Original Article. Knowledge, Attitude, and Behavioural Response of Corporate Employees in India towards Influenza: A Questionnaire Based Study

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1 44 Original Article Knowledge, Attitude, and Behavioural Response of Corporate Employees in India towards Influenza: A Questionnaire Based Study Parvaiz A Koul 1, Nargis K Bali 2, Sandeep Sonawane 3 Abstract Objective: Understanding about influenza would be helpful in adapting preventive measures like social distancing, seeking medical attention and getting vaccinated. The objective of this study was to evaluate knowledge, attitude and practices (KAP) towards influenza among Indian corporate employees and assessment of their awareness through a questionnairebased survey. Methods: Indian corporate employees of either gender ( 18 years) were provided with a self-administered questionnaire with domains namely knowledge (21 questions), attitude (6 questions), and practices (6 questions). Results: Overall, 500 corporate employees completed the survey from four zones. Total of 50.8% respondents had low level of knowledge of influenza, 34% had moderate knowledge, and 15.2% had high knowledge of influenza. Attitude domain revealed that 66% respondents were quiet concerned and 24% were extremely concerned regarding influenza. The practice domain demonstrated that 57.8% respondents took high level of precautions while 36.6% took moderate level precautions for the prevention of infection. Conclusion: Knowledge and attitude regarding importance of vaccine against influenza is not adequate. This study emphasizes the need for effective awareness programs for the management of influenza. Introduction Influenza, a viral respiratory infection, has varied presentation that can range from asymptomatic infection to a serious one that can be fatal. 1,2 Common symptoms of influenza include fever, chills, cough, headache, muscle aches, tiredness, vomiting, and diarrhoea. 3 Globally, 5-10% adults and 20-30% children are affected by influenza every year as per a report released by the World Health Organization (WHO) in In India, influenza contributes to 5-10% of all acute respiratory infections in children and 10/100 children are affected with influenza. 5 Multicentric surveillance conducted across different cities in India between 2009 and 2013 showed that influenza is reported consistently across the surveillance sites with the highest prevalence in Srinagar (18%) followed by Vellore (17.6%), Pune (16.8%), and Editorial Viewpoint Knowledge about influenza will be helpful in adapting preventive strategies. In this study 50% of corporate employees had low level of knowledge of influenza. This emphasizes the need for awareness programs to tackle this issue. Dibrugarh (16%). The prevalence peaked in the year 2011 (14.5%). 6 Another epidemiological study reported prevalence of influenza in Pondicherry to be 17% during 2009 and 2013 with maximum patients between yr of age. 7 Recently, influenza related mortality and morbidity has witnessed a rise globally. 8 This has raised question on the preparedness of our country to combat future outbreaks. More than 30,000 lab confirmed patients were recorded in the countrywide outbreak in , more than 2000 succumbing to the illness, outnumbering the Ministry of Health s recorded toll in WHO declared pandemic times in 2009 (27,236 affected/981 deaths) and 2010 (20,604 affected/1763 deaths). 9,10 These data suggest the need of developing a comprehensive and standardized 1 Sheri Kashmir Institute of Medical Sciences, Srinagar; 2 Department of Microbiology, Government Medical College, Srinagar; 3 Medical Sciences Division, Abbott India Limited, Mumbai Received: ; Accepted:

2 45 management of influenza epidemic outbreaks. 2 Improved surveillance, strict monitoring, and prevention strategies viz. vaccines for Influenza virus are the critical steps in achieving adequate influenza control. 2 Awareness towards the disease embarks the primary step in attempts to achieve adequate control. Adequate knowledge about the vector, mode of transmission, symptoms, and serious complications associated with the disease helps an individual take proactive steps towards prevention and control. A Knowledge, Attitude, and Practice (KAP) study from Thailand showed that 42% of the pregnant women familiar with the influenza vaccine showed willingness to be vaccinated. 11 Knowledge regarding effectiveness of the vaccine and its side effects are the key predictors of getting vaccinated. 