Asian Journal of Psychiatry 51 (2020) 102083

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Study of knowledge, attitude, anxiety & perceived mental healthcare need in T

Indian population during COVID-19 pandemic
Deblina Roya, Sarvodaya Tripathya, Sujita Kumar Kara,*, Nivedita Sharmaa,
Sudhir Kumar Vermaa, Vikas Kaushalb
a
King George’s Medical University, Lucknow, Uttar Pradesh, India
b
Uttar Pradesh Technical Support Unit (UP TSU), Lucknow, Uttar Pradesh, India

A R T I C LE I N FO A B S T R A C T

Keywords: Novel Corona Virus Disease (COVID-19) originating from China has rapidly crossed borders, infecting people
Awareness throughout the whole world. This phenomenon has led to a massive public reaction; the media has been re-
Attitude porting continuously across borders to keep all informed about the pandemic situation. All these things are
Anxiety creating a lot of concern for people leading to heightened levels of anxiety. Pandemics can lead to heightened
Mental healthcare
levels of stress; Anxiety is a common response to any stressful situation. This study attempted to assess the
COVID-19 pandemic
knowledge, attitude, anxiety experience, and perceived mental healthcare need among adult Indian population
during the COVID-19 pandemic. An online survey was conducted using a semi-structured questionnaire using a
non-probability snowball sampling technique. A total of 662 responses were received.
The responders had a moderate level of knowledge about the COVID-19 infection and adequate knowledge
about its preventive aspects. The attitude towards COVID-19 showed peoples' willingness to follow government
guidelines on quarantine and social distancing. The anxiety levels identified in the study were high. More than
80 % of the people were preoccupied with the thoughts of COVID-19 and 72 % reported the need to use gloves,
and sanitizers. In this study, sleep difficulties, paranoia about acquiring COVID-19 infection and distress related
social media were reported in 12.5 %, 37.8 %, and 36.4 % participants respectively. The perceived mental
healthcare need was seen in more than 80 % of participants. There is a need to intensify the awareness and
address the mental health issues of people during this COVID-19 pandemic.

1. Introduction Philippines on 2nd February. On 11th February, WHO announced a

name for the new coronavirus disease: COVID-19 (WHO, 2020c). On
COVID-19 started in December 2019, like a viral outbreak in Wuhan the 11th of March, WHO declared COVID-19 - a pandemic as by then
city of central Hubei province of China (Holshue et al., 2020). A cluster about 114 countries were affected (WHO, 2020c).
of about 40 cases of pneumonia of unknown etiology was reported, Coronaviruses, so named due to the outer fringe of envelope pro-
some of the patients being vendors and dealers in the Huanan Seafood teins resembling crown ('corona’ in Latin), are a family of enveloped
market there. World Health Organization (WHO) along with Chinese RNA viruses (Burrell et al., 2017). They are generally pathogenic to
authorities started working together and the etiological agent was soon mammals and birds and cause mild upper respiratory tract infections in
established to be a new virus and was named Novel Corona Virus humans. They occasionally can be transmitted to a larger human po-
(2019-nCoV). Meanwhile, on 11th January China announced its first pulation and can cause severe respiratory illnesses exemplified by Se-
COVID-19 related death of a 61-year-old man, exposed to the seafood vere Acute Respiratory Syndrome (SARS) and Middle-East Respiratory
market (WHO, 2020a). Over a period of few weeks, the infection spread Syndrome (MERS) in 2003 and 2012 respectively.
across the globe in rapid pace (WHO, 2020b). Looking at the stretch of Due to the similarity between COVID-19 and SARS Coronavirus, and
countries this outbreak spread to, WHO declared it a Public Health because the virus was posing to be a global threat, online courses for
Emergency of International Concern on 30th January 2020 (WHO, awareness of healthcare workers around the world were initiated
2020b, 2020c). Amidst the increasing deaths in China, the first death (WHO, 2020c). Funds were raised globally and Strategic Preparedness
outside China was (of a Chinese man from Wuhan) reported in the and Response Plan (SPRP) was set up aimed to protect the states with

⁎
Corresponding author.
E-mail address: skkar1981@yahoo.com (S.K. Kar).

