obscurity of this novel virus, in that location has been a lot of confusion and misunderstanding about the virus itself, how information technology can spread and the necessary precautions that should be taken to prevent infection. This becomes increasingly challenging with the vast amount of misinformation and disinformation shared on social media that is clouding people'southward understanding of COVID-19 [half dozen]. When the initial MCO declaration was made, Malaysians reacted in panic and confusion. Aside from panic buying, people crowded public transportation hubs to travel dorsum to their hometowns, potentially increasing the hazard of infection to other parts of the country. While this reaction to the MCO was not unexpected, it raises questions regarding the level of understanding and attitudes toward COVID-19 amidst Malaysians.

The cognition, attitudes and practices (KAP) toward COVID-19 play an integral role in determining a society'southward readiness to have behavioural modify measures from wellness regime. KAP studies provide baseline information to determine the blazon of intervention that may be required to alter misconceptions about the virus. Assessing the KAP related to COVID-nineteen among the general public would be helpful to provide better insight to accost poor cognition about the disease and the development of preventive strategies and health promotion programs. Amidst the lessons learned from the SARS outbreak is that knowledge and attitudes are associated with levels of panic and emotion which could farther complicate measures to contain the spread of the affliction [vii,8]. The survey also gives a general pic of Malaysians COVID-nineteen prevention practices earlier the MCO and this can ameliorate prepare the government to address future wellness crises involving infectious diseases. The results of this study are important to inform hereafter efforts focusing on societal readiness to comply with pandemic control measures.

2. Methods

Study design

A quantitative arroyo was utilised to reach the objectives of this study. A survey is most appropriate as it allows large populations to be assessed with relative ease [nine]. In this study, a cantankerous-sectional survey was deemed most advisable to gather information on COVID-19 for the Malaysian context. Data drove was performed online using the Survey Monkey platform. The call for participation was made on social media.

Ethical approval

The Ethics Committee of Universiti Kebangsaan Malaysia approved our report protocol, procedures, information sheet and consent statement (JEP-2020-276). Participants who gave consent to willingly participate in the survey would click the 'Continue' button and would then exist directed to complete the self-administered questionnaire.

Recruitment procedure

This cross-sectional survey was conducted in the second week of the MCO, betwixt 27^th March 2020 to three^rd April 2020. The target sample size was 3,640, determined by identifying the smallest acceptable size of a demographic subgroup with a ±5% margin of error and a confidence level of 95% [ten,11]. As information technology was not feasible to behave a systematic nationwide sampling procedure during this period, the researchers opted to utilise an online survey using Survey Monkey Advantage Annual. Members of the Malaysian public above the historic period of 18 and currently residing in the country were eligible to participate in the survey. We utilised several strategies to reach every bit many respondents as possible all over the state within the ane-week data collection period. This includes relying on professional person and personal networks of the researchers, reaching out to community leaders and social media influencers to broadcast and share the survey. Two main platforms used in disseminating this survey were social media (Facebook, Twitter and Instagram) and WhatsApp. Facebook and Whatsapp were selected every bit ii of the most popular communication and social platforms in Malaysia [12]. While Facebook is generally preferred by older Malaysians, Twitter and Instagram are more popular amidst the younger generation. A standardised general description nearly the survey was given in the WhatsApp bulletin/social media postings earlier the link was provided to both English and Malay linguistic communication versions of the questionnaire. A total of 4,850 participants took function in the survey.

Study instrument

The survey musical instrument is an adaptation of the measures adult in a report on Chinese residents' knowledge, attitudes and practices (KAP) towards COVID-19 in China [13]. The questionnaire consisted of four main themes: 1) demographics, which surveyed participants' socio-demographic data, including gender, age, country of residence, occupation, and household income; two) cognition near COVID-xix; three) attitudes toward COVID-19; and 4) practices relevant to COVID-19. The survey was offered in the English language and Malay languages. A backward-translation approach was used in translating the items between English and Bahasa Malaysia, so as to ensure linguistic and conceptual equivalence [xiv]. Discrepancies between the two versions were rectified, and equivalence of measuring on all items was ensured through consultation with bilingual researchers.

To measure out noesis virtually COVID-xix, 13 items were adapted from previous research [xiii]. These items include the participant noesis about clinical presentations (items 1–4), transmission routes (items v–8) and prevention and control (items 9–thirteen) of COVID-19. Participants were given "truthful," "faux," or "not sure" response options to these items. A correct response to an particular was assigned one point, while an incorrect/not certain response was assigned 0 points. The maximum total score ranged from 0–13, with a higher score indicating better cognition about COVID-nineteen.

