Evaluation of the Knowledge, Attitude and Practice of Patients on Immunosuppressive Drugs Towards COVID-19 Attending Dermatology Department- A Multicentric Cross-Section Study.

BACKGROUND: The deadly COVID-19 (Coronavirus Disease 2019) or SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) was identified for the first time in December 2019 from Wuhan, China, and by the beginning of March 2020, it was declared a pandemic by the World Health Organization (WHO). Despite so many government regulations and awareness measures, there is still a lacuna between the gravity of illness and the knowledge of the average person toward it.
OBJECTIVE: We aimed at assessing the knowledge, attitude, and behavioral practice (KAP) of patients on immunosuppressive medication attending the dermatology department toward, COVID-19.
MATERIAL AND METHODS: A self-designed printed/digital questionnaire consisting of 30 questions (Hindi and English) was supplied to patients being treated with any systemic immunosuppressives (for at least 3 weeks), for any dermatological ailment. The questionnaire consisted of 12 questions assessing the knowledge, 11 for attitude, and 7 for practices of patients toward COVID-19.
RESULTS: The study included 237 patients with a mean age of 44.57 ± 13.72 years. The correct knowledge toward COVID-19 was present in 126 (53.16%) patients with a mean score of 7.79 ± 3.08 out of 13. The mean attitude score was 8.35 ± 2.16 (out of 11) while the mean score of practice was 5.64 ± 2.03 (out of 8). Increased hygiene levels were seen in 220 (92.83%) patients. Sixty-six (27.85%) patients admitted to stopping their prescribed immunosuppressives by themselves during COVID-19 and a significant proportion agreed to the use of alternative medicines with questionable efficacy (n = 91; 38.39%). A significant difference in KAP was found across various strata of society like gender, age, socioeconomic status, literacy, and residence (P < 0.001). LIMITATIONS: Our study was limited by small sample size, absence of a control group with healthy individuals, and short duration of the study.
CONCLUSIONS: Most of the participants had poor knowledge, a positive attitude, and good practices toward COVID-19. Proper counseling of patients and the use of telemedicine could help combat the gap in KAP without compromising the healthcare facilities needed for the management of such patients. Copyright:

Introduction

The deadly COVID-19 (Coronavirus Disease 2019) or SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) was identified for the first time in December 2019 from Wuhan, China. Soon the cases started rising exponentially, mainly due to a very high rate of asymptomatic transmission.[1] Due to the soaring infection rate, the virus soon took over the entire world, and by the beginning of March 2020, it was declared a pandemic by the World Health Organization (WHO).[2] India became the second most severely affected country in September 2020 and the number of cases has been increasing catastrophically ever since.[3]

Due to this rapid rate of disease transmission in India, the behavior, and practices of Indian citizens toward COVID-19 are bound to have a dramatic impact on disease control in our country. The need for correct knowledge, attitude, and practice (KAP) is crucial in at-risk populations. From a dermatological point of view, this risk population would consist of patients on immunosuppressive/immunomodulatory therapies for various chronic dermatoses.

According to “the Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology” a handful of immunosuppressive/immunomodulators have been described to increase the risk for more severe COVID-19, namely, rituximab (within the last 1 year), Prednisolone (>10 mg/kg/day), azathioprine, methotrexate, cyclophosphamide, mycophenolate mofetil, mycophenolic acid, and cyclosporine.[4]

We conducted a study among patients with any chronic dermatosis being treated with any immunosuppressive/immunomodulatory drugs. Our aim was to assess the impact of SARS-CoV-2 on these patients' health care and their general awareness toward the pandemic situation using the KAP score.

Materials and Methods

This descriptive cross-sectional study was conducted from July 1, 2020 to December 31, 2020, in dermatology outpatient departments of three tertiary care centers in Rajasthan. Study participants included adult patients, who were being treated for any chronic dermatosis, with one or more of the following drugs for at least 3 weeks Ethical approval obtained on 17-06-2020:

Oral steroids: Prednisolone (>10 mg/kg/day) or Betamethasone oral mini pulse (5 mg on 2 consecutive days per week)

Azathioprine

Methotrexate

Cyclophosphamide

Mycophenolate mofetil/mycophenolic acid

Cyclosporine

Additionally, patients treated with rituximab (within the last 1 year) were also included.

Designing of the questionnaire, piloting, and validating

To develop the questionnaire, a thorough review of the literature was done beforehand. Additionally, the questionnaire was evaluated by experts, and subjected to pretesting, and validation as hereinafter mentioned.