https://doi.org/10.1016/j.ajp.2020.102083
Received 1 April 2020; Accepted 3 April 2020
1876-2018/ © 2020 Elsevier B.V. All rights reserved.
D. Roy, et al. Asian Journal of Psychiatry 51 (2020) 102083

weaker health systems. The targets were to limit transmission, provide who are kept in isolation and quarantine experience significant distress
early care, communicate key information and minimize social and in the form of anxiety, anger, confusion and post-traumatic stress
economic impacts. Also, WHO focused on developing easy-to-apply symptoms (Brooks et al., 2020). The knowledge and attitudes of the
diagnostics, accelerating existing vaccine candidates and preventing public are expected to largely influence the degree of adherence to the
infection (WHO, 2020c). personal protective measures and ultimately the clinical outcome.
The state of lock-down in many parts of the world, which are con- Hence, it is important to study these domains in the Indian population.
tributing largely to the global economy has led to the halting of services The mental health issues are other major health concerns, which are
and products. This has led to a break in the global supply chains and expected to increase day by day during this epidemic. There is a paucity
thus, affected the global economy brutally (Ebrahim et al., 2020). of research that evaluated the mental health concerns during this
Transport has been affected globally. Import of steel, iron, inorganic pandemic. Considering the relevance of all the above factors, it was
chemicals, etc. from China and other countries has been grossly af- aimed to evaluate knowledge, attitude, anxiety and perceived mental
fected. Transport business even at national levels has ceased due to healthcare needs in the community during the coronavirus pandemic in
lock-down in different countries. Most company employees are working India.
from home, which has its financial disadvantages. Educational institu-
tions have been shut down. The uncertainty and postponement of ex- 2. Materials and methods
aminations is also a stressor for young minds.
Along with the economic impacts, the ever-increasing morbidity This was a cross-sectional, observational study carried out in India.
and mortality due to COVID-19 is the biggest setback. The WHO report A Snowball sampling technique was used. An online semi-structured
revealed the mortality rate to be between 3–4 % (WHO, 2020b); questionnaire was developed by using google forms, with a consent
however, it seems that the morality statistics are underestimated (Baud form appended to it. The link of the questionnaire was sent through e-
et al., 2020). mails, WhatsApp and other social media to the contacts of the in-
Yet, because COVID-19 infection is a highly contagious disease and vestigators. The participants were encouraged to roll out the survey to
has affected a large population, the total number of deaths caused due as many people as possible. Thus, the link was forwarded to people
to this virus has exceeded that caused by any of its predecessors. As on apart from the first point of contact and so on. On receiving and clicking
the morning of 30th March 2020, a total of 693,224 confirmed cases the link the participants got auto directed to the information about the
has been reported from 204 countries of the world; also, there are study and informed consent. After they accepted to take the survey they
33,106 confirmed deaths across the globe, as reported by the WHO filled up the demographic details. Then a set of several questions ap-
(WHO, 2020d). peared sequentially, which the participants were to answer.
As COVID19 is a new disease and is having the most devastating It was an online study. Participants with access to the internet could
effects globally, its emergence and spread, causes confusion, anxiety participate in the study. Participants with age more than 18 years, able
and fear among the general public. Fear is the breeding ground for to understand English and willing to give informed consent were in-
hatred and stigma. Social stigma has arisen as certain populations cluded. The data collection was initiated on 22nd March 2020 at 4 PM
(Indian north-east people) are targeted as being the reason for this IST and closed on 24th March 2020 at 4 PM IST. We were able to collect
outbreak (WHO, 2020c). It is vital to avoid this stigma as it can make data from across various states of India. The socio-demographic vari-
people hide their illness and not seek health care immediately. WHO is ables included age, gender, occupation, education, domicile, area of
providing expert guidance and answers to public questions, to help residence and religion.
people manage fear, stigma, and discrimination during COVID-19 The online self-reported questionnaire developed by the in-
(WHO, 2020c). As research into COVID-19 continues, a lot of the facts vestigators contained the following six sections related to awareness
keep on changing and many myths are also prevalent in the general (knowledge), attitude, anxiety and perceived mental health care needs
population regarding the prevention and management of the infection. during the pandemic of the novel coronavirus.
In the time of widespread use of social media, these myths along with There were 6 multiple choice questions in the awareness section.
fake news around corona are also spreading rapidly. These are some- The attitude section contained 7 items that were to be rated in the 5-
times very disturbing for certain individuals. Several sites including point Likert scale format. Anxiety related to novel coronavirus infection
WHO are thus providing myth busters and authentic information had 18 items that were supposed to be rated on a 5-point Likert scale
(WHO, 2020c). Governments are also urging people to not sharing these ranging from never, occasionally, sometimes, often and always. The
messages without checking their authenticity. perceived mental healthcare need was assessed by 4 items on a 3-point
Since the onset of the coronavirus pandemic there has been an in- Likert scale. Descriptive statistics have been used in the study to analyse
creased use of masks (Feng et al., 2020) and sanitizers resulting in the findings. Mean and standard deviation and proportions have been
exhaustion of resources in the market. A shortage of personal protective used to estimate the results of the study.
equipment endangers health workers worldwide (WHO, 2020c). The
absence of appropriate protective measures is a major cause of concern 3. Result
among medical personnel. Especially in a country like India which is a
densely populated country without a robust healthcare infrastructure, it An online survey, related to awareness, attitude, anxiety experience,
is a cause of worry. Some degree of panic also resides in public due to and perceived mental health care needs in the community during the
the unavailability of basic protection measures. As of 30th March 2020, corona pandemic, was conducted in the Indian population. A total of
Indian Govt. has registered a total of 1250 cases (1117 active cases, 101 662 responses were recorded. All the participants were above 18 years
cured or discharged and 32 deaths) due to COVID-19 infection of age and Indian origin. The study included only those participants
(MoHFW, 2020). The governments, media, doctors, researchers, ce- who understood English and had access to the internet. Hence, by de-
lebrities, police and other stakeholders of the society appealed to the fault individuals with a higher level of education were included in the
public to avoid public gatherings including sports, religious ceremonies, study. The lowest educational level in this study was observed to be
family functions, meetings as well as classes in school, to prevent the standard 10th. The highest qualification of more than 90 % of the po-
global spread of coronavirus infection (McCloskey et al., 2020). Despite pulation was graduation and above. Approximately, half of the popu-
these efforts, many people ignore the importance of social distancing lation were healthcare professionals. The mean age of the participants
due to attitudinal issues. was 29.09 ± 8.83 years. Among the participants, 51.2 % were females
The anxiety and concerns in society are globally affecting every and 48.6 % were males. More than 80 % of participants were from
individual to variable extents. Recent evidence suggests that individuals urban areas. The participants belong to 25 states or union territories of