12 Although the awareness among the healthcare professionals is high, there is a paucity of data regarding the level of awareness among other sections of the society. Thus evaluating awareness among other individuals of the society is extremely important through systematic and validated KAP studies to assess awareness and knowledge gap. Corporate employees represent an important pool of educated Indian population. Assessing KAP regarding influenza in this group has a probability of providing an overall level of awareness in the educated class of the society. Furthermore, the closed environment, and working conditions makes this population vulnerable to airborne infections like influenza and pose a potential risk for transmission of the infection at home and workplace. By understanding the KAP of influenza in this group, health authorities and clinicians can initiate educational programs to aid prevention of spread of influenza and avoid epidemics. Therefore, this multicentre, questionnaire based study was conducted to assess the knowledge, awareness, and behavioural response in Indian corporate employees towards influenza. Methodology Study Design This study evaluated the KAP and behaviour of corporate employees towards influenza. Corporate employees from eight randomly selected consenting organizations across four different geographical zones (North, South, West and East) of India were selected and assessed for their awareness about influenzathrougha questionnairebased survey. This study was conducted in accordance with the protocol, International Conference on Harmonization-Good Clinical Practice (ICH-GCP) guidelines, the Declaration of Helsinki, Indian Council of Medical Research (ICMR), and Indian GCP guidelines. 13 Independent Ethics Committee (IEC) approved the study protocol, questionnaire, and participant authorization form (PAF) were used in this study. Selection Criteria Indian corporate employees of either gender aged 18 years, willing to provide a written authorization to participate in the study were included in the study. Corporate employees of non-indian origin and /or employees unwilling or unable to provide complete information as per questionnaire were excluded from the study. Study Assessments A self-administered study questionnaire with three domains namely knowledge, attitude and behavioural response (practices) was used for assessing awareness about influenza in the study participants (Appendix 1). The questionnaire was adapted from a previously conducted study which evaluated the KAP of influenza in general public of Saudi Arabia. 14 The questionnaire was validated and modified as per the requirement in a different study population. Validation of the questionnaire was conducted in a separate sample of 100 corporate employees prior to being used in the present. The knowledge domain of the questionnaire included 21 factual statements related to cause, route of transmission, symptoms, complications, preventive measures and vaccination of influenza. The participants were to respond if the statements were true or false or if they did not know. A scoring system was applied, where 1 point was given for each correct answer and no point was given for an incorrect answer including the response of don t know. Depending on the number of correct answers, the level of knowledge of corporate employees was categorized as low ( 13 points), average (14-17 points) or high ( 18 points). The attitude domain of the questionnaire had 6 questions that were designed to assess the attitude of corporate employees towards the disease, treatment, and vaccination. Employees ranked their responses using a 5-point Likert scale ranging from 5 to 1, where 5: strongly agree, 4: agree, 3: neutral, 2: disagree, 1: strongly disagree. Depending on the level of concern, the corporate employees were grouped into 4 categories: extremely concerned (if agreement was evident for all 6 statements), quite concerned (if agreement was evident for 3-5 statements), little concerned (if agreement was evident for 1-2 statements) or not concerned (if there was no agreement). The agreement was defined as a strongly agree or agree response to positive statements and a strongly disagree or disagree response to negative statements. The behavioural response domain of the questionnaire had 6 questions which aimed at assessing the precautionary actions taken by corporate participants and required

3 46 Table 1: Baseline characteristics of the study participants Level of Awareness in Knowledge, Attitude, and Practice Domains Parameter Total no. of participants (N=500) 28.0 (19,60.0) Low Level 50.8% Age, Median (Min, Max) Age group, n (%) yr 472 (94.4%) 40 yr 28 (5.6%) Gender, n (%) Male 376(75.2%) Female 124(24.8%) Education, n (%) (N=500) Post-graduate 198 (39.6%) Graduate 261 (52.2%) Under-graduate 37(7.4%) Others 4(0.8%) Diploma 4(100.0%) *Max= Maximum, Min=Minimum, N= Total number of participants, n= Number of participants, SD = Standard Deviation Knowledge Attitude Average Level High Level Quite Concerned Extremely Concerned Little Concerned 9% 15.2% 24% 34.0% 66% the participants to respond as yes or no to each precautionary measure. A scoring system was applied. One point was given for each required precautionary measure undertaken. Thus, the total precaution score ranged from 0 to 6 points. A high level of precaution was considered 5-6 points, a moderate level as 3-4 points, and a poor level as 2 points or less. Since the questionnaire was self-administered, the participants themselves completed all answers to the questionnaire. The participants discussed any queries on the questionnaire