To measure attitudes towards COVID-nineteen, surveyed participants were asked whether they agreed, disagreed or were not certain that the pandemic would be successfully controlled. They were also asked nigh their confidence towards the regime in winning the battle against COVID-19 (yes or no) and nearly the ability of the government in handling the COVID-19 crunch (agree, disagree, or not sure). To measure practices, participants were asked yes/no questions on whether they had avoided going to crowded places such as weddings; wore a confront mask when leaving dwelling; and whether they skilful proper hand hygiene in the calendar week before the movement control social club (MCO).

Statistical analysis

For this study, the collected data were analysed using the Statistical Bundle for the Social Sciences (SPSS), version 26. Descriptive analysis focused on frequencies, and percentages while chi-foursquare tests, independent samples t-tests and 1-style analysis of variance (ANOVA) were utilised to determine the differences between groups for selected demographic variables. The statistical significance level was prepare at p < 0.05. Internal consistency of the noesis measures was tested using a reliability test where the Cronbach alpha coefficient aided in determining the reliability of the variables. The results showed that the Cronbach alpha for cognition (13 items) was 0.655. The result added credence where according to Griethuijsen, the range of Cronbach blastoff inside 0.6 to 07 is considered adequate and reliable [15]. It is attested that the items used to measure knowledge on COVID-19 are therefore adequate.

3. Results

Demographic characteristics

A total of 4850 participants participated in the study. Out of the full, the average historic period was 34 years (SD = 11.2, range = xviii–73), 2808 (57.9%) were women, 1993 (41.1%) resided in Central Malaysia and 2173 (44.eight%) were employed in the public sector. Other demographic characteristics are detailed in Tabular array 1.

Assessment of knowledge

A total of 13 questions were used to measure cognition on the COVID-nineteen virus. The average knowledge score for participants was 10.v (SD = 1.4, range 0–thirteen). The overall correct answer rate of the knowledge questionnaire was lxxx.5% (10.5/13*100) while the range of right answer rates for all participants were between 46.2 to 100%. Almost 77.ii% of participants were able to obtain scores above 10, representing an acceptable level of knowledge on COVID-19.

Near participants knew that people who had contact with an infected person should exist immediately isolated for a period of 14 days (99.1%) and that this is an effective mode to reduce the spread of the virus (98.9%). However, there was noticeable confusion among participants regarding transmission of the virus. Only 43.three% of participants answered correctly when asked if the virus was airborne and just 35.7% answered correctly when asked if eating and touching wildlife could consequence in infection [Tabular array 2].

Differences in knowledge scores among different demographic characteristics were assessed using t-tests and ANOVA. The results show that knowledge scores were significantly different across genders, age groups, regions, occupation groups and income categories. Higher knowledge scores were obtained amidst female participants, those above the age of 50, people residing in Central Malaysia and in the higher income category.

The results of the ANOVA analyses show that the noesis scores of people living in the Central region were significantly higher than other regions. Additionally, the average knowledge score of students were significantly lower than those of other occupation categories and those earning below RM3,000 per month showed significantly lower knowledge scores [Table iii].

Assessment of attitudes

Participants were asked 3 questions in assessment of attitudes. The first question asked whether or non they agreed that the COVID-19 situation would be successfully controlled; second, whether they thought Malaysia would be able to win its battle against the virus; and third, whether they idea the Malaysian regime was treatment the wellness crisis well [Fig 1].

For the first question, a bulk of participants agreed that COVID-19 would successfully be controlled (83.ane%). All the same, xiv% of participants were unsure whether the virus would be controlled and a smaller number of participants disagreed that information technology would exist successfully controlled (2.1%). The mental attitude of successfully controlling COVID-xix was significantly associated with age group, region and occupation. Knowledge scores of those who were unsure were also significantly lower than those who agreed that the virus would be successfully controlled [Table four].

For the second mental attitude question, the majority of participants had confidence that Malaysia would be able to win the battle confronting COVID-19 (95.nine%), while a small percentage did not take that confidence (three.iii%). The confidence that Malaysia would be able to win the battle against COVID-xix was associated with age group and occupation. No significant divergence was establish betwixt the two confidence groups in terms of knowledge score.

The third mental attitude question asked whether the participant agreed that the Malaysian government was handling the COVID-xix health crunch well. A large percentage of participants agreed with this statement (89.9%). Rates of disagreement and dubiousness were at 3.viii% and v.4% respectively. Agreement that the Malaysian government was performing well in handling the COVID-nineteen crisis was significantly associated with gender, age grouping, region and occupation. Knowledge scores were also significantly different between those who agreed that the government was doing a practiced task at handling the crisis and those who were unsure.

Assessment of practices

Practices toward COVID-19 were measured using 3 questions enquiring on: i) avoidance of crowded places, 2) wearing of face masks; and 3) practising proper hand hygiene in the week earlier the Motility Control Gild (MCO) was implemented in Malaysia [Fig 2].