The initially developed questionnaire was assessed by senior faculty members of our dermatology department for the significance of the questions, content validity, face validity, and additional inputs. Accordingly, some questions were removed, and others were added on faculty recommendation.

The initial pilot study for pretesting included 15 patients whose KAP questionnaire response was used for content validity. The pretesting was done to note any fallacy of equivocation encountered by the patients during understanding and responding to a question. The feedback received from these patients, regarding the comprehensibility and relevance of the questionnaire, was used to refine the language of the questions and make them easier to understand. Their response to the questions was also evaluated for content validity. For internal consistency, the Cronbach's α coefficient of 0.7 or higher was used for establishing the reliability of each section of the questionnaire. The psychometric property of this questionnaire was established by the assessment of content and face validity.

Sample size calculation

The sample size was determined by considering the average number of new patients with chronic dermatoses attending our three tertiary care centers, who fulfilled the inclusion criteria. However, the footfall kept varying depending upon the government-imposed lockdown measures, with a sudden fall during the beginning of the study, and a gradual rise in the number of patients during the latter part of the study. The sample size was calculated using the Raosoft® calculator with a confidence level of 90%.[5]

The KAP questionnaire

The KAP questionnaire consisted of 30 questions or items divided into three sections. The first 12 questions assessed the knowledge (K1–K12) of the patients about the COVID-19 illness; the next 11 (A1–A11) concerned the attitude of patients toward this disease, and the remaining 7 (P1–P7) items for evaluation of the practices of patients amidst the pandemic [Table 1].

Table 1

The KAP Questionnaire

Section 1: Knowledge Regarding COVID-19 Maximum Score-13
Questions	Response	Score
K1. What is the causative organism of COVID-19?	Virus	1
	Virus	0
	Fungi	0
	Parasite	0
	Immunodeficiency	0
	No opinion	0
K2. Is COVID-19 a contagious disease?	Yes	1
	No	0
	Do not know	0
K3. What is the incubation period of COVID-19?	Less than 1 day	0
	3–14 days	1
	No opinion	0
K4. Can COVID-19 be transmitted sexually?	Yes	0
	No	1
	Do not know	0
K5. Can COVID-19 be transmitted directly through sneezing?	Yes	1
	No	0
	Do not know	0
K6. Can COVID-19 be transmitted directly through the consumption of contaminated meals, dairy, and meat?	Yes	0
	No	1
	Do not know	0
K7. Are features like sneezing, high-grade fever, and continuous cough seen in ALL patients of COVID-19?	Yes	0
	No	1
	Do not know	0
K8. Is difficulty in breathing or chest pain a symptom of COVID-19?	Yes	1
	No	0
	Do not know	0
K9. Is loss of smell or taste a symptom of COVID-19?	Yes	1
	No	0
	Do not know	0
K 10. Is diarrhea a symptom of COVID-19?	Yes	1
	No	0
	Do not know	0
K 11. Is headache a symptom of COVID-19?	Yes	1
	No	0
	Do not know	0
K 12. Which of the following subgroups of population are more prone to catching COVID-19 (you can choose multiple options)?	1. Pregnant females	If options from 1 to 4 are chosen: score given is 1
	2. Elderly
	3. Children
	4. Healthy adults	If option 5 is chosen: score given is 2
	5. All of the above
Section 2: Attitude Toward the COVID-19 Pandemic Maximum Score-11
Question	Response	Score
A 1. Do you think your skin disease make you more prone to catching COVID-19 than others?	Yes	0
	No	1
	Maybe	0
A 2. Do you think your medication makes you more prone to catching COVID-19 than others?	Yes	0
	No	1
	Maybe	0
A 3. Do you think you can catch COVID-19 if your diseased skin comes in contact with infected articles?	Yes	0
	No	1
	Do not know	0
A 4. In your opinion is reinfection of COVID-19 in a cured patient possible or not?	Yes	1
	No	0
	Do not know	0
A 5. Do you think you can catch COVID-19 from pet animals?	Yes	0
	No	1
	Do not know	0
A 6. Do you think the use of gloves, masks, and hand sanitizers can prevent the spread of COVID-19?	Yes	1
	No	0
	Maybe	0
A 7. Do you think that the lockdown in India is helpful in preventing the spread of COVID-19?	Yes	1
	No	0
	Maybe	0
A 8. In your opinion is COVID-19 a curable disease?	Yes	1
	No	0
	Maybe	0
A 9. Over the last 2 weeks, how often did you get nervous, anxious, or felt on the edge with the thought of catching COVID-19?	-Never or rarely (not more than once a week)	0
	- Sometimes (not more than thrice a week)	0
	- Most of the times (more than thrice a week)/Always	1
A 10. Do you think India is severely affected with COVID-19?	Yes	1
	No	0
	Do not know	0
A 11. Do you think a change in climate can reduce the severity of COVID-19?	Yes	0
	No	1
	Do not know	0
Section 3: Behavioral Practices During the Pandemic Maximum Score-8
Questions	Response	Score
P 1. In order to prevent contracting COVID-19, do you use herbal products and traditional medicine on your diseased skin without consulting a doctor?	Yes	0
	No	1
P 2. Are you regularly taking the prescribed medication for your skin disease during the COVID-19 outbreak?	Yes	1
	No	0
P 3. Have you been to a crowded place recently?	Yes	0
	No	1
P 4. Do you ALWAYS wear face masks while going out of your house?	No	0
	Yes:
	If your response is ‘Yes’ then what kind of mask do you wear most often (choose only one option)?
	Homemade mask	1
	Triple layer surgical mask	1
	N-95 mask	2
P 5. Do you still go outdoors to eat food or order food from outside?	Yes	0
	No	1
P 6. Do you strictly practice social distancing?	Yes	1
	No	0
P 7. Are you paying more attention to your personal hygiene than usual?	Yes	1
	No	0