with the field physician. The field physician and coordinators ensured that the participants completed questionnaires correctly. The completed questionnaires were then sent to the data management team and the investigator for analysis and archival. Study Variables Being a KAP based study the primary variables of the study were percentage of corporate employees with high, average and low level of knowledge; percentage of corporate employees who were little, quiet and extremely concerned about influenza and its treatment; percentage of corporate employees Practice Not Concerned Poor Level of Precaution Moderate Level of Precaution High Level of Precaution Fig. 1: Awareness level of study participants with respect to knowledge, attitude, and practice regarding influenza taking high, moderate and poor level of precaution towards influenza. However, there were no secondary variables defined for the study. Statistical Analysis All continuous and semiquantitative variables were described in terms of a number of observations (n), mean, standard deviation (SD), median, minimum and maximum. The summary of categorical data was presented in terms of frequency count (n) and percentages (%). All statistical tests were to be done at 2-sided 5% level of significance. Further, depending on the availability of data, Chisquare/Fisher s Exact test was used 1% 5.6% at 5% level of significance to see if these factors (level of knowledge, level of concern about influenza, level of precaution towards influenza) had any association with gender, age or educational qualification of the employees who participated in the survey. Results 36.6% 57.8% 0% 10% 20% 30% 40% 50% 60% 70% Study Participants Total of 507 participants agreed to participate and 500 successfully completed the survey (from major cities of India across four zones- North, South, West and East). The median age of the participants was 28 yr (min, 19, max, 60) and majority of the study population

4 47 Table 2: Awareness in study participants with respect to knowledge domain Survey statement True False Don t know Influenza vector and mode of transmission Influenza is different from a common cold 75.6% 12.8% 11.6% Influenza is caused by virus 85.4% 4.4% 10.2% Influenza is a hereditary disease 9.2% 74.4% 16.4% Influenza can be transmitted by droplets of coughing/sneezing 79.8% 7.4% 12.8% of infected person Influenza is transmitted by touching infected person 22.4% 63.4% 14.2% Influenza is transmitted by sexual route 14.8% 61.4% 23.8% Sign and symptoms Fever or feverish chills are symptoms of influenza 73.0% 11.4% 15.6% Sore throat is a symptom of influenza 61.2% 14.2% 24.6% Muscle or body aches are symptoms of influenza 67.0% 14.2% 18.8% Mood swings is a symptom of influenza 23.4% 44.0% 32.6% Headache is also a symptom of influenza 68.8% 12.0% 19.2% Runny and stuffy nose is a symptom of influenza 72.4% 9.2% 18.4% Tiredness is a symptom of influenza 60.2% 21.6% 18.2% Itching is a symptom of influenza 19.4% 53.6% 27.0% Complications and prevention Influenza can lead to other respiratory infections such as 48.8% 14.8% 36.4% pneumonia Influenza can occur more than once in lifetime 64.4% 9.6% 26.0% The best way to prevent seasonal influenza is by getting a flu 51.4% 17.2% 31.4% vaccination each year Vaccination can keep you free from getting sick from influenza 56.6% 18.2% 25.2% Vaccination can help protect people who are at greater risk of 63.0% 10.0% 27.0% getting seriously ill from influenza, like older adults, people with chronic health conditions and young children Vaccination also may make your illness milder if you do get 47.4% 17.0% 35.6% sick with influenza Vaccination can reduce the risk of more serious influenza outcomes, like hospitalizations and deaths 67.8% 9.4% 22.8% was male (75.2%). More than half of the participants were graduates (52.2%), and the remaining were post-graduates (39.6%), or undergraduates (7.4%). The baseline characteristics of the participants are presented in Table 1. Knowledge Domain The results of knowledge domain revealed that about 50.8 % of the participants had low level knowledge regarding influenza whereas 34% had moderate level knowledge and only 15.2% had high level knowledge regarding influenza (Figure 1). Majority of the participants (75.6%) were aware that influenza is different from common cold; 85.4% knew that it is caused by a virus; 74.4% mentioned it is not a hereditary disease. Participants were well informed (79.8%) that influenza is transmitted through droplets of cough/sneeze of the infected person and not by touching the infected person (63.4%) or via sexual route (61.4%). However; a significant proportion of participants believed that influenza can spread by touching the infected person (22.4%) or through sexual route (14.8%). Regarding awareness of the symptoms of influenza, variable number of participants knew that fever and chills (73%), sore throat (61.2%), muscle or body aches (67%), headaches (68.8%), runny and stuffy nose (72.4%), and tiredness (60.2%) are common symptoms of influenza. About 51.4% of the study