For the first question, 83.4% of participants reported that they were avoiding crowded places in the week before the MCO was implemented. The other 16.6% did not avert crowded places.

In examining the differences betwixt demographic groups, it was establish that there were pregnant associations between historic period group, income category and avoidance of crowded places. Younger people and those earning below RM3,000 monthly were more avoidant of crowded places in the calendar week before the MCO. At that place were also significant differences in knowledge scores between those who did and did not avoid crowded places. Those with college knowledge scores did not avoid crowded places in the calendar week before the MCO [Table five].

The second question asked participants if they were wearing face up masks when exterior the home during the week earlier the MCO began. More than than half of the participants reported wearing a face mask when going out in public (51.2%). The remaining participants did not habiliment a mask (48.8%).

The wearing of confront masks was found to exist significantly associated with gender, age grouping, region, occupation and income grouping. Males, people betwixt the ages of 18 and 49, students and those earning less than RM3,000 per calendar month showed higher percentages in wearing face masks when leaving the house. People living in the Central region, those above the age of 50 and people with an income over RM12,000 per month were less likely to wear a face mask. The results besides prove that in that location was a significant divergence between knowledge scores in terms of mask-wearing. Those with higher noesis scores did non wearable masks when leaving the firm in the week earlier the MCO was enforced.

Lastly, when enquired virtually hand hygiene, a majority of participants reported that they practised proper hand hygiene by frequently washing their hands and using hand sanitiser (87.8%). However, there was still a percent of participants who were non practising proper manus hygiene in the calendar week before the implementation of the MCO (12.2%).

There were significant associations constitute between proper paw hygiene and gender, age grouping, region and occupation. Females, those living in the Primal region, people between the ages 18 to 29 and students were more likely to practise good mitt hygiene. Those above 50, residents in the Eastern region and retirees were among the highest percentage of participants who had not practised good hand hygiene in the week before the MCO.

4. Word

COVID-nineteen is a relatively new virus that has had devastating effects within the short time since information technology was first detected in Dec 2019. To appointment, at that place has been limited published information on population knowledge, attitudes and practices toward COVID-19, specifically in Malaysia. The novelty of this affliction, along with its uncertainties, arrive disquisitional for health authorities to program appropriate strategies to prepare and manage the public. Information technology is therefore of utmost importance that the knowledge, attitudes and practices of the population be studied to guide these efforts.

The average knowledge score of Malaysians in regards to COVID-19 was moderate at 10.5±1.iv with an overall right rate of 80.5%. Even so, correct rates of COVID-19 knowledge ranged widely indicating that while some participants had high levels of knowledge on the illness, others did not. Malaysians above the age of fifty held college knowledge scores, perhaps due to a college risk perception of contraction and complications from the disease [16]. On the other hand, those with low monthly income scored amid the lowest cognition scores. This may point limited admission to credible and timely data almost the virus. This variation in levels of cognition may be cogitating of the electric current COVID-19 information landscape in the state. Although health authorities accept been consistently disseminating COVID-19 information since the disease was first detected in Malaysia, in that location has also been a surge in false and inaccurate information [17,18]. The overload of information may accept caused confusion and difficulty ascertaining right information.

Several studies conducted in other Asian countries have indicated loftier levels of COVID-xix knowledge among the full general population [thirteen] and healthcare workers [xix]. Differences in measurement and scoring systems do not make it possible for accurate comparisons of knowledge levels across these studies.

The present report constitute that a large majority of participants held positive attitudes toward overcoming COVID-19. Roughly eight out of ten participants agreed that COVID-19 would exist successfully controlled. Similarly, approximately nine out of ten participants were confident that Malaysia would be able to win its battle against the virus and that the Malaysian government was handling the wellness crisis very well. High levels of positive attitudes were likewise detected in the KAP study conducted in Prc [thirteen]. The authors attributed the positive attitudes to the drastic measures taken by the Chinese government in mitigating the spread of the virus. In Malaysia, the swift activeness taken by the Malaysian government in enforcing the MCO may take besides contributed to these positive attitudes.

Although the per centum of participants reporting uncertainty toward success in fighting against COVID-19 was low (14%), this was significantly associated with lower knowledge scores. These results reinforce conclusions from previous studies associating higher levels of cognition with college conviction and positive attitudes in wellness crises [twenty].

Positive attitudes were higher among those working in the public sector. This group showed the highest confidence that COVID-19 would be successfully controlled, that Malaysia would win the battle against the illness and that the Malaysian government were handling the health crisis well. This may be due to work duties or affiliations directly related to government efforts toward the containment of the virus.

