Gender differences in Knowledge, Attitude and Preparedness to Respond to COVID-19 among adult population in Bangladesh: A Cross- sectional Study

Effective pandemic management requires understanding the level of community knowledge, attitude of people and preparedness towards COVID-19. This study aimed to assess the knowledge, attitude and preparedness toward COVID-2019 among Bangladeshi general people. A cross sectional survey was conducted from 20th March 2020 to 20th April 2020 among 1007 Bangladeshi adult people. A convenience sampling strategy was utilized and the data was collected through a self-administered questionnaire. Chi-square test was used to identify the gender differences regarding knowledge, attitude and preparedness towards COVID-19. Respondents predominately used social media to inform themselves about COVID-19 (68.10%) and female used social media more than male (p<0.001). Female had more correct knowledge about staying home with sickness and/or symptoms to contain the COVID-19 transmission (p=.02). While male had more negative attitude about staying out during the pandemic than female (<0.001) and men were less likely to take preventative measures than female counterparts. A number of people were still believing the myths like “COVID-19 can transmit via mosquito” (9.14%) and male had more incorrect knowledge regarding this (p<0.001). Moreover, 17.81% of the respondents thought that COVID-19 can spread in warm weather. Some findings are directing us to a knowledge gap among general population in Bangladesh which calls for uncovering those aspects. Adequate and effective communication are necessary so that general people can stay alert with positive attitude and hygienic practices to fight against this ongoing crisis.


Introduction
The unprecedented global health crisis due to the COVID-19 pandemic has brought critical challenges to public health and made the world stand still with a number of 33,058,750 cases and 998,747 deaths worldwide as of 20 th November 2020. This relatively higher mortality has led the global scientific community to focus on researches for development of treatments, vaccines and preventive strategies [1]. But the efficient handling of the pandemic calls for help from the vulnerable population for efforts to alleviate the transmission of the pandemic [2]. Having correct knowledge about COVID-19 symptoms, transmission and prevention is crucial because better knowledge equated with stronger implementation of precautionary practices [3]. Insufficient information and wrong attitudes contribute to delayed diagnoses, ineffective infection management and lack of personal hygiene [4]. Moreover, there is no exact cure or vaccine for COVID-19 till to date which indicates the importance of maintaining recommended guidelines to prevent COVID-19. When community people will have correct knowledge, positive attitude and better preparedness towards COVID-19, we will be able to impede COVID-19 transmission and have a safe community. It was reported by various studies that assessing knowledge and awareness regarding the disease is very important to combat any infectious disease [5,6]. Poor knowledge about transmission affects the control measures as the spread rate of infectious disease has been found higher among the population who had poor knowledge about the disease [7].
To date, male vulnerability has been observed with 54-73% COVID-19 infection rate in men [8]. The crucial understanding of the epidemiological pattern of this epidemic and the efficacy and effectiveness of public health interventions depends on the awareness, behavior and behaviors of the general population towards COVID-19 [9]. Though, COVID-19 affected both genders, male and female have different behaviours and perceptions towards this pandemic. Females used to be well informed and have a better attitude to the prevention measures of the disease [10]. Another study in United States showed that higher percentage of females were practicing preventive behaviours during this recent outbreak [11]. Although very few studies in Bangladesh demonstrated information about knowledge, attitude and perception [12], there is a knowledge gap about gender differences in knowledge, attitude, preparedness towards COVID-19.
Considering the importance of investigating community peoples' knowledge, attitude and preparedness, his study aimed address that knowledge gap by assessing gender differences regarding the knowledge, attitude and preparedness toward coronavirus disease-2019 among Bangladeshi adult people and evaluated gender differences which will help to effectively detect suitable types of health education programs for the community peoples.

Study Design & Participants
A cross-sectional study was conducted through an online survey among the general people of Bangladesh. The study was conducted following the Checklist for Reporting Results of Internet ESurveys (CHERRIES) guidelines [13]. Inclusion criteria included: (i) being Bangladeshi , ii) willing to participate; (iii) providing electronic informed consent; [1] age ≥18 years; v)able to understand Bangla language and residing in Bangladesh during the survey. An online convenience sampling technique was chosen to meet the study aims considering the lockdown situation as the face-to-face interview was risky.

