|Year : 2020 | Volume
| Issue : 2 | Page : 118-125
Knowledge, attitudes and preparedness to respond to COVID-19 among the border population of northern Thailand in the early period of the pandemic: a cross-sectional study
Peeradone Srichan1, Tawatchai Apidechkul1, Ratipark Tamornpark1, Fartima Yeemard2, Siriyaporn Khunthason1, Siwarak Kitchanapaiboon1, Pilasinee Wongnuch1, Asamaphon Wongphaet3, Panupong Upala2
1 Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University; School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand
2 Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, Chiang Rai, Thailand
3 School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand
|Date of Web Publication||07-Sep-2020|
Dr Tawatchai Apidechkul
Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University; School of Health Science, Mae Fah Luang University, Chiang Rai
Background: Chiang Rai province in northern Thailand is a site of many people travelling among nearby countries and areas, including Yunnan province, China. In February 2020, there was concern about the population’s vulnerability to coronavirus disease 2019 (COVID-19).
Methods: A cross-sectional study was conducted in 15 villages less than 10 km from a border. A questionnaire was developed and tested for reliability and validity; 48 questions covered participant characteristics, plus knowledge about, attitudes to and preparedness for COVID-19. Chi-squared tests were used to detect any significant association between variables. Unadjusted and adjusted odds ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of various factors with participants’ level of reported knowledge, attitudes and preparedness.
Results: A total of 520 participants were recruited of whom 320 (61.5%) were women. The age range was 18–90 years; the average age was 45.2 years. Variables with an association with good to moderate preparedness for COVID-19 prevention and control that remained after adjustment were: women were better prepared than men (adjusted odds ratio (ORadj) = 2.52; 95% CI = 1.36–4.68); those aged 18–30 years (ORadj = 4.26; 95% CI = 1.18–15.30), 31–45 years (ORadj = 4.60; 95% CI = 1.59–13.32) or 46–60 years (ORadj = 2.69; 95% CI = 1.16–6.26) were better prepared than those aged 60–90 years; and, compared with those with no formal education, those educated to primary school level (ORadj = 2.43; 95% CI = 1.09–5.43) or to university level (ORadj = 3.18; 95% CI = 1.06–9.51) were better prepared.
Conclusion: Effective communication of essential, accurate and up-to-date information regarding COVID-19 prevention and control is essential in this population – especially for men, older age groups and those lacking formal education.
Keywords: COVID-19, emergency response, South-East Asia, Thailand
|How to cite this article:|
Srichan P, Apidechkul T, Tamornpark R, Yeemard F, Khunthason S, Kitchanapaiboon S, Wongnuch P, Wongphaet A, Upala P. Knowledge, attitudes and preparedness to respond to COVID-19 among the border population of northern Thailand in the early period of the pandemic: a cross-sectional study. WHO South-East Asia J Public Health 2020;9:118-25
|How to cite this URL:|
Srichan P, Apidechkul T, Tamornpark R, Yeemard F, Khunthason S, Kitchanapaiboon S, Wongnuch P, Wongphaet A, Upala P. Knowledge, attitudes and preparedness to respond to COVID-19 among the border population of northern Thailand in the early period of the pandemic: a cross-sectional study. WHO South-East Asia J Public Health [serial online] 2020 [cited 2020 Oct 1];9:118-25. Available from: http://www.who-seajph.org/text.asp?2020/9/2/118/294305
| Background|| |
On 31 December 2019, the World Health Organization (WHO) Country Office for China picked up a media statement by the Wuhan Municipal Health Commission from its website on cases of “viral pneumonia” in Wuhan, China. On 11 February, WHO announced that the disease, caused by a novel coronavirus, would be named coronavirus disease 2019 (COVID-19). On 13 January, the first recorded laboratory-confirmed case outside China was confirmed in Thailand. By 20 January, there were 7818 confirmed cases of COVID-19, the majority of which were in China. On 14 February, the WHO Country Office for Thailand reported that there were 34 confirmed cases of COVID-19 in Thailand. A global pandemic was declared on 11 March.
Chiang Rai province is located in northernmost Thailand and has land borders with the Lao People’s Democratic Republic and Myanmar; there is also a sea route from China’s Yunnan province to Chiang Saen port. Many people move across the borders among these countries every day, using both temporary and permanent crossing channels. There are two permanent border crossings and six temporary ones between Thailand and the Lao People’s Democratic Republic, and more than 1 million people cross the border each year. There are four permanent crossings and five temporary ones on the long border (2400 km) between Thailand and Myanmar, with more than 2 million people per year crossing the border. By late January, all people crossing all permanent border crossings were being screened for COVID-19 by trained public health officers using body temperature monitoring; however, no screening was being done at temporary border crossings. The one official sea route between Thailand and China at Chiang Saen port is used for trade and for tourism along the Mae Khong River from China to Thailand; screening by public health officers was being done at the port. There are also a number of unofficial border crossings, which were not being monitored.