participants were knowledgeable that vaccination every year is the best way to prevent influenza, and vaccination can keep an individual free from influenza (56.6%). However; 31.4% participants were unaware that vaccination every year is the best measure to prevent seasonal influenza whereas 25.2% did not know that vaccination can keep them free of influenza (Table 2). A statistically significant proportion of men were present in the all three levels of knowledge namely low level, moderate level, and high level knowledge. Similar association was found with age and educational qualification. Attitude Domain The attitude of study participants towards influenza showed that 66% participants were quite concerned regarding influenza and 24% participants were extremely concerned (Figure 1). Most of the participants (90%) were of the opinion (strongly agreed: 43%; agreed: 47%) that physician should be consulted immediately if suffering from influenza. Additionally, majority (88.4%) of the participants believed (strongly agreed: 48.8%; agreed: 39.6%) that medication should be taken in consultation with physician only. A total of 68.4% participants (strongly agreed: 33.8%; agreed: 34.6) mentioned that it is appropriate to avoid contact with others and skip office while suffering from influenza. When inquired if healthy individuals must be vaccinated, the results revealed that only 17% of the participants strongly agreed with the statement and 39.2% of them agreed while 34.6% remained neutral. Although 42.6% participants agreed that individuals at a greater risk of getting seriously ill from flu must be vaccinated, the proportion of participants who strongly agreed was low (24.6%) and there were 10.6% participants who disagreed (Table 3). A statistically significant proportion of men were present in the all three levels of attitude namely not concerned, little concerned, quite concerned, and extremely concerned. Similar association was found with age and educational qualification. Behaviour/Practice Domain Practices and behaviour of an individual can either protect or increase the risk of acquiring influenza. The practices followed

5 48 Table 3: Awareness in study participants with respect to attitude domain Survey statement Strongly agree Agree Neutral Disagree Strongly disagree Physician should be consulted 43.0% 47.0% 7.6% 2.2% 0.20% immediately if suffering from influenza For treating influenza, medication 48.8% 39.6% 8.6% 2.8% 0.2% should be taken in consultation with physicians only When you are suffering from 33.8% 34.6% 19.2% 11.6% 0.8% influenza, you should avoid working in office, stay home and avoid contact with other people except to get medical care Vaccination should be taken for 19.6% 38.4% 30.2% 11.0% 0.8% preventing influenza every year Vaccination should be taken by 17.0% 39.2% 34.6% 7.8% 7.8% healthy adults Vaccination should be taken by people who are at greater risk of getting seriously ill from flu, like older adults people with chronic health conditions and young children 24.6% 42.6% 20.2% 10.6% 2.0% by participants of the study were evaluated and revealed that 57.8% of the study participants took high level precautions, and 36.6% took moderate level precautions for the prevention of infection (Figure 1). Most of the study participants washed their hands often (92%), and avoided touching eyes, nose, or mouth frequently when suffering from influenza (71.2%). Other precautions taken by the participants included covering nose and mouth with tissue paper while sneezing and coughing (90%); throwing the used tissue paper in trash (93.2%); using face mask in crowded areas when suffering from influenza (55.2%); and avoiding normal activities such as work, school, travel, and shopping when suffering from influenza (60.8%) (Table 4). A statistically significant proportion of men were present in the all three levels of knowledge namely poor level of precaution, moderate level of precaution, and high level of precaution. Similar association was found with age and educational qualification. Discussion Our study has given an insight of the KAP among one of the most educated section of our society. To the best of our knowledge, this is the first KAP study among the corporates of India. India, being a developing country requires awareness campaigns to make its people knowledgeable and well equipped with the disease condition. The awareness level evaluated as three separate domains viz. knowledge, attitude, and practice, has demonstrated the preparedness of the country against influenza. In the knowledge domain of our study, the results revealed that only 15.2% of the study participants had high level knowledge about influenza and half of the study participants (50.8%) had poor level knowledge. Further, although about half of the study participants were aware of the causative agent and mode of transmission of influenza, misconceptions like influenza being transmitted by touching infected person and sexual route were seen as well, albeit in a smaller proportion of participants. Rathi et al reported that 96% of the Vadodara population included in their study were aware that influenza is an infectious disease. 