Data Collection
Data collected took place from 20th March 2020 to 10th April 2020. Responses came from 1050 participants (aged between 18-68 years old). An online structured questionnaire was developed using google forms which was used as a data collection tool. A pilot test was performed on 30 respondents to confirm the reliability of the questionnaire and further modifications were done in the questionnaire after that. The questionnaire link was disseminated online on different social media (i.e., Facebook). For ensuring the quality of data, rapid checking of data was done every day. An information sheet describing the aim and process, right to refuse their participation from the study was presented on the first page of the survey attaching an electronic consent form with it. Participants were informed that their information will only be used for the research purpose. Anonymity and confidentially was fully ascertained. All the procedures of this study complied with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for any experiments involving human and ethical standards of the "Biosafety, Biosecurity & Ethical Committee" the ethical review board of the Faculty of Biological Sciences, Jahangirnagar University, Savar, Dhaka-1342, Bangladesh. After giving informed consent, participants voluntarily proceeded to the survey. It took participants about 10-15 minutes to complete the survey.

Socio-demographic characteristics
Demographic variables included age, gender, number of family members, name of the residing district, educational qualification and occupation. Educational qualification included three sub categories as: i) higher Secondary; ii) honors or Above; iii) up to Secondary.

Chronic disease, knowledge, attitude and preparedness related information
Participants were asked if they had any chronic disease such as diabetes, hypertension, renal disease, etc. Moreover, questions regarding knowledge about COVID-19 transmission, prevention were administered. Attitude towards COVID-19 were measured by close-ended questions. An example item includes "Do you consider yourself safe from the virus?". Preparedness towards COVID-19 were also assessed where an example item includes "I will self-isolation or quarantine if COVID-19 symptoms appear". All the questions had two response option either "yes" or "no".

Data analysis
Data were analyzed with STATA version 14.1 (StataCorpLP, College Station, TX, USA). Microsoft Excel was used for editing, sorting and coding of data. Descriptive statistics such as frequency, percentage were obtained to understand participants' characteristics. Chisquare test was formulated to identify the gender differences regarding knowledge, attitude and preparedness towards COVID-19. P-value less than or equal to .05 was considered to be statistically significant for all analyses.

Socio-demographics
Respondents' socio-demographic characters were reported in table 1. It shows that 65.90% of respondents were below the age of 25 years. The majority of the respondents were male (63.43%). Most of the respondents had educational qualification equivalent to honors or above (83.52%). Respondents were mostly students (76.19%). Apart from that, there was Govt. or private service holders (14.38%) and others such as housewives, freelancers etc. (9.43%).

General information
Almost all the respondents knew about the virus (98.48%) and the majority acknowledges the virus to be extremely dangerous (86.29%). It is also noticeable that most of the respondents came to know about the virus via social media (68.10%). Respondents' response to "How did you first come to know about the virus?" differed by gender, χ 2 (3, N = 1050) = 19.10, p< 0.001.

Attitude towards COVID-19
More than half of the respondents were very worried about COVID-19 (51.90%). More than half of the respondents are still going out of home and they reported the duration of staying out as less than half an hour (41.81%), half an hour to 2 hours (9.05%), 2 to 4 hours (1.33%) and more than 4 hours (2.95%). The responses for "Are you worried about COVID-19" differed by gender, χ 2 (2, N=1050) =7.73, p=0.02. Again, the responses for "How long do you stay out lately" differed by gender, χ 2 (4, N=1050) =67.78, p<0.001. (Table 3

Discussion
As COVID-19 vaccine has not been unfolded yet, preventative and control measures regarding the virus are most crucial now. The appropriate knowledge, attitude and preparedness towards COVID-19 among general public are backbone for ensuring any preventative or control measures. This study unveils the overall picture of a subset of Bangladeshi adult populations' knowledge, attitude and preparedness towards COVID-19.
Our results indicate that 86.29% respondents reported COVID-19 as extremely dangerous ( Table 2). It was claimed before that higher perceived threat of fatal infection resulted in higher rates of precautionary practices [14]. A substantial proportion of respondents from current study gave incorrect answer about the symptoms of COVID-19 as respondents didn't know diarrhea (47.90%), fatigue (56.15%), pneumonia (50.57%), muscle pain (59.24%), vomiting (68.95%) as symptoms of COVID-19. Those incorrect answers indicate the poor knowledge which may affect in control measures greatly as public knowledge is crucial in dealing with pandemics [15]. A possible reason for this poor knowledge can be the source of information because social media (68.10%) was the main source of COVID-19 information while only 4.19% respondent sought information from doctor or family in the present study. Misleading and false information can spread in social media which might misguide general population regarding knowledge of COVID-19. With the global pandemic, pandemic of misinformation has also been reported that might lead to the concern of xenophobia globally as reported by scientists and WHO official personnels [16,17]. Previous studies also showed a significant association between sources of information and knowledge [6]. The result is in line with studies conducted in Bangladesh, Vietnam, and China in which the main source of knowledge was social media [6,18,19]. This finding has significant gender difference showing male used social media more that the female counterparts to gather knowledge on COVID-19. (Table 2). This situation demands careful evaluation of sources and ensuring of authentic information regarding COVID-19.
Corresponding to the present study, a previous study reported that 67% respondents believed COVID-19 can transmit through close contact with infected person [19] and another study showed almost half of the respondents were unaware about person-to-person transmission of COVID-19 [20]. Furthermore, present study showed that 17.81% and 9.14% respondents had incorrect knowledge saying that COVID-19 can't spread in warm weather and can spread through mosquito, respectively ( Figure 2). It was documented before that