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D. Roy, et al. Asian Journal of Psychiatry 51 (2020) 102083

Fig. 1. Distribution of study sample across various states of India].

the country with maximum representation from Uttar Pradesh, fol- partying meetings, and gatherings. Around 3/4th of the participants
lowed by Odisha, Haryana, and West Bengal (Fig. 1). Approximately 87 avoided ordering food online last week. A total of 80 % of participants
% of the participants were Hindus. repeatedly discussed the pandemic with their friends during this period.
In our study, 41 % of the people affirmed feeling scared when someone
3.1. Part I: awareness about COVID-19 pandemic in their social circle became sick. About 1/3rd participants reported
having inappropriate social behavior owing to the fear of contracting
A considerable number of responders were passably aware of the the virus. Almost 33 % of the people accepted that they felt obliged to
basic elements of the disease, as shown in Fig. 2. Out of the total par- buy and stock essentials at home. In this study, 37 % of participants
ticipants, 29.5 % answered that the virus spreads through multiple admitted using a mask without the apparent signs and symptoms of the
modes like touching, kissing, sneezing, and food; also 56 % negated the infection and more than 75 % felt the need to use sanitizers and gloves.
notion of pets transmitting the virus. Only 43 % of responders regarded Almost 85 % agreed that they frequently washed their hands. Nearly
COVID-19 as a highly contagious disease. Most participants (97 %) half the participants felt panic by the reports of COVID-19 pandemic on
acknowledged that washing hands frequently could stop the spread of the electronic and print media over the past week.
infection. Only 18.2 % regarded fever as a symptom of COVID-19,
which is known to be a major symptom. 3.4. Part IV: perceived mental healthcare needs

3.2. Part II: attitude towards COVID-19 pandemic As shown in Table 2, for about 2/3rd of the participants an idea of
someone being there to absolve their worries regarding the COVID-19
As shown in Fig. 3, more than 96 % of the participants agreed to pandemic was welcoming. A total of 75 % agreed on the necessity of
quarantine/ isolate themselves if they had a fever and cough. Most (98 mental healthcare for individuals who panic amid the pandemic si-
%) of the participants thought social distancing is essential to stop the tuation. More than 80 % of participants felt the need for the profes-
virus from spreading. However, 88.7 % of them considered traveling sional help from mental health experts to deal with emotional issues
within the country to be safe during the pandemic. Approximately 60 % and other psychological issues during this pandemic.
of participants believed that patients recovered from COVID-19 infec-
tion, should not be allowed to stay within the community at this time. 4. Discussion

