|Year : 2021 | Volume
| Issue : 2 | Page : 218-226
The other corona warriors: A KAP study on COVID-19 among janitors and housekeeping staff from a tertiary care hospital in Eastern India
Vineeta Shukla, Ripan Saha, Ankita Mishra, Meghna Mukherjee, Mausumi Basu, Raghunath Misra
Department of Community Medicine, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
|Date of Submission||05-Nov-2020|
|Date of Acceptance||20-Apr-2021|
|Date of Web Publication||31-May-2021|
Dr. Mausumi Basu
Department of Community Medicine, IPGME and R and SSKM Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
BACKGROUND: Janitors and housekeeping staff are an integral part of our health-care system and are also in the frontline to fight this pandemic. COVID-19 infection is a new disease which currently has no specific treatment and vaccine, but this disease is preventable if there is a high level of awareness. This is especially important for housekeepers as they are unable to get adequate protection unlike doctors and nurses. They also receive less importance and appreciation than other frontline workers.
OBJECTIVES: To assess the knowledge, attitude, and practice (KAP) of janitors and housekeeping staff of a tertiary care hospital on COVID-19 and to find out the factors associated with KAP.
MATERIALS AND METHODS: An observational study was carried out among 214 janitors and housekeeping staff of a tertiary care hospital in Kolkata. The data were analyzed using SPSS software version 20.0. Each response was scored, and subjects having a total score above the median score of KAP scores were said to have adequate knowledge, positive attitude, and satisfactory practice, respectively. Multivariate logistic regression was done to check the association between KAP of the study population with their sociodemographic profile.
RESULTS: About 53.3% of the study population had adequate knowledge, 56.1% had positive attitude, while 62.6% had satisfactory practice (≥median score). Age, posting in medicine & allied departments and surgery and allied departments were found to have statistically significant odds of inadequate knowledge. Odds of having negative attitude was found to be statistically significant in those working as security and kitchen staff and residing within the institution premises. Odds of having unsatisfactory practice was found to be statistically significant in the age group of 34 years and above and those following Islam religion.
CONCLUSION: The janitors and housekeeping staff had adequate knowledge on COVID-19, and their attitude was mainly positive with satisfactory practice. However, the proportion of adequate knowledge, positive attitude, and satisfactory practice could have been higher. As the global threat of COVID-19 continues to increase, greater efforts through campaigns that target frontline workers and the wider population are urgently needed.
Keywords: Attitude, COVID-19, knowledge, pandemic, tertiary care hospital
|How to cite this article:|
Shukla V, Saha R, Mishra A, Mukherjee M, Basu M, Misra R. The other corona warriors: A KAP study on COVID-19 among janitors and housekeeping staff from a tertiary care hospital in Eastern India. Indian J Health Sci Biomed Res 2021;14:218-26
|How to cite this URL:|
Shukla V, Saha R, Mishra A, Mukherjee M, Basu M, Misra R. The other corona warriors: A KAP study on COVID-19 among janitors and housekeeping staff from a tertiary care hospital in Eastern India. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Jun 17];14:218-26. Available from: https://www.ijournalhs.org/text.asp?2021/14/2/218/317410
| Introduction|| |
The novel coronavirus (COVID-19) started as an outbreak in Wuhan, China, as an epicenter in December 2019. It is primarily a respiratory infection caused by SARS-CoV-2 virus which belongs to the family of ribonucleic acid viruses. The main symptoms of COVID-19 have been identified as fever, dry cough, fatigue, myalgia, shortness of breath, and dyspnea. COVID-19 infection is characterized by rapid transmission and can occur by close contact with an infected person. In the last week of January 2020, the World Health Organization (WHO) announced a Public Health Emergency of International Concern and requested for collaborative effort from all countries to prevent its worldwide spread. On March 11, 2020, the WHO declared it as a pandemic.
Since its outbreak, the virus has spread across the globe, affecting people of every age group, gender, race, religion, caste, and creed. Cases of coronavirus in India have been ticking rapidly, with doctors, nurses, paramedical staff, laboratory technicians, and other support staff being on the frontline. The Government of India ordered its population of 1.3 billion people not to leave their homes as a preventive measure for 3 weeks on March 24, 2020, initiating the world's largest lockdown when cases numbered only in hundreds. The health-care system has been on its toes and continued to provide timely and quality care throughout. As of November 1, 2020, there are about 5.7 lakh active cases of COVID-19 (total cases 81 lakhs) in our country.
