key: cord-0705461-cuplht23 authors: Wong, Cho Lee; Chen, Jieling; Chow, Ka Ming; Law, Bernard M.H.; Chan, Dorothy N.S.; So, Winnie K.W.; Leung, Alice W.Y.; Chan, Carmen W.H. title: Knowledge, Attitudes and Practices Towards COVID-19 Amongst Ethnic Minorities in Hong Kong date: 2020-10-27 journal: Int J Environ Res Public Health DOI: 10.3390/ijerph17217878 sha: 26e84f6855df8e06e630b2fea37c3b110552ca2b doc_id: 705461 cord_uid: cuplht23 This study assessed the knowledge, attitudes and practices (KAP) towards coronavirus disease 2019 (COVID-19) among South Asians in Hong Kong and examined the factors that affect KAP towards COVID-19 in this population. This cross-sectional descriptive study recruited participants with assistance from South Asian community centres and organisations. A total of 352 participants completed questionnaires to assess their level of KAP towards COVID-19. The mean knowledge score was 5.38/10, indicating a relatively low knowledge level. The participants expressed certain misconceptions regarding the prevention of COVID-19 infection. They perceived a mild risk related to the disease, had positive attitudes regarding its prevention and often implemented recommended disease-preventive measures, such as maintaining social distance (88.1%) and wearing masks in public (94.3%). Participants who were male, had a secondary school education or lower and who perceived a lower risk of being infected and lower self-efficacy were less likely to implement preventive measures. Culturally and linguistically appropriate health education could be developed to increase the knowledge of South Asians, especially those with lower education levels, about COVID-19 and to encourage them to implement the necessary preventive measures. Coronavirus disease 2019 (COVID- 19) , an emerging respiratory disease that was first reported in Wuhan, Hubei Province, China, in December 2019, is caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This virus is highly contagious, and symptoms of the related disease include fever, malaise, dry cough and dyspnoea [1] . The mode of transmission of SARS-CoV-2 is primarily through respiratory droplets and direct contact. Its incubation period ranges between 1 and 14 days, with an average of 5 days [1] . The global COVID-19 pandemic is ongoing and has spread quickly, and confirmed cases have been reported in the majority of countries. The World Health Organization (WHO) declared this disease a public health emergency of international concern on 30 January 2020 and encouraged all countries to work together to prevent the worsening of the pandemic [2] . As of 9 September 2020, there have been more than 27 million confirmed cases, resulting in more than 891,000 deaths worldwide [2] . Compared with other countries and regions worldwide, Hong Kong appears to be less severely affected by the COVID-19 pandemic. According to the Center of Health Protection (CHP) [3] , almost 5000 cases of COVID- 19 have been recorded to date in the region, and 99 patients were reported to have died of the disease. Currently, no vaccines are available for the effective prevention of SARS-CoV-2 infection. The current COVID-19 treatment regimen is limited to symptom management. Accordingly, the implementation of preventive measures and infection control procedures is of utmost importance to reduce the spread of this disease [1] . Some unprecedented measures have been implemented by the Hong Kong Government to control the spread of infection, including the enactment of regulations to maintain social distancing by prohibiting any group gatherings of more than four people in public places and ordering the closure of public facilities. Other currently enforced measures include the denial of entry of all foreign nationals to Hong Kong, compulsory quarantine for inbound travellers and isolation of infected persons and suspected cases at certain healthcare facilities. In addition, the Government has endeavoured to raise the public's knowledge and awareness of COVID-19 and its prevention through advertisements and social media [3] . The effectiveness of these implemented COVID-19 preventive measures is largely affected by the knowledge, attitudes and practice (KAP) of the public towards this disease. Knowledge pertains to the community's comparative level of knowledge about relevant biomedical concepts. Attitude refers to thoughts, feelings and actions about a concept that predispose people to act in a preferential manner. Practice refers to the extent to which preventive measures have been implemented among the public [4] . KAP may vary substantially among population groups according to their cultural and socio-economic characteristics. A study in Egypt demonstrated that individuals who are older, less educated, have a lower income or live in a rural area have a lower level of knowledge about COVID-19 [5] . Another study in China also revealed similar findings [6] . Emerging evidence from Italy, the United Kingdom and the United