3.3. Part III: anxiety towards the COVID-19 pandemic Epidemics and pandemics are a periodic phenomenon. People in the
community face several challenges during such periods. Lack of
Drawing from the data given in Table 1, more than 80 % of the awareness often leads to an unconcerned attitude, which may adversely
participants were preoccupied with the COVID-19 pandemic over the affect the preparedness to meet these challenges. Impacts of these
past week. Approximately 40 % of the participants were paranoid with epidemics and pandemics are often intense, which may adversely affect
the thought of contracting the Novel Coronavirus infection over the the mental well-being of a given population. The fear and anxiety re-
past week. About 72 % of participants reported being worried for lated to epidemics and pandemics also influence the behavior of people
themselves and their close ones during the ongoing pandemic. Ap- in the community. Hence, this study attempted to evaluate the aware-
proximately, 12 % of the participants had sleeping difficulty due to ness, attitude, anxiety and perceived mental healthcare needs in the
being worried about the pandemic in the past week. Among the parti- society.
cipants, 82 % had reduced social contact, and about 90 % avoided Rubin et al. (2009) had conducted a similar study during the swine

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D. Roy, et al. Asian Journal of Psychiatry 51 (2020) 102083

Fig. 2. Awareness of participants about COVID-19 pandemic].

flu outbreak in the United Kingdom (Rubin et al., 2009). They had Alele, 2016).
conducted the survey telephonically over four days in the native po- Most of the participants in our study were educated - either grad-
pulation who heard the term "swine flu" and was able to speak English. uate or post-graduate and (%) were healthcare professionals. The par-
There is much similarity like illness between swine flu and COVID-19 ticipants had a moderate level of awareness regarding the mode of
infection. Both illnesses are viral in origin involving the respiratory spread, symptoms, and yet adequate awareness about the preventive
system and spreading by droplet infection. Similar precautions are often measures. It was possibly due to the government and media empha-
recommended for the prevention of swine flu and COVID-19 infection. sizing more on the preventive measures. Educated and especially
Unfortunately, there is no specific treatment or vaccine available for healthcare people get more sensitized by these information’s.
COVID-19 infection, whereas both treatment and vaccines are present The study participants reported frequent use of sanitizers, hand
for swine flu. wash, and masks during the past one week. This indicates the increasing
All epidemics and pandemics have their unique characteristics in concern of participants towards personal hygienic measures to avoid
terms of causality, progression and control measures. It is crucial to COVID-19 infection. Sensitization and awareness about COVID-19 are
provide health education and create awareness during such situations reflected in their behavior and attitude significantly as most of the
for effective prevention of disease spread (Johnson and Hariharan, participants (more than 4/5th) agreed with – social distancing,
2017). It has been seen in a previous study that health professionals avoiding travel, self-quarantine and adequate hygienic measures.
often have better awareness, positive attitudes towards epidemics/ However, their fear, apprehension and possibly stigma is reflected
pandemics and they often experience low levels of anxiety (Mishra when they were asked about the inclusion of recovered COVID-19 pa-
et al., 2016). But, a study from Ethiopia reported, poor knowledge and tients to the mainstream of society. Stigma is associated with many such
erroneous believes of healthcare professionals, during the Ebola virus health conditions. Adequate awareness may minimize the stigma and
outbreak in 2015 and it urged for intense training of the healthcare facilitate acceptance in the general population.
professionals (Abebe et al., 2016). In a study conducted in Trinidad and When anxiety affects a larger population, it may result in panic
Tobago in 2016, following the H1N1 epidemic, it was seen that a sig- buying, leading to exhaustion of resources. It also can lead to limita-
nificant proportion of the general public was unaware of the seriousness tions in daily activities, avoidance behavior causing limited socializa-
and measures of prevention of the epidemic (Johnson and Hariharan, tion, self-medication. Because of anxiety, people adopt various un-
2017). A similar study, evaluating the knowledge, attitude, and per- wanted lifestyle and dietary modifications under the influence of
ception of Ebola virus infection among secondary school children of rumors. These may affect mental health adversely. Hence, it is im-
Nigeria, found that most of the participants had inadequate knowledge portant to deal with the mental health difficulties in situations of the
and carried a negative attitude towards the outbreak (Ilesanmi and pandemic. Similarly, additional changes like – isolation, social

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D. Roy, et al. Asian Journal of Psychiatry 51 (2020) 102083

Fig. 3. Attitude of participants towards COVID-19 pandemic].