15 Kamate et al, in 2010 evaluated the level of awareness among the public in Udaipur and reported that although around 83% population had only heard about Influenza, Table 4: Participant response on behaviour/practice domain Survey questions Yes No Do you wash hands often? 92.0% 8.0% Do you avoid touching your eyes, nose, or mouth frequently when suffering from influenza? 71.2% 28.8% Do you cover your nose and 90.0% 10.0% mouth with a tissue when you cough or sneeze? Do you throw the tissue in 93.2% 6.8% the trash after you use it? Do you use a face mask 55.2% 44.8% in crowded areas when suffering from influenza? Do you avoid normal activities, including work, school, travel, shopping etc. when suffering from influenza? 60.8% 39.2% 47% population knew more about influenza virus. 16 Knowledge regarding the symptoms of influenza showed that most of the participants were aware regarding the symptoms however; few had a misconception that itching is also a symptom of influenza. Understanding of the route of transmission is equally important for the prevention of infection however; a few participants of our study believed that influenza could also spread via sexual route and while 23.8% participants did not have any knowledge regarding the route and method of transmission. Damor et al reported that only 0.6% of OPD attendees of a tertiary care hospital believed that influenza spreads through sexual route. 17 However; it is important to note that this misconception exists among general population medicine, paediatric, pulmonary medicine, and ENT OPDs. Vaccination is the most important factor that can be used for the prevention of influenza and when the study participants were questioned regarding this aspect, the survey revealed that close to half of the participants were aware that vaccination is beneficial in preventing influenza and its complications. A KAP study conducted in school employees showed that most of the individuals

6 49 avoid getting vaccinated because they believe that it is not required, or it may not be effective in protecting them against influenza, or that the vaccine is not safe. 18 Hence the real challenge will be to increase the level of awareness in the rest of the population in this highly educated population. These percentages suggest the need for awareness programs to educate everyone regarding the epidemic. The attitude domain of the study showed that majority of the participants (66%) were quite concerned and a negligible proportion of participants (1%) were not concerned regarding their attitude towards influenza infection. In the attitude domain, less than half of participants mentioned that it is appropriate to consult the physician if suffering from influenza. Another KAP study conducted in highly educated group of individuals demonstrated that 96% of the participants preferred consulting the physician immediately for the management of influenza. 15 Avoiding social contact while suffering from influenza may prevent the spread of infection however; unlike our study, another survey conducted among school teachers showed that very few participants agreed to avoid social contact (17.7%) and wore mask to work place (19.8%). 19 When questioned regarding the attitude of the participants towards vaccination, very few participants (19.6%), agreed that vaccination must be taken every year for the prevention of influenza or vaccination may help prevent infection in high risk individuals such as older individuals with chronic health conditions (24.6%). Contrary to the results of our study, another study reported that literate population of Udaipur believed vaccination to be the most effective preventive measure against influenza. 16 Healthcare workers in Srinagar who were not vaccinated against influenza mentioned that poor knowledge of vaccine availability, misperceptions about vaccine effectiveness, and fear of adverse events were major reasons for not getting vaccinated. 20 The results of our study also demonstrated that the perceptions of individuals towards vaccination may lead to increased chances of infection as only 17% participants mentioned that vaccination must be taken by healthy individuals. The practice domain of the study showed that a considerable proportion of participants exercised preventive measures such as washing hands (92%), avoiding touching eyes, nose, or mouth (71.2%), covered nose and mouth while coughing/sneezing (90%) and threw tissue in the trash after using it (93.2%). Washing hands frequently is one of the most commonly used preventive measure against infection in several other studies conducted in the past. 16,21,22 Among the other effective precautions which prevent spread of infections, the study participants in our study used face mask in crowded areas. The use of face mask in crowded areas was reported in other studies conducted in Pune and Karnataka. 