With the outbreak of COVID-19, many people living in this area were in a state of panic. Moreover, most people living in the area have low socioeconomic status and have a low level of education. Some are from minority groups that have migrated from China to Thailand over centuries, such as the hill tribe people, who account for 30% of the population of Chiang Rai province. Therefore, in February 2020, there was an urgent need to examine their understanding of this new disease. This cross-sectional study was undertaken to gain a better understanding of the knowledge, attitudes and preparedness to respond of this population in relation to the outbreak of COVID-19, in order to support policy development and public health implementation.
| Methods|| |
A cross-sectional study was performed to collect information from participants living in the border areas in Chiang Rai province, northern Thailand, specifically on the borders of Thailand, Myanmar and the Lao People’s Democratic Republic, close to southern China. Those who were not willing to participate in the study or could not provide the answers to the questionnaire were excluded.
We calculated the sample size required to estimate prevalence with a specified level of confidence and precision. The outcomes sought were estimates of the levels of knowledge, attitudes and preparedness to respond to COVID-19. The prevalence of knowledge, attitudes and preparedness of the population for COVID-19 patients was estimated as 0.91% from a previous study in a Chinese population. We aimed for a precision of 2.5% in the prevalence estimate (i.e. a 95% confidence interval (CI)) for an infinite sample, resulting in a sample size of 503. The sample size was calculated using the formula N = (Z2 * P(1 – P)) / e2, where Z = value from standard normal distribution corresponding to desired confidence level (Z = 1.96 for 95% CI), P = expected true proportion, and e = desired precision (half desired CI width).
A questionnaire was developed and tested for reliability and validity. The item–objective congruence (IOC) technique was used to evaluate validity. The IOC index ranges from –1 to 1, i.e. congruent (+ 1), questionable (0) and incongruent (–1). Three external experts in the field (one epidemiologist, one medical doctor and one public health practitioner) scored and commented on each item. Items with an average score from the committee of less than 0.5 were excluded from the questionnaire, while items with an average score of between 0.51 and 0.7 were revised according to the comments and included in the questionnaire. Items with scores greater than 0.7 were included in the questionnaire without revisions. The questionnaire was also piloted with 15 participants who had similar characteristics to the study participants in Mae Fah Laung District, Chiang Rai province, on 1 and 2 February 2020. This step was used to determine the feasibility of using the questionnaire for the study and to decide on the order of the questions.
The questionnaire in its final form consisted of five parts and 48 questions and is available from the corresponding author. Part 1 was made up of eight questions used to collect data on the general characteristics of participants, including sex, age, religion and marital status. Part 2 comprised 10 questions that were used to collect information on medical history and exposure to influenza (e.g. history of influenza diagnoses, history of family members being diagnosed with influenza).
The 10 questions in Part 3 examined knowledge about COVID-19, covering statements such as “COVID-19 is a close-contact communicable disease”. For this part, each participant was scored 0 for an incorrect answer and 1 for a correct answer. Those who received scores of 0–5 were classified as having poor knowledge, those with scores of 6–8 were classified as having moderate knowledge and those with scores of 9–10 were classified as having good knowledge.
Part 4 consisted of 10 questions regarding attitudes related to COVID-19 prevention, asking participants to respond to statements such as “Staying at home is a good way to prevent and control COVID-19”. Each question was rated on a 5-point scale reflecting attitudes ranging from “totally agree” to “totally disagree”. Responses to positive-attitude questions were scored on a scale ranging from 5 for “totally agree” to 0 for “totally disagree”. Responses to negative-attitude questions were scored on a scale ranging from 0 for “totally agree” to 5 for “totally disagree”. There were five negative-attitude questions and five positive-attitude questions, resulting in a maximum score of 50. People who scored less than 26 were classified as having a poor attitude to COVID-19 prevention, those who scored 26–40 were classified as having a moderate attitude and those who scored 41–50 were classified as having a good attitude.
The 10 questions in Part 5 assessed behaviours related to preparedness to respond to the occurrence of COVID-19 in the area, such as hand washing, mask use and avoiding crowded areas. Three response options were provided for each item: “always”, “sometimes” and “never” (resulting in a maximum score of 30). A score of less than 16 indicated a poor level of preparedness to respond to an outbreak of COVID-19, a score of 16–24 indicated a moderate level of preparedness and a score of 25–30 indicated a good level of preparedness.