States indicates that ethnic minorities may experience worse outcomes associated with COVID-19, as evidenced by an overrepresentation of these populations among hospitalised COVID-19 patients [7, 8] . Previous research suggested the existence of an interaction between ethnicity and disease spread and progression that is driven by differences in biological, cultural, behavioural and social characteristics, including comorbidities, low socioeconomic status, work conditions, living standards, intergenerational cohabitation and health-seeking behaviours [8] . However, data pertaining to the KAP of ethnic minorities in Hong Kong towards COVID-19 are scarce. According to the Census and Statistics Department [9], the population of ethnic minority residents in Hong Kong has increased by more than 30% in the past decade. Most ethnic minorities (excluding foreign domestic helpers from Indonesia and the Philippines) originate from South Asian countries, such as India, Pakistan and Nepal. However, only approximately 10% of residents of Pakistani and Nepalese ethnicity have attained post-secondary education, and less than 10% of either population speaks either English or Cantonese in their daily communications [9] . Therefore, South Asian residents of Hong Kong may possess insufficient knowledge about COVID-19 because they are unable to comprehend the primarily Chinese-and English-language information about COVID-19 and its preventive measures as disseminated by the Hong Kong Government. Individuals' cultural beliefs may also pose remarkable challenges to the effective dissemination of health information [10] . For instance, the fatalistic belief that illness can occur outside of a person's direct control suggests that some individuals tend to externalise their responsibility to implement preventive measures for the benefit of society [11] . These observations suggest that ethnic minorities generally have a greater need for education on the effective prevention of COVID-19. To effectively control the pandemic in Hong Kong, local ethnic minorities should be provided education with the aim of increasing their awareness about the importance of implementing the Government-recommended infection prevention measures. A better understanding of the KAP towards COVID-19 held by individuals in South Asian minority populations at the height of the pandemic is needed to ensure the delivery of more effective education on this issue. Moreover, identifying the KAP held by South Asians in Hong Kong towards COVID-19 would help to reveal any misconceptions possessed by these individuals that may reduce their intentions to exhibit health behavioural changes. This study assessed the KAP of South Asians towards COVID-19 and examined the factors that affect their KAP towards the disease. This cross-sectional descriptive study was conducted in a community-based setting in Hong Kong. Participants were recruited via South Asian associations and community centres. Web-based and community-based convenience and snowball sampling approaches were applied for subject recruitment. In this regard, we sought support through our close connections with South Asian community centres and organisations, which were developed during collaborations for the implementation of our previous health promotion projects [12] . These organisations were asked to circulate an online questionnaire to be completed by their members. The eligibility criteria for participation in this online survey were (1) South Asian minority status, (2) an age of 18 years or older and (3) an ability to comprehend and communicate in Urdu, Nepali or English. A sample size of 118 participants was determined to be adequate to detect a medium effect size in a multiple regression model with 10 predictors at a power of 80% and a significance level of 5%. The questionnaire was developed by the research team with reference to previous research on KAP toward SARS [13] and in accordance with the current recommendations and guidelines from the United States Centre for Disease Control and Prevention (CDC), WHO and CHP. The primary version was prepared in English and translated into Urdu and Nepali using standard translating procedures. The translated versions were then reviewed by expert panels to ensure semantic and content equivalence. A convenience sample of nine South Asian residents of different ages was recruited to ensure that the contents of the questionnaire would be comprehensible to South Asians. Knowledge about COVID-19 was assessed using 10 true-or-false question items that aimed to determine the participants' knowledge about the signs and symptoms, transmission route and prevention measures of COVID-19. One point was awarded for each correct answer, while zero points were given for each item that was answered incorrectly or left unanswered by selecting the response 'do not know'. The possible knowledge score ranged from 0 to 10, with a higher score indicating a better level of knowledge possessed by