The scores of the 'knowledge' domain ranged from 0 to 13. Question K1 was concerned with the causative organism, questions K2–K6 were related to the knowledge about disease transmission, and questions K7–K12 were regarding the knowledge about disease presentation and severity. Patients with a knowledge score of ≥11 were considered to have adequate knowledge and understanding of the COVID-19 illness; patients with >5 score were regarded as having average knowledge, while those with a score of ≤5 were regarded as having poor knowledge.

The domain of 'attitude' had scores ranging from 0 to 11, with a total of 11 questions. Questions A1–A3 asked questions about the perception of patients toward their chronic dermatosis during COVID-19. Items A4 and A5 were aimed at ascertaining patients' attitudes toward acquiring COVID-19. Items A6 and A7 concerned patients''' confidence in being able to protect themselves from the infection, and A8–A11 were related to patients' personal opinions and anxiousness toward COVID-19. A score of ≥9 was an indicator of good attitude; a score of >5 indicated average attitude, while a score of ≤5 was designated to be an indicator of a poor attitude.

The third section of items had seven questions related to the 'practice' of patients amidst the COVID-19 pandemic with a score range of 0–8. P1–P2 asked questions pertaining to the patients' self-care measures for their skin disease. Items P3–P5 were related to the behavior of patients while going outdoors. The remaining two questions, P6–P7, were about the self-protection measures adopted by the patients amidst the pandemic. Patients with a score of ≥6 were considered to be following good practices. Scores >4 and ≤4 were labeled as indicators of average and poor practices, respectively.

The printed/digital questionnaire consisting of 30 questions (Hindi and English) was supplied to the patients. For digital questionnaires, a link to the Google form was sent to the participants, including an informed consent section at the beginning of the questionnaire. The questionnaire was either filled by the patients themselves, or by their attendants if the patients were illiterate. The demographic details of the patients were noted at the beginning of the questionnaire.

Statistical analysis

Statistical analysis of the data was done using SPSS version 20.0. Mean and standard deviation were calculated to find the distribution of the continuous numbers, while proportion or percentages were used for qualitative variables. A P value of <0.05 was considered statistically significant. For sample size calculation, a 5% margin of error, a confidence level of 95%, and response distribution of 50% were taken. Content validity was established by the response of the experts and pilot study participants. The internal consistency of the questionnaire was confirmed by Cronbach's α coefficient of >0.7. For sample size calculation, the Raosoft ® calculator was used with a confidence level of 90%.[5]

Results

A total of 237 patients fulfilling the inclusion criteria participated in the study. The mean age of the patients was 44.57 ± 13.72 years, while the male: female ratio of our subjects was 1.55:1. The detailed demographic profile and socioeconomic status of the patients have been tabulated [Tables 2 and 3].