distancing, self-quarantine, restriction of travel and the ever-spreading reporting sleep difficulties. More than two-thirds of participants re-
rumors in social media are also likely to affect mental health adversely ported themselves worried after seeing posts about COVID-19 pandemic
(Banerjee, 2020). In our study, we found approximately 28 % of people in various social media platforms and approximately 46 % of

Table 1
Anxiety related to COVID-19 pandemic.
Sl. Items % of responses who feel anxious (often and always) (N
= 662)

1 From the last week, how often do you think about Novel Coronavirus Pandemic? 82.2
2 From the last one week, how often you feel paranoid about contacting the novel Corona Virus infection? 37.8 %
3 From the last week, how often you avoid partying? 90.1
4 From the last week, how often you avoid social contact? 82.1
5 From the last week, how often you avoid large meetings and gatherings? 89.1
6 From the last week, how often you avoid ordering food online? 76.7
7 From the last week, how often you have talked to your friends about the corona Pandemic? 80.7
8 From the last one week, how often you have had difficulty sleeping by being worried about the Coronavirus 12.5
pandemic?
9 From the last week, how often you feel affected by the posts on social media about corona Virus infection? 36.4
10 From the last week, how often do you feel affected by the talks of Novel Corona Virus Pandemic on the newspaper 46.1
and news channels?
11 From the last week, how often do you feel the need to buy and stock all essentials at home? 31.7
12 From the last week, how often do you get afraid if anyone in your social circle reports of being sick? 41.3
13 From the last week, how often do you feel the need to use the sanitizer/gloves? 77.4
14 From the last week, how often do feel the need to constantly wash your hands? 84.5
15 From the last one week, how often do you feel worried about yourself, and close ones regarding the spread of Novel 72
COVID19 Viral Infection?
16 From the last week, how often do you use a mask without any apparent signs and symptoms of the infection? 36.6
17 From the last week, how often does the Idea of Novel Corona Viral Infection freak you out leading to inappropriate 30.5 %
behaviours with anyone?
18 From the last week, how often does the Idea of Novel Corona Viral Infection freak you out post on social media? 44.7 %

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D. Roy, et al. Asian Journal of Psychiatry 51 (2020) 102083

Table 2
Perceived mental healthcare needs among participants during COVID-19 pandemic.
Sl. Items Percentage of people who perceive there is a mental health need.
(N = 662)

1 Do you think it would be nice to talk to someone about your worries for the COVID 19 viral epidemic? 66.5
2 Do you think it is necessary to get mental health help if one panics in lieu of the Pandemic situation? 75.1
3 Do you think it would be beneficial if mental health professionals help people in dealing with the current 83.5
COVID19 pandemic situation?
4 Will you suggest people for obtaining mental health help to people who are highly affected by the 82.9
COVID19 pandemic?

participants reported their worries related to the discussion of COVID- acquiring the COVID-19 infection. People have higher perceived needs
19 pandemic in news channels and print media. This indicates that a to deal with their mental health difficulties. There is a need to intensify
significant proportion of participants in the survey, despite having the awareness program and address the mental health issues of people
adequate awareness about coronavirus infection, are largely influenced during this COVID-19 pandemic. There is no study to date that eval-
by media information. Media influences the mental well-being and add uated the mental health perspectives of people during the COVID-19
to the level of anxiety. The swine flu pandemic of 2009–2010, which pandemic. It is important to study the mental health impacts in various
resulted in high mortality worldwide also caught global media attention populations (general populations, cases of COVID-19, close contacts of
and evoked anxiety among the public significantly (Everts, 2013). COVID-19 and healthcare workers) for planning effective intervention
Approximately, one-third of participants had the urge to buy and strategies for them.
stock things at home during the past week. Panic buying is often seen
during pandemics/epidemics, which leads to the exhaustion of re- Financial support
sources. Media reporting about the shortage of resources and essential
things of daily living further increases the panic buying. Sensible media None.
reporting during such a crisis may be beneficial in tackling mental
health challenges. Declaration of Competing Interest
In our study, frequent inappropriate behaviors (anger, restlessness,
worry) and pre-occupation about COVID-19 infection leading to posting None.
on social media, was seen in 1/6th and 1/3rd of the participants re-
spectively. Similarly, two-thirds of the participants felt the need to talk Acknowledgement
about their worries related to COVID-19 pandemic with someone. The
opportunities to vent out their distress was limited in most places due to None.
the lockdown state. At the same time, the electronic and print media, as
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