17,18 The low level of awareness among the study population has generated the need for developing awareness programs among general population. Additionally, the study showed high level of precaution being exercised by 57.8% of the participants in the practice domain. Although evaluating the KAP of influenza among the corporates has revealed valuable information, we further tried to identify whether the study participants practiced everything they were aware of. Although 22.4% participants felt that influenza can transmit by touching the infected person, most of the participants (90.0%) covered their nose and mouth with a tissue when they coughed or sneezed. This practice is very essential to prevent spreading of infection. Although a majority of the participants were aware (79.8%) that influenza is transmitted by droplets of coughing/sneezing of infected person; only a little more than half of the participants (55.2%) used face mask in crowded areas when suffering from influenza. Majority of the participants (60.8%) avoided normal activities such as work, school, travel, and shopping when suffering from influenza however; the attitude of only half the participants (33.8%) of the study revealed that they strongly agreed with the fact that while suffering from influenza they must avoid working in office, stay home and avoid contact with other people except to get medical care. While 51.4% were aware that getting a flu vaccination every year is the most effective way of avoiding influenza infection, only 19.6% participants in the attitude domain mentioned that they strongly agreed that getting vaccinated every year was the best way to prevent influenza. A total of 63% participants were aware that vaccination can help protect people who are at greater risk of getting seriously ill from Influenza, like older adults, people with chronic health conditions and young children however; in the attitude domain only 24.6% participants strongly agreed to the fact that vaccination should be taken by people who are at greater risk of getting seriously ill from flu, like older adults people with chronic health conditions and young children. Most influenza KAP studies conducted in the past have evaluated the association of gender, age, and educational qualification with the level of awareness among the participants. One of the major limitations of the present study is that it attempted to make an association between educational level, gender, and age with the level of awareness among the corporate employees, however; due to unmatched baseline demographic parameters this interpretation was not successfully conducted.

7 50 The baseline demographics were not well matched and most of the study participants were male, and below 40 yr. of age. Also, most participants were at least graduates and there were limited undergraduates in the study. This may be considered as the main limitation of our study. However; it becomes extremely important to mention that corporates are usually younger and at least hold a graduate degree and that inclusion of this group in the study could not be avoided. Being the first KAP study among the corporates of the country may be considered as a strength of the present study. Conclusion In conclusion, the results have revealed that half the participants had low level of knowledge (50.8%), a considerably higher proportion of participants exercised high level of precaution (57.8%) against influenza, and majority of the study participants (66%) were quite concerned regarding their attitude towards influenza. Knowledge and attitude regarding importance of vaccine against influenza is not adequate. Hence, more awareness is required for improvement in this area. These results hold more importance for the formulation of guidelines which can provide a management protocol to the healthcare professionals. Additionally, these results can be used to identify the gaps in the society and to raise better awareness. Acknowledgements The authors acknowledge Turacoz Healthcare Solutions, New Delhi, India for writing support. Funding The study was funded by Abbott India Ltd. Conflict of Interest Dr. Koul has received research funding from Abbott India Ltd as a consultant/advisor for conducting the study. Dr. Koul has also received research grants from various governmental and nongovernmental organizations for carrying out research in Influenza. Dr. Sonawane is an employee of Abbott India Ltd. Author Contributions All authors met the ICMJE criteria for authorship and all those who met those criteria are listed as authors. All authors contributed to study design, implementation, data interpretation, and development of this manuscript; also approved the final manuscript for submission. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. References 1. Centres for Disease control and Prevention paper on Influenza. Available from: disease.htm#seasonal-flu.accessed on 18 Feb Harper SA, Bradley JS, Englund JA, et al. Seasonal Influenza in Adults and Children- Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2009; 48: Influenza: Signs, symptoms and complications; Recommendations for prevention. 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