key: cord-0804402-qt0q3aew authors: Pal, Rimesh; Yadav, Urmila; Grover, Sandeep; Saboo, Banshi; Verma, Anmol; Bhadada, Sanjay K. title: Knowledge, attitudes and practices towards COVID-19 among young adults with Type 1 Diabetes Mellitus amid the nationwide lockdown in India: A cross-sectional survey date: 2020-07-22 journal: Diabetes Res Clin Pract DOI: 10.1016/j.diabres.2020.108344 sha: 12ffda3fc9093df578b0e56f7c12dbeee0302842 doc_id: 804402 cord_uid: qt0q3aew AIMS: To assess knowledge, attitude and practices (KAP) of young adults with type 1 diabetes mellitus (T1DM) towards COVID-19 amid nationwide lockdown in India. METHODS: We conducted a cross-sectional web-based survey among young adults with T1DM (aged 18-30 years) in the North, Central, South and West zones of India. It consisted of fifteen, five and eight questions pertaining to knowledge, attitude and practices towards COVID-19, respectively. Certain questions relevant to T1DM were also incorporated. RESULTS: After exclusion, 212 participants were included (mean age=25.1±4.3 years; M:F=10:11). The overall correct rate of the knowledge questionnaire was 83% (mean total knowledge score=12.4±1.9). Most (74%) had average knowledge score (mean±1SD). Higher educational status, urban residence and being married were associated with better knowledge scores; however, only urban residence was found to be statistically significant on multinomial logistic regression. Most (88%) felt that being a patient of T1DM, they were at higher risk of getting infected with COVID-19. At the same time, 98% were confident about self-protection. Fifty-one percent of respondents had left home amid lockdown mostly to procure insulin/injection needles/syringes/glucometer strips from pharmacy. However, all were maintaining proper hand hygiene and most were following routine dietary advice (95%) and administering prescribed insulin doses (99%). Seventy-two participants (34%) had experienced one or more episodes of hypoglycemia since commencement of lockdown. CONCLUSIONS: Young adults with T1DM have average knowledge, positive attitude and healthy preventive practices towards COVID-19. Awareness campaigns targeted towards rural communities and providing doorstep delivery of insulin/needles/syringes may be more rewarding. Data availability statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Word count: 4652 To assess knowledge, attitude and practices (KAP) of young adults with type 1 diabetes mellitus (T1DM) towards COVID-19 amid nationwide lockdown in India. We conducted a cross-sectional web-based survey among young adults with T1DM (aged 18-30 years) in the North, Central, South and West zones of India. It consisted of fifteen, five and eight questions pertaining to knowledge, attitude and practices towards COVID-19, respectively. Certain questions relevant to T1DM were also incorporated. After exclusion, 212 participants were included (mean age=25.1±4.3 years; M:F=10:11). The overall correct rate of the knowledge questionnaire was 83% (mean total knowledge score=12.4±1.9). Most (74%) had average knowledge score (mean±1SD). Higher educational status, urban residence and being married were associated with better knowledge scores; however, only urban residence was found to be statistically significant on multinomial logistic regression. Most (88%) felt that being a patient of T1DM, they were at higher risk of getting infected with COVID-19. At the same time, 98% were confident about self-protection. Fifty-one percent of respondents had left home amid lockdown mostly to procure insulin/injection needles/syringes/glucometer strips from pharmacy. However, all were maintaining proper hand hygiene and most were following routine dietary advice (95%) and administering prescribed insulin doses (99%). Seventy-two participants (34%) had experienced one or more episodes of hypoglycemia since commencement of lockdown. The novel coronavirus disease has been on the rampage ever since its outbreak in December 2019, affecting over 4 million people and claiming more than 278000 lives in over 200 countries all over the world (1) . The brunt of the disease has been borne by China, the United States of America, Europe and Iran. The disease has also infiltrated the Indian borders. Considering a population of more than 1.3 billion people, India could very well become the next epicenter of the pandemic. In an attempt to prevent its spread, a nationwide lockdown has been imposed in the nation since March 25, 2020 . Even then, the disease is spreading fast with 70756 confirmed cases been reported from India as of Although the overall mortality rate varies from 0.7%-10.8% (2) , COVID-19 tends to be severe and portend a poor prognosis specially in patients with advancing age and underlying co-morbidities (3) . Likewise, diabetes mellitus (DM) has emerged as a distinctive co-morbidity that is associated with severe disease, acute respiratory distress syndrome and increased mortality in COVID-19 (4) (5) (6) (7) . In the absence of any definite therapy against COVID-19, it becomes imperative that people with DM take extra precautions, stringently abide by advisories of social distancing and hand hygiene and ensure good glycemic control (4, 8, 9) . However, people's adherence to these control measures will be largely affected by their knowledge, attitude and practices (KAP) towards COVID-19, in accordance with the "KAP theory". The "KAP theory" is a health behavior change theory wherein change in human behavior are divided into three successive processes, namely, acquisition of right knowledge, generation of attitudes and adoption of behavior (or practice) (10) . Several studies have shown that the KAP level in individuals are associated with effective prevention and management of illness and promotion of one's own health (10) (11) (12) (13) . On the contrary, deficiencies in KAP are linked to poor health and maladaptive disease preventive behavior (10, 14, 15) . Thus, it is expected that KAP levels of people with DM will be the deciding factor in their battle against COVID-19. Hence, the present study was undertaken to assess the knowledge, attitude and practices with regard to COVID-19 in young adults with type 1 diabetes mellitus (T1DM) amid the nationwide lockdown in India. The cross-sectional survey was conducted from April 25, 2020 to May 2, 2020 amid the nationwide lockdown in India. Because it was not feasible to perform a communitybased survey during this period, we conducted a web-based survey using the Survey Monkey platform. The survey link was mailed to non-profit organizations working for the betterment of people with T1DM in different parts of the country, namely, ADITI (Association of Diabetes in Tricity; http://aditidiabetes.com), DIYA (Diabetes India Youth in Action; http://diya.org.in) and JDF (Juvenile Diabetes Foundation; https://www.jdfmumbai.org). The survey link was then disseminated by the respective organizations to their enrolled T1DM patients through social media (mainly WhatsApp). The survey link stated that all people with T1DM of at least 1-year duration, aged 18-30 years and able to read and write in English were eligible to take part in the survey. In addition, it was clearly mentioned that participation in the survey was entirely voluntary and that all the information would be kept strictly confidential. As an additional measure, the participants had to answer a 'yes-no' question to confirm their willingness to participate in the survey voluntarily. The survey was duly approved by the Institute Ethics Committee. The questionnaire consisted of three parts: demographics, disease/therapy-related and knowledge-attitude-practice (KAP). Demographic details included age, gender, residence (urban vs. rural including name of city/village and state), highest educational status, employment status, monthly family income and present marital status. Disease/therapy related details included duration of T1DM, latest value of glycated hemoglobin (HbA 1c ) available over the past 6 months, ongoing insulin regimen, availability of glucometer at home, difficulty in procuring prescribed insulin preparations from pharmacy amid the prevailing lockdown, occurrence and frequency of hypoglycemic episodes (documented capillary glucose on glucometer < 70 mg/dl with or without typical symptoms) and any need and reason for hospitalization since the commencement of lockdown in the country. Similarly, comparisons between total knowledge score and categorical demographic variables (gender, educational status, employment status, marital status) were made using Independent Student's t-test or one-way analysis of variance (ANOVA). Subsequently, a participant was classified as having poor knowledge (total knowledge score < Mean -1 SD), average knowledge (total knowledge score = Mean ± 1 SD) and good knowledge (total knowledge score > Mean + 1 SD) (17, 18) . Multinomial logistic regression analysis was used to find out the statistically significant predictors of average and good knowledge (as compared to poor knowledge). The degree of association was quantified using odds ratio (OR) (95% confidence intervals). A p-value <0.05 was considered significant. A total of 224 participants completed the survey questionnaire. Twelve participants were excluded (two were below 18 years of age, four were above 30 years, six had incomplete data). The final sample thus consisted of 212 participants of whom 101 were men (male:female ratio 10:11). The mean (± SD) age of the participants was 25. All except two participants had glucometer at home (99%). Seventy-two participants (34%) had one or more episodes of hypoglycemia (documented capillary glucose on glucometer < 70 mg/dl with or without symptoms) since the commencement of lockdown. Thirteen participants (6%) required hospital admission for hypoglycemia. The correct answer rates of the 15 questions pertaining to knowledge about COVID-19 were 40%-100% (table 1). The mean (± SD) COVID-19 total knowledge score was 12.4±1.9 (range: 5-15) amounting to an overall correct rate of 83% (12.4/15 * 100%). Total knowledge scores showed a positive correlation with participant's age (r=0.206, p=0.003), monthly family income (r s =0.329, p < 0.001) and duration of T1DM (r s =0.148, p=0.032). In addition, knowledge scores significantly differed across marital status, educational status, and place of residence (urban vs. rural) (table 4) . When the level of knowledge was classified according to the score, poor knowledge corresponded to score < 10.5 (approximately ≤ 10), average knowledge to score was significantly associated with average knowledge (as compared to poor knowledge). None of the parameters were significantly associated with good knowledge. Fifty percent of the participants felt anxious when they thought of COVID-19. Majority of the participants (88%) did think that being a patient of diabetes mellitus they were at a higher risk of getting infected with COVID-19. Three-fourth of the participants (75%) did not feel that abiding by their routine dietary advice would weaken their immunity and in turn make them more prone to COVID-19. The attitude towards success in being able to prevent oneself from COVID-19 was positive in majority of the participants (98%). Likewise, 95% of the participants were confident that the prevailing lockdown would be successful in controlling COVID-19 in India. Other than the mean knowledge scores, the attitude towards COVID-19 of the study participants did not differ with respect to gender, place of residence, educational or marital status (supplementary table 1 ). The practices of the study participants have been summarized in table 5. Of note, half of the participants had left their homes amid the lockdown. Most of them (64%) had to leave the safe confines of their homes for ≤ 5 days, while 21% and 15% had been out for 6-10 times and > 10 times, respectively. Amongst them, 51% of the participants had to visit a pharmacy for procuring insulin or insulin injection needles or glucometer strips. However, all the 108 participants who had ventured out of their homes had used a facemask. The survey showed that the participants preferred to use a medical mask (surgical-grade mask) (81%) to a homemade cloth mask (19%). Regarding management of T1DM, most of the participants were following their routine dietary advice (95%) and administering their prescribed doses of insulin (99%). Comparison with the total knowledge scores showed that people who preferred not to venture out of their homes had a better knowledge score compared to those who did went out of their homes (supplementary table 2 ). To the best of our knowledge, this is first ever study assessing the knowledge, attitude and practices of young adults with T1DM towards COVID-19 amid the ongoing pandemic. In this predominantly well-educated, urban-residing population, we found an overall correct rate of 83% on the knowledge questionnaire. Majority of the participants (74%) had average knowledge. Their knowledge was reflected in their attitude, as 98% of the participants were confident in being able to protect themselves from COVID-19. Similarly, all the participants were abiding by the practice of regular hand washing, however, as much as 51% of the respondents had left home on one or more occasions amid the lockdown, mostly to procure insulin/insulin needles/glucometer strips from the pharmacy. Ample data exist to suggest that underlying DM, although not associated with an increased risk of infection, does augur a poor prognosis in patients with COVID-19 (4, 6, 19) . A study comprising of 1590 COVID-19 patients from China showed that DM was an independent predictor of admission to ICU or invasive ventilation or death (Hazard Ratio 1.59, 95% CI: 1.03-2.45) (20) . Although most of the available studies have made no distinction between type 1 and type 2 diabetes mellitus (T2DM), it is likely that the risks hold true for both the disease entities (21) . Hence, people with T1DM and T2DM should be extra-cautious and take all necessary precautions to prevent COVID-19. However, the effective adoption of self-protection measures (practices) will be largely dictated by their knowledge and attitude towards COVID-19. This is in accordance with the "Knowledge-Attitude-Practice (KAP) theory" which states that a change in human behavior (or practice) is a step-wise process that involves acquisition of knowledge, subsequent generation of attitudes and finally adoption of behavior (or practice) (10) . In other words, increasing personal knowledge will influence a change in behavior. Similarly, the knowledge of a person with DM regarding COVID-19 will be the main factor that will decide whether the individual will be able to protect himself/herself from the pandemic. We conducted a cross-sectional survey to assess the KAP of people with T1DM in India. Although the large majority of people with DM in India falls under the category of T2DM, the incidence of type 1 diabetes mellitus (T1DM) in India is on the rise with an estimated 3-5% increase per annum (22, 23) . Furthermore, India stands first in terms of the estimated number of incident cases of T1DM in children and adolescents, per annum (24) . We had intentionally excluded children and adolescents (< 18 years) with T1DM, as we wanted to assess the KAP of the patients and not their parents/caregivers. Besides, young adulthood represents a critical period for those with T1DM. Only 17% and 30% of early (18-25 years) and late (26-30 years) young adults with T1DM, respectively, meet the current recommendations for glycemic control (HbA 1c ≤ 7.0%) (25) . Young adults with T1DM with a history of significant hypoglycemia or hyperglycemia are also at a slightly increased risk of poor neuropsychological performance in terms of working memory and mental efficiency (26) . Moreover, the early adult age group represents a period of transition from pediatric to adult medical care that can in turn lead to inconsistent engagement with healthcare facilities (27) . In addition, young adults tend to engage in risky behaviors that may negatively impact health. This is reflected by the relatively high rates of emergency department use among young adults with T1DM (28). Thus, young adults with T1DM represent an extremely vulnerable section of the society amid the ongoing pandemic. In this survey catering to T1DM patients from four zones of India (North, Central, West and South), we found an overall correct rate of 83% on the knowledge questionnaire with almost three-fourth of the participants having average knowledge. The questionnaire was strategically prepared to include all aspects of COVID-19, namely symptoms, modes of transmission and means of prevention. In addition, some of the questions were customized to specifically cater to people with DM (K4, K10). A recently conducted online cross-sectional