The whole structure of hospital system rests on the people who clean and provide waste management services. Our housekeeping staff, have watched their jobs take on new meaning at this time when soaps, sanitizers, and other material used are extremely valuable and hand washing has become a national activity. However, what has remained the same, is lack of better protection, respect, importance, and, often, inadequate compensation. On March 22, 2020, a day announced as curfew, people took to their balconies and rooftops clapping, cheering, singing, and ringing bells to pay their gratitude to the health-care workers and essential service employees who were risking their lives every day to save people from the pandemic. It was disappointing that all news channels and other media were talking about doctors, nurses, and police personnel with very little mention of hospital cleaners.
Personal protective equipment and fresh N-95 masks are mostly given to doctors and nurses; the janitors and housekeeping staff are provided with clothed masks and rubber gloves, which they often have to reuse. Although it is well known that they are at a huge risk, adequate protection is not always provided to them. The cleaning staff have families with little children, have comorbidities, have people they go home to that they could be infecting. The doctors and nurses have that too, but they get better protection and appreciation. On the contrary, the people who clean it up after they are gone are not often mentioned.
Although since the start of the pandemic many knowledge, attitude, and practice (KAP) studies have been done, most of them have been done over general population as online surveys or among doctors, nurses, and other health-care professionals. There is a dearth of research studies among janitors and housekeeping staff.
COVID-19 infection is a new disease, with its epidemiology still being studied. There is no specific treatment or vaccine available as yet. Therefore, awareness plays the key role here so that adequate preventive measures can be taken. Despite their importance, these workers are often the last to learn about new protocols and procedures as may have been the case with coronavirus. Furthermore, evidence shows that knowledge is important in tackling pandemics. By assessing awareness about the coronavirus, deeper insights into the existing perception and practices can be obtained, thereby helping to identify ways that influence in the adaption of healthy practices and behavior. Assessing public knowledge is also important in identifying gaps and strengthening ongoing prevention efforts. Thus, keeping this background, a study was conducted among the janitors and housekeeping staff of a tertiary care hospital in Kolkata to assess their KAP on COVID-19 and to find out the factors associated with KAP.
| Materials and Methods|| |
Study type, design, area, and study population
An institution based observational study, cross sectional in design, was conducted among the janitors and housekeeping staff of a tertiary care teaching hospital in Kolkata over a period of 4 weeks (April–May 2020). Staff employed under reliable hospitality services, Ex-servicemen Resettlement Society (ERS), and central kitchen staff present during the data collection period were included in the study. Those who did not give written informed consent for the study were excluded from the study.
Sample size and sampling technique
Sample size was calculated using the following formula: N = Zα2pq/L2, where N = initial sample size,
Z = 1.96, p = proportion of the study population with adequate knowledge, q = 1 − p, L = allowable error (15% of p). (We took 15% relative error for logistic feasibility and because a smaller error was computing a larger sample size, far more than the number of housekeeping staff available). Assuming 50% had adequate knowledge (as no published study was available during the time of study protocol preparation and because 50% assumption would give the largest required sample size), at 95% level of confidence, the sample size was calculated as ([1.96]2 × 0.5 × 0.5)/(0.075)2 = 171. After adding non response of 25%, the final sample size was taken as 214. (A rate of nonresponse of 25% was kept as many departments were functioning with less than half the load of housekeepers and janitors during the lockdown days.) From the daily attendance register maintained at the housekeeping department office of the hospital, a line listing of janitors and housekeeping staff including security personnel and kitchen staff was prepared and the required sample size was achieved by simple random sampling technique.
Study tool and study variables
The study tool was a predesigned, pretested, structured schedule consisting of the following four domains:
- Sociodemographic profile
- Knowledge (comprising 13 items)
- Attitude (comprising 6 items)
- Practice (comprising 9 items).
The schedule was designed in consultation with the following three experts: one public health expert, one epidemiologist, and one from internal medicine department. It was pretested among thirty janitors and housekeeping staff of the same institution after which minor corrections were made in the schedule in a language and style to ensure the understanding of the study population and it was again validated by another three experts.
The study variables were broadly dependent variables (KAP) and independent variables (sociodemographic characteristics such as age, gender, caste, religion, education, current department of posting, duration of service, and socioeconomic class).
Method of data collection
The selected janitors and housekeeping staff were approached personally and were informed about the nature and purpose of the study and ensured about their anonymity and confidentiality. The data were then collected by face-to-face interview after wearing masks and maintaining social distancing.