Table 2

Demographic profile of study population

Parameter	Value
Age (mean±standard deviation)	44.57±13.72 years
Gender Distribution
Males	144
Females	93
Literacy Status
Illiterate	12 (5.06%)
Educated up to 10th standard	71 (29.96%)
Educated up to 12thstandard	96 (40.51%)
Graduate	47 (19.83%)
Post-graduate	11 (4.64%)

Table 3

Socioeconomic distribution of patients

Socioeconomic class	Rural; n=149 (modified BG Prasad SES 2019)[6]	Socioeconomic class	Urban; n=88 (Modified Kuppuswamy’s SES 2019)[7]
Group 1 (n=70)
Upper	8	Upper	12
Upper middle	29	Upper middle	23
Group 2 (n=167)
Middle	46	Lower middle	35
Lower middle	47	Upper lower	11
Lower	19	Lower	7

The various types of chronic dermatoses encountered in our study population have been summarized in Figure 1. Psoriasis was the most commonly encountered dermatosis, followed by immunobullous disorders, and connective tissue disorders. The mean disease duration of dermatosis was 4.3 ± 4.1 years (range 3 months to 17 years). The most frequently prescribed medication was systemic steroids, followed by methotrexate and azathioprine. A handful of patients were also being treated with multiple drugs.

Figure 1

Distribution of dermatoses in the study population

Patients' knowledge of COVID-19

The correct knowledge toward COVID-19 was present in 126 (53.16%) patients, while 62 (26.16%) had only an average knowledge, and the remaining 49 (20.68%) had poor knowledge. The mean score of the patients was 7.79 ± 3.08 out of 13. On a detailed analysis of the responses, the patients had the greatest knowledge about the viral origin of COVID-19 (n = 201; 84.81%). However, their knowledge was significantly low about the modes of disease transmission, with the correct response given only by 91 (38.39%) patients. Adequate knowledge about clinical symptoms and disease severity was present in 139 (58.64%) patients [Figures 2 and 3]

Figure 2

Grading of response for KAP questionnaire as good, average, and poor

Figure 3

Distribution of correct response in KAP questionnaire

Patients' attitude toward COVID-19

The mean attitude score of our patients was 8.35 ± 2.16 (out of 11). A majority of patients believed that their chronic dermatoses made them more liable to acquiring COVID-19 (n = 151; 63.71%). More than half of the patients were of the opinion that the medication prescribed to them for their skin condition made them more prone to contracting this novel virus (n = 123; 51.89%). However, only a small fraction of the study participants had the wrong perception that their diseased skin could acquire infection by direct contact (n = 69; 29.11%). Seventy-nine (33.33%) patients agreed that they have felt on the edge, nervous, or anxious regularly (more than thrice a week) in the last 2 weeks with the thought of catching COVID-19 [Figures 2 and 3].

One hundred and eighty-three (77.21%) patients agreed that India is severely inflicted with COVID-19, while at least 157 (66.24%) patients believed that the lockdown measures in India can help prevent its spread. The questionable belief that climatic change could reduce the severity of this novel infection was seen in 137 (57.81%) patients.

Patients' practices amidst Covid-19

The mean practice score of our study population was 5.64 ± 2.03 (out of 8). Increased hygiene levels were seen in 220 (92.83%) patients. Sixty-six (27.85%) patients admitted to stopping their prescribed immunosuppressives by themselves during COVID-19. A significant proportion of the participants admitted that they were using alternative medicines with questionable efficacy instead of the medication prescribed by their dermatologist (n = 91; 38.39%) [Figures 2 and 3]. Despite the flare-up in preexisting symptoms or appearance of new symptoms, 93 (39.24%) patients avoided visiting the hospital.

The precautionary measures like wearing a mask, regular sanitization of hands, and social distancing were strictly followed by 76.37% of the patients. While quarantine regulations and self-isolation were taken seriously only by 56.54% of patients.

A significant difference in knowledge, attitude, and practice was found across various strata of society like gender, age, residence (urban vs. rural), literacy rate, and socioeconomic status (P < 0.01) [Tables 4 and 5].

Table 4

Analysis of the KAP score between gender, socioeconomic status and residence

Parameter	Knowledge score (mean±SD)	P	Attitude score (mean±SD)	P	Practice score (mean±SD)	P
	7.79±3.08		8.35±2.16		5.64±2.03
Gender
Male (144)	8.53±3.81	<0.0001	9.08±1.77	<0.0001	6.84±1.96	<0.0001
Female (93)	6.64±2.57		7.22±2.13		3.78±3.02
Socioeconomic status
Group 1 (upper and upper middle) n=70	8.83±3.71	0.0029	9.13±1.52	0.0003	6.98±1.32	<0.0001
Group 2 (middle and lower) n=167	7.35±3.34		8.02±2.31		5.07±0.98
Residence
Urban (149)	8.72±3.27	0.0021	8.81±2.04	0.0101	6.93±1.52	<0.0001
Rural (88)	7.24±3.95		8.08±2.18		4.88±0.94
Age of patients
Below 50 years (41)	9.42±3.01	0.0003	9.5±1.69	0.0004	7.84±2.61	<0.0001
Over 50 years (196)	7.45±3.15		8.11±2.37		5.18±3.35