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(7.03%) *P-value<_0.05; **P-value<_0.01; df= degree of freedom COVID-19 can be transmitted in hot and humid weather and mosquito bites can't transmit COVID-19 [21]. Possible explanation for this higher rate of incorrect knowledge can be the initial survey of this study when people were confused with different myths spreading on social media. Communication between health care providers and the public at frequent intervals is recommended in order to overcome myths and to inform the public about health education [22].
Moreover, 94.76% respondents gave the correct answer saying that sick person should stay at home to prevent COVID-19 ( figure 3) which is comparable to a previous study where 96.4% believed lockdown as an effective measure of transmission control [23]. Of note that, 10.38% respondents had incorrect knowledge reporting antibiotics can cure from COVID-19 which is comparable to a study which showed 41.6% participants believed antibiotics as the first line treatment [19].   In regards to attitude towards COVID-19, 98.19% of the respondents agreed that they would like to stay in quarantine if any COVID-19 symptoms appear which is comparable to a study where 97.9% participants agreed to isolation if needed [19]. This positive attitude can be the result of correct knowledge among the participants [19]. In our study, 44.86% participants did not go out which is comparable to previous studies where 87% didn't go to any crowded place and 95% participants didn't attend any social events [20,24]. Of note, 11.41% male respondents stayed out for 30 min to 2 hours which is more when compared to female counterparts (4.95%). Data from other countries are in accordance with our findings which showed females were 3.6 times more likely to avoid going out than males [24] and women were found to be have a more responsible attitude than male and males tend to be show risky behaviors [6]. It is worthy to mention that psychological facts (i.e., behavior induced by fear, misleading information) and concerns related to economy can act behind the limited agreement to obey governmental initiatives (i.e., lockdown) by posing serious pressure [25]. This major finding highlights the importance of encouraging people in maintaining social distancing to prevent the transmission of COVID-19.
Highest (90.95%) positive preparedness was observed in washing hands more than 4 times in a day with soap which is similar to the findings of Maheshwari et al. who reported 96.6% participants increased their frequency of washing hands [26]. In the present study, females (83.85%) washed hands with handwash more than male (71.02%). This finding is consistent with other previous findings showing that men were less likely to take preventative measures than female counterparts [27]. 4.76% of the respondents never used masks (Table  4). If avoidance of mask usage is not managed, this could impede the progression of COVID-19 transmission control in future [28]. According to experts' opinion, there prevails a lack of harmony towards the management of COVID-19 despite of having enough time [29] which should be taken into account when adopting any intervention strategies.

Strengths & Limitations
The findings are congruent for policy makers and other concerned authorities to address the gaps in public health knowledge, attitude and preparedness towards a pandemic like the COVID-19 by ensuring prompt yet adequate policy, effective health education programs, short and long term interventions for improving COVID-19 response, prevention and control. The findings can also work as a baseline to understand public perception to contain any future outbreak.
The study has some limitations to consider when interpreting the results. Firstly, the study was only able to include participants who had access to internet and were mostly educated due to the online nature of the survey. Educated people are more likely to have good knowledge and positive attitude towards COVID-19. Thus, this may overestimate the overall result and can't be generalized to whole population. This problem might be overcome by replicating the study including all types of groups in the population. Secondly, self-reported data and convenience sampling technique might affect the result as some biases (reporting bias, selection bias, social desirability bias) couldn't be ignored. Thirdly, determination of cause-effect mechanisms was not possible for the cross-sectional nature of the study. Future longitudinal study including focus group discussion and in-depth interview are recommended.

Conclusion
To conclude, our findings suggest that public health education services with special emphasis on disseminating correct knowledge is vital in order to encourage initiating healthy behavior during such a pandemic. A number of people are still believing the myths about COVID-19 which is really alarming. Awareness programs should be emphasized focusing on gender specific proper information to ensure effective preventative measures. Furthermore, community-based health education programs and other interventions should be strengthened by ensuring appropriate knowledge about symptoms, transmission & prevention and improve the rate of positive attitude to safeguard general population.