Three villages were randomly selected from five districts: Chiang Saen, Wiang Ken, Chiang Khong, Mae Sai and Wiang Pa Pao. These five districts are located at the border of Thailand and the Lao People’s Democratic Republic and at the border of Thailand and Myanmar. All the selected villages are less than 10 km from a border. Moreover, they are close to, although not directly bordering, Yunnan province in southern China, which is a common place of transit for people moving among countries.
Access to the villages was granted by district officers. After that, village leaders were contacted and agreed to provide villagers with all the essential information and explain the significance of the study. People aged 18 years or older living in the selected villages were invited to participate in the study. Data were collected between 3 and 10 February 2020, by trained researchers. All participants were asked to respond to the questionnaire verbally, giving their answers to a researcher. For those who could not read Thai, the researcher read the questionnaire to them so that they could provide their answers. The questionnaire required 20 minutes for participants to complete.
Data from the questionnaires were coded and entered into an Excel spreadsheet to check for errors before they were transferred into SPSS (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp) for analysis. Data explorations were performed by running frequency checks and descriptive statistics. A chi-squared test and Fisher’s exact test (when the total per cell was less than 5) were used where appropriate to assess associations between any two independent parameters. Associations between participant characteristics and each of the defined outcomes of knowledge, attitudes and preparedness were evaluated using univariable and multivariable logistic regression. The statistical significance level was set at 5% (P value < 0.05).
Ethics approval and consent to participants
All study materials, including research protocols, were approved by the Chiang Rai Public Health Provincial Ethical Committee (No. CRPPHO 12-2563). All participants gave their informed consent before their data were collected.
| Results|| |
A total of 520 participants were recruited to the study and all completed the questionnaire; 320 (61.5%) were female and almost all were Buddhist (468, 90.0%). The age range was 18–90 years; the average age was 45.2 years (standard deviation = 16.5 years). The majority were married (379, 72.9%), were of Thai nationality (460, 88.5%), had completed primary school or high school (316, 60.8%) and had an annual family income of less than 50 000 baht (256, 49.2%). Among the participants, 193 (37.1%) had a chronic disease. Only nine people (1.7%) had received the influenza vaccine in 2017–2018; however, 186 people (35.8%) had been immunized in 2019. A few people had been diagnosed with influenza by a medical doctor in 2017–2018 (1.7%) or 2019 (1.9%). Only three people (0.6%) had been to Wuhan, China, and 69 (13.3%) had been in close contact with people who had been to Wuhan in late 2019 or early 2020 (see [Table 1]).
Regarding participants’ perception of the danger posed by COVID-19, the majority (351, 67.5%) considered it dangerous to seriously dangerous, while 140 people (26.9%) reported that they did not consider it dangerous. A total of 293 people (56.3%) reported feeling very worried to most worried about the situation, and 507 (97.5%) perceived that there was a moderate to high risk of contracting COVID-19. Half of the participants (245, 47.3%) agreed that it was a treatable disease, and 310 people (59.6%) perceived those who had travelled to China and those who had had close contact with people who had been in Wuhan, China, as being highly vulnerable to COVID-19. Of the participants, 162 (31.2%) believed that a vaccine was available for COVID-19, and 295 people (56.7%) did not know the major signs of the infection. The majority (297, 57.1%) received information on COVID-19 primarily from television, and 404 people (77.7%) reported that the information they received was not sufficient for making decisions. A total of 144 people (27.7%) reported that they never wore a mask, and 285 people (54.8%) did not always use soap while washing their hands (see [Table 1]).
In the assessments of independent parameters, several variables were statistically significantly associated with knowledge, attitudes and preparedness (data not shown). Six variables were significantly associated with knowledge: marital status; education; occupation; annual income; close contact with people who had been in Wuhan, China, between November 2019 and January 2020; and main channel for receiving COVID-19 information.
Nine variables were significantly associated with attitudes: age; marital status; education; occupation; annual income; having a chronic disease; having a family member who had been diagnosed with influenza in 2019; close contact with people who had been in Wuhan, China, between November 2019 and January 2020; and main channel for receiving information on COVID-19.
Eight variables were significantly associated with preparedness: sex; age; education; occupation; annual income; having a family member who had been diagnosed with influenza in 2019; close contact with people who had been in Wuhan, China, between November 2019 and January 2020; and main channel for receiving COVID-19 information.