the participant. Attitudes towards COVID-19 were assessed using 10 items that covered two aspects: the participants' perceived risk of disease (7 items) and their perceived self-efficacy in controlling the disease (3 items). Each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The mean score of each subscale was calculated to indicate the degrees of participants' attitudes in the respective domains. In this study, the Cronbach's alpha for the entire scale was 0.80; the perceived risk of disease subscale was 0.76, and the perceived self-efficacy subscale was 0.76. Practices of preventive measures against COVID-19 were assessed using 10 items that covered the aspects of personal hygiene practices and maintaining social distance. Each item was rated on a 4-point Likert scale ranging from 1 (never) to 4 (always). A higher score indicated a higher level of implementation of the preventive measures. This portion of the questionnaire received a Cronbach's alpha of 0.85 in our study. The author-developed questionnaire was also designed to collect socio-demographic information from the participants during the online survey. This information included age, gender, birthplace, marital status, work status, education level, monthly household income and religion. The data were collected via self-administered online surveys or face-to-face interviews. An online survey portal was created using SurveyMonkey, a secure and mobile device-based data collection tool. The portal included a brief description of the study, a consent form and the questionnaire. Organisations that consented to collaborate with our team were provided a link to the online questionnaire and were asked to promote our study by circulating the link among their members. Potential participants who were interested in the study were invited to access the link and the online questionnaire via their personal electronic devices, and were asked via the portal to provide informed consent to participate in the study and to complete the online questionnaire. Our research assistants also invited the members of South Asian community centres and organisations to complete the questionnaire via face-to-face interviews. The questionnaire took about 10 min to complete. IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. Descriptive statistics, such as means and standard deviations for continuous variables and proportions for categorical variables, were used to summarise the participants' socio-demographic characteristics. The frequencies of correct knowledge answers and various attitudes and practices were reported. The associations of demographic factors with KAP were examined using the F test for categorical variables and Pearson correlation for continuous variables. A Pearson correlation was used to examine relationships among KAP. Additionally, a multivariable linear regression analysis was conducted to identify the factors that affected the participants' practices of preventive measures, using demographic factors, knowledge and attitudes as the independent variables and practices as the outcome variable. All statistical tests were two-tailed, and the statistical significance level was set at p < 0.05. Ethical approval was obtained from the Survey and Behavioural Research Committee of the Chinese University of Hong Kong. The survey did not collect identifiable data. A consent form was prepared in three languages (English, Urdu and Nepali). The participants were assured that their participation was voluntary, that their right to withdraw at any time would be upheld and that their collected information would remain confidential. All collected information was kept safely in a locked cabinet that could only be accessed by the researchers. The participants were also informed that all collected data would be destroyed after project completion. All study procedures involving human participants were conducted in accordance with the Declaration of Helsinki. The ethical approval code is SBRE-19-633. All of the participants provided informed consent to participate in the study before completing the online questionnaire. A total of 361 South Asians provided informed consent and participated in the study. Nine respondents had missing data on more than 30% of the questionnaire items. Hence, 352 eligible participants were included in our analysis, of which 228 participants completed the questionnaire through online surveys, and 124 participants completed the questionnaire through face-to-face interviews. The mean age of the participants was 38.92 years (SD = 13.42), and 59.7% were female. The participants' countries of origin were India (35.8%), Pakistan (34.9%) and Nepal (29.1%). One fifth of the participants (20.5%) had an education level of primary school or lower, while 46.6% had received a secondary school education and 33.0% had received tertiary education or higher. More than half (51.4%) had a full-time or part-time job, and 57.9% had a monthly household income of HKD 20,000 or less (