P ≤0.05 statistically significant. Calculated using unpaired t test

Table 5

Analysis of the effect of literacy status on KAP score

Literacy Status	Illiterate (n=12)	Up to 10th standard of education (n=71)	Up to 12th standard of education (n=96)	Graduate (n=47)	Post-graduate (n=11)
Knowledge Score (Mean±SD)	6.03±1.53	6.04±2.27	7.16±2.76	11.11±1.60	12.31±1.21
F ratio	63.68
P	<.00001
Attitude Score (mean±SD)	7.92±2.08	7.99±1.63	8.06±1.61	9.02±1.66	10.81±0.41
F ratio	14.08
P	<.00001
Practice Score (mean±SD)	4.91±2.07	5.43±1.61	5.54±1.59	5.85±1.44	7.18±0.60
F ratio	4.60
P-value	0.00377

F ratio and P value calculated using one-way ANOVA

Discussion

Despite the best efforts of various government agencies throughout the world the COVID-19 has crippled the entire world.[89] A major cause for this rapid progression has been the absence of critical knowledge about the ailment in the general population. Various practices have been adopted by global policymakers to contain this expeditious spread, including home and institutional quarantine, social distancing, regular handwashing habits, and self-isolation. Strictly following these habits has also proven to be efficient in preventing the spread of the infection.[10]

Our study highlighted the veil of misinformation curtaining the knowledge of the general population toward the disease, especially in populations from a low socioeconomic stratum. We observed a significant gap in the knowledge toward COVID-19 between various strata of society, age groups, literacy rates, and gender.

Compared to other similar studies, our participants had a weaker level of knowledge.[11121314] The attitude of our study population was also not up to the mark, with high levels of anxiety seen in 79 (33.33%) patients. A small proportion of patients admitted that they believe that their diseased skin can contract COVID-19 from direct contact (29.11%).

We observed that a significant proportion of patients avoided visiting the hospital despite the flare-up of their dermatoses. Many patients were of the opinion that their prescribed immunosuppressive medication made them more susceptible to contracting and did not take their prescribed medications or switched to alternative medicines with questionable efficacy. All these factors could account for disease progression and worsening of their dermatoses. If such patients are not adequately counseled at the right time, the consequences can be grave.

Although a plethora of data is available on the KAP of health care professionals regarding COVID-19, only a handful of reports from India have explored this domain in the general population or ill patients.[15161718] A study conducted by Amalakanti et al.[15] had observed that women and people with a low level of education have poor knowledge and practices toward the ailment, while laborers had a poor attitude. Pal et al.[16] had also conducted a similar study in patients with type 1 diabetes mellitus in which they found a fairly good KAP score in young adult patients. According to Christy et al.,[18] patients over 50 years of age and illiterates had significantly low KAP scores. Our findings were in close agreement with the studies mentioned above.

Apart from ours, only one more study had aimed at evaluating the KAP in patients on immunosuppressive drugs.[14] This study had included patients with multiple sclerosis. However, unlike our patients, their subjects were found to have a superior level of behavioral practices, possibly due to the inclusion of only bachelor's degree holders as study participants.

Ingenious technological tools like teledermatology and telemedicine should be utilized for remote delivery of health care services to rural and debilitated patients. A few authors have also attempted to lay down guidelines for the use of immunosuppressives during the pandemic.[419]

ACR has recommended guidelines for the timing and use of immunosuppressive drugs with the COVID-19 vaccination. Corticosteroids, hydroxychloroquine, azathioprine, oral cyclophosphamide, mycophenolate mofetil, IVIg, and corticosteroids require no modification with the vaccination. However, the ACR recommends holding methotrexate and IV cyclophosphamide for at least a week after each dose of vaccination. It is advised to schedule vaccination at least 4 weeks before starting rituximab, and a gap of 2–4 weeks is advised between the second dose of vaccination and IV rituximab.[20]

Conclusions

We observed a below-average understanding of patients toward the currently prevalent deadly COVID-19, with poor knowledge. However, a majority of the participants had a positive attitude and fairly good practices. A large proportion of the patients had false beliefs about the interaction of their diseased skin with the virus. We found a significant impact of the pandemic on the medical health care of our patients with irregular hospital visits and repeatedly interrupted treatment.

Limitations

Our study was limited by small sample size, absence of a control group with healthy individuals, and short duration of the study. Moreover, the findings of this study cannot be generalized to depict the knowledge of the rest of the country as only three tertiary care centers from Rajasthan were included.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.