In the current study, most participants reported taking precautions such as avoiding crowded places and practising proper hand hygiene in the week before the MCO was implemented. This indicates a general willingness for participants to make behavioural changes in the confront of the COVID-xix pandemic. Nonetheless, people in a higher place the historic period of fifty and people who earned more than RM12,000 per month were amid those who did not avoid crowded places in the week earlier the MCO. The week before the implementation of the MCO coincided with the school holidays in Malaysia, a mutual flavour for family holidays and gatherings such every bit weddings. Those higher up the age of 50 were too more likely to nourish daily religious congregations like praying at the mosque. Cultural norms may take been influential in the conclusion to attend these gatherings despite the health risks, especially among the older generation. Previous inquiry has also shown that those with higher income were less willing to comply with wellness recommendations [21] perceived less fright and more command in pandemic situations [22].

Interestingly, enquiry into the wearing of face masks garnered a mixed response. Almost half of the participants indicated that they did not habiliment a face mask when leaving the home in the calendar week before the MCO. There are ii possible explanations for this behaviour in the Malaysian context. Firstly, the use of face masks is not a norm in Malaysian society. It is uncommon for the typical Malaysian to habiliment a face mask when ill. The emergence of COVID-19 acquired an increment in demand for medical face masks (and hand sanitiser) in the country and supplies were short [23]. The scarcity of face masks meant that many regular members of the public were unable to obtain them. The shortage of personal protective equipment was not limited to Malaysia. It had become a global problem due to increased demand in response to COVID-19 [24]. Secondly, the Ministry of Health Malaysia has been adamant that medical face up masks should but be worn past those who are showing symptoms of COVID-19 or similar illnesses. This was to ensure ample supplies of personal protective equipment for medical workers on the frontline. Nevertheless, mixed messages had been communicated to the public by different authoritative bodies on the use of face masks. It is possible that the lack of supply and the confusion acquired past the mixed letters led to the divided response on the wearing of face masks when out in public.

Absolutely, COVID-xix has been a teething public health problem around the world. Scientists are working diligently to explore dissimilar vaccines and handling options. Social scientists, especially those in public health and health communication, are working to place the levels of cognition, attitudes and practices on COVID-19 amongst the public every bit to blueprint cost-effective public wellness campaigns and education programmes. The current survey, in fact, exposes the demand for more comprehensive education programmes with focus on consistency of information from the government and related regime. COVID-19 didactics efforts should take a proactive approach and focus on dispelling misinformation in the grade of alien opinions, one-time wives' tales and incorrect information. Due to the levels of media and telecommunication usage in Malaysian society [25–27] and evidence from prior research [28], government would benefit from utilising both mainstream and social media in disseminating these messages.

5. Limitations

Sampling for the study was conducted via a convenience sample through the networks of the researchers and disseminated through different social media platforms (Whatsapp, Facebook, Twitter etc.). As a event, there is a possibility of bias as underprivileged populations may non accept been able to participate in the written report. Additionally, when compared to current population statistics in Malaysia [29], the sample of the study were over-representative of women, people below the historic period of l, and those employed in the public sector. Therefore, in that location are limitations to the representativeness of the findings. A more than systematic, inclusive sampling method is warranted to meliorate representativeness and generalisability of the findings.

The 2nd limitation is related to the KAP instrument used in this study. The instrument was adjusted from a survey that had been previously tested and utilised in Communist china [13]. Fifty-fifty so, a more than thorough assessment of musical instrument validity and reliability would accept produced a more robust instrument. Due to the limited time and urgency of the survey, attitudes and practices were measured with only 1 item each. In improver to this, possible factors contributing to knowledge, mental attitude and practice such every bit hazard perceptions and wellness literacy [xxx,31] were not measured in this study. These would have been a useful addition in understanding the knowledge, attitudes and practices of COVID-xix in Malaysia.

A further limitation of the present study is the possibility of participants giving socially desirable responses. Equally this report used self-reported information, information technology is possible that participants may accept answered attitude and practice questions positively based on what they perceive to be expected of them [32].

vi. Conclusions

In summary, the present written report was able to provide a comprehensive test of the noesis, attitudes and practices of Malaysians toward COVID-nineteen. The findings suggest that Malaysians have an acceptable level of knowledge on COVID-xix and are generally positive in their outlook on overcoming the pandemic. Notwithstanding, consistent messaging from the government and/ or wellness regime are central to help public knowledge and understanding of COVID-19. Additionally, some categories of the population may benefit from specific wellness education programs to raise COVID-nineteen knowledge and improve practices.

Supporting data

Acknowledgments

We would like to express our appreciation to the Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, specially to Associate Professor Dr. Kadaruddin Aiyub and Noraznita Anor Basri for their help and a sincere thank yous to all members of the Malaysian public who participated in the survey.

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