survey assessing KAP towards COVID-19 among Chinese residents found an overall knowledge rate of 90%. However, most of the participants were females (65.7%) and belonged to a relatively high socioeconomic status, thereby, might not be representative of the Chinese population at large (29) . Another cross-sectional survey conducted amongst general Iranian population also found an overall correct knowledge rate of 90%. However, most of the study participants were educated and had an academic degree (30) . We found that the participants who were living in urban areas, having a higher educational status and who were married had higher total knowledge scores. That higher educational status correlate with better knowledge scores is well known (29, 30) . Likewise, married people have been shown to have higher knowledge scores compared to unmarried counterparts (30) , likely attributable to an additional source of knowledge from the spouse. People living in the urban community tend to have better and more ready access to awareness campaigns propagated through social, digital or print media and hence are more likely to have higher knowledge scores compared to people living in remote and rural areas. Based on these findings, it would be prudent to target awareness programs regarding COVID-19 towards certain demographic groups such as unmarried individuals, those with lower educational status and those residing in rural areas are required. We found no gender difference in knowledge scores as was seen in the Chinese study where females had higher knowledge scores compared to males (29) . As per as attitudes of the participants towards COVID-19 were concerned, most of them (98%) were positive that they would be able to protect themselves from COVID-19 through social distancing and regular hand washing. Similarly, 95% of the participants were confident that lockdown would be able to control the pandemic in India. The confidence would have stemmed from the Government's robust response in order to contain COVID-19. Fifty percent of the participants felt anxious at the thought of COVID-19. Although it can affect the psychological well-being of an individual (9), being worried or anxious about COVID-19 ensures that they are aware of the disease and in turn will make them more cautious. Infact, it has been shown that people having low health literacy are more likely to be less worried about COVID-19 and thereby deny the fact that they would get infected and be less prepared for the outbreak (31) . With regard to T1DM, 88% of the participants felt that being patients of DM, they are at a high risk of getting infected with COVID-19. Although the available literature denies this fact (19) , it would be prudent on the part of a patient to err on the side of caution. Regarding respondents' practices all had stated that they were regularly washing their hands with soap and water. However, 51% of the participants had to leave the safe confines of their homes inspite of prevailing nationwide lockdowns. Half of them had to visit a pharmacy to procure insulin or insulin injections needles/syringes or glucometer strips. This might have been circumvented though use of online pharmacies and social support organizations providing insulin preparations at the doorstep on demand. Nevertheless, all the participants who had left home had used a facemask and 96% of them had maintained a distance of 1 meter of more from others, thereby reflecting healthy preventive practices. Similarly, majority of the participants were continuing their prescribed doses of insulin. However, as many as 34% of the respondents had experienced one or more episodes of hypoglycemia over the last 1 month ever since the commencement of lockdown on March 25. A study conducted in Tayside, Scotland found that 82% of people with T1DM had one or more self-reported episodes of hypoglycemia over a period of 1 month. Most of the patients in the study were however on biphasic or intermediate and short acting insulin preparations that could have been one of the major contributing factors underlying hypoglycemia (33) . However, in the DIALOG study that had included 1317 people with T1DM, 31.5% of whom had been on insulin pump, 85.3% reported experiencing at least one confirmed hypoglycaemic event over 30 days (34) . Thus, a self-reported hypoglycemia rate of 34% amongst the study participants represents good diabetes self-care on part of the patients. Majority of the study participants were well educated with 73% of the participants having a graduate or post-graduate degree. This is in stark contrast to India's literacy rate of 74% (35). In addition, median monthly family income of the respondents stands above the average income of an Indian household (36). Besides, 84% of the participants belonged to an urban community; on the contrary, 66% of the native population lives in rural India (37). Thus, it would be prudent to say that the study population represented a relatively well-educated and well-to-do section of the community and hence might not be representative of the common Indian masses. Moreover, the East zone of the country was not represented in the study, thereby making it more difficult to generalize the findings of the present study. Young adults with T1DM in India have average knowledge regarding COVID-19. It is reflected in their positive attitude and healthy preventive practices towards COVID-19. This will ultimately help protect them from COVID-19, as the disease tends to be more severe and lethal in people with underlying diabetes mellitus. 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