Results from logistic regression are shown in [Table 2], [Table 3], [Table 4]. For these analyses, we combined the good and moderate groups. This was because (i) we assumed that even a moderate level of knowledge, a moderately good attitude and a moderate degree of preparedness might have an impact on COVID-19 prevention and control, and (ii) since this research was done early in the pandemic we assumed that few participants would receive a high score for any of the parameters. The results indicated that the variables with an association with good to moderate preparedness for COVID-19 prevention and control that remained after adjustment for other variables were as follows: women were better prepared than men (adjusted odds ratio (ORadj) = 2.52; 95% CI = 1.36–4.68); those aged 18–30 years (ORadj = 4.26; 95% CI = 1.18–15.30), 31–45 years (ORadj = 4.60; 95% CI = 1.59–13.32) or 46–60 years (ORadj = 2.69; 95% CI = 1.16–6.26) were better prepared than those aged 60–90 years; and, compared with those with no formal education, those educated to primary school level (ORadj = 2.43; 95% CI = 1.09–5.43) or to university level (ORadj = 3.18; 95% CI = 1.06–9.51) were better prepared (see [Table 2]). Analyses of factors associated with good to moderate knowledge and good to moderately good attitude are shown in [Table 3] and [Table 4].
|Table 2: Univariable and multivariable logistic regression results for factors associated with good to moderate preparedness for COVID-19 prevention and control|
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|Table 3: Univariable and multivariable logistic regression results for factors associated with good to moderate knowledge about COVID-19 prevention and control|
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|Table 4: Univariable and multivariable logistic regression results of factors associated with good to moderately good attitude to COVID-19 prevention and control|
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| Discussion|| |
People who live in northern Thailand are close to the original source of the COVID-19 outbreak in Wuhan, China. With several border crossings between China, Myanmar, the Lao People’s Democratic Republic and Thailand, these individuals are a population vulnerable to COVID-19, particularly those who have poor knowledge, attitudes and preparedness to engage in COVID-19 prevention and control. This study found that women, younger adults and those with certain levels of education were more likely to have a good level of preparedness for COVID-19 prevention and control. To our knowledge, there are no other similar data on COVID-19 for this population with which our findings could be compared. However, in a study among migrant workers in Chiang Rai, half of participants had poor knowledge of and one third had a negative attitude towards tuberculosis prevention and control measures.
In view of the urgency of managing the COVID-19 outbreak, nearly 400 world scientists met at WHO’s Geneva headquarters on 11 and 12 February 2020 to assess the current level of knowledge about the new coronavirus, to agree on critical research questions that needed to be answered urgently, particularly with respect to care and diagnosis at the community level, and to optimize the use of protective equipment and other infection prevention and control measures in health-care and community settings. At the end of January 2020, Wu et al. reported that COVID-19 was already a global problem requiring plans and mitigation interventions for quick deployment globally, particularly in neighbouring countries. At the same time, Chen et al. reported that the population most vulnerable to COVID-19 was older men. Since then, the severity of COVID-19 has been widely reported to be influenced by age, sex and underlying comorbidities.,
Given their low economic and educational profiles, and since there are a number of busy border crossings, people living in Chiang Rai province in northern Thailand are vulnerable to COVID-19. Furthermore, knowledge and attitudes toward disease prevention and control are poor. While a few people were adequately prepared to prevent and control the disease, there is still a need for the implementation of public health efforts to improve knowledge of, attitudes to and preparedness for COVID-19 among those living in Chiang Rai province near busy border crossings. Effective, continuous communication of essential, accurate, up-to-date and sufficient information regarding COVID-19 prevention and control – especially to men, older age groups and those lacking formal education – is a major public health concern and is currently being prioritized by the government.
Acknowledgements: The authors thank all participants for providing all the essential information. They would also like to thank the Center of Excellence for Hill Tribe Health Research, Mae Fah Luang University, for supporting the study with a grant. In addition, the authors thank Professor Dr Samlee Pliangbangchang, former Director of the WHO Regional Office for South-East Asia, who provided technical and academic support throughout the project.
Source of support: The study was supported by the Center of Excellence for Hill Tribe Health Research, Mae Fah Laung University. The funder had no role in the design of the study, in the collection, analysis and interpretation of the data, or in writing the manuscript.
Conflict of interest: None declared.
Authorship: PS developed the questionnaire, collected the data, analysed the data, and prepared and approved the final manuscript. TA designed the study, developed the questionnaire, analysed the data, and prepared and approved the final manuscript. RT, FY, SKh, SKi, PW, AW and PU conducted the pilot survey, collected the data, analysed the data and approved the final manuscript. All authors have read and approved the manuscript.
Availability of data and materials: The raw data are available upon reasonable request from the corresponding author.
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[Table 1], [Table 2], [Table 3], [Table 4]