The data were tabulated into Microsoft Excel 2016 (Microsoft Corp, Redmond, WA, USA) and then imported into Statistical Package for the Social Sciences (SPSS for Windows, version 20.0, SPSS Inc., Chicago, IL, USA). For descriptive statistics, frequency (n) and proportion (95% confidence interval) were calculated and presented by suitable tables and figures. Bivariate analysis was performed to ascertain the relationship between the dependent and independent variables. All independent variables having P < 0.20 were considered biologically plausible to be included in the multivariate regression model. The data were checked for multicollinearity (VIF <10, tolerance >0.1) and variables with P < 0.05 were considered statistically significant.
Knowledge was assessed on 13 questions. Each correct response was scored one (1), whereas incorrect/don't know zero (0). Adequate knowledge was score ≥8 (median score).
For attitude, out of 6 items, positive response was given a score of two (2), neutral one (1), and negative zero (0). Those having median score ≥11 were said to have positive attitude.
Practice was evaluated on 9 items, each carrying a score of one (1). A score of ≥7 was interpreted as satisfactory practice.
Ethics committee approval
Institutional ethics committee approval was taken (Letter No. IPGMEandR/IEC/2020/392; Dated May 18, 2020), and all the ethical principles were strictly abided by throughout the course of the study.
- Janitor: one who performs sanitation and maintenance duties at a hospital including bio-medical waste management.
- Housekeeping: Refers to the management of duties and chores involved in the running of a hospital such as cleaning, changing linen, and transferring patients from one place to other for consultation and diagnostic tests.
| Results|| |
[Table 1] shows the sociodemographic profile of the study population. Out of the total 214 janitors and housekeeping staff who were interviewed, 42.1% belonged to the age group of 26-–35 years, with the mean age of the study population being 33.7 ± 8.3 years and a range being 39 years. About 88.8% were males, 89.7% followed Hinduism, and 65.4% belonged to others' (general) caste. Regarding education, 43.0% had completed secondary and 32.7% had completed higher secondary. About 78.5% were married and 67.3% came from joint family. About 70.1% were employed in reliable hospitality services, while 18.7% were employed in ERS. Their median duration of service was 5 years with a range of 16 years. About 37.4% of the study population belonged to Class III socioeconomic class (middle class) as per the Modified BG Prasad Scale 2020 with Rs. 2857.14 as the median per capita income. About 66.4% were residing outside the institution premises and traveled daily for their duty during the lockdown period. About 19.6% were current smokers, while 17.8% consumed pan/gutka and other forms of tobacco.
|Table 1: Sociodemographic characteristics of the study population (n=214)|
Click here to view
[Figure 1] shows distribution of the study population according to KAP, which reveals that 53.3% of the study population had adequate knowledge, 56.1% had positive attitude, while 62.6% had satisfactory practice.
|Figure 1: Multiple bar diagram showing distribution of the study population according to knowledge, attitude, and practice (n = 214)|
Click here to view
The various components of KAP on COVID-19 are described in [Table 2]. Only 23.4% could answer all the four symptoms (fever, cough, sore throat, and breathlessness) correctly, whereas only 36.4% knew all the modes of prevention (frequent hand washing, wearing face masks regularly, wearing gloves, maintaining social distancing of at least 1 m, and avoiding contact with a positive case). Mass media such as TV, radio, and caller tune on mobile was the most common source of knowledge (89.7%) followed by awareness from doctors, nurses, and paramedical staff (72.9%).
|Table 2: Knowledge, attitude, and practice of the study population on COVID-19 (n=214)|
Click here to view
[Table 3] shows multivariate logistic regression between inadequate knowledge of the study population with sociodemographic variables. Predictors of inadequate knowledge were age (adjusted odds ratio [AOR] = 1.04, P = 0.047), posting in medicine and allied departments (AOR = 4.44, P < 0.001), and posting in surgery and allied departments (AOR = 2.68, P = 0.036).
|Table 3: Multivariate logistic regression predicting inadequate knowledge (n=214)|
Click here to view
[Table 4] shows multivariate logistic regression between negative attitude and unsatisfactory practice of the study population with sociodemographic variables. Odds of having negative attitude was found to be statistically significant among security and kitchen staff (P = 0.026) and residing within institution premises (AOR = 3.97, P < 0.001). Odds of having unsatisfactory practice was found to be statistically significant in the age group of 34 and above (AOR = 2.92, P = 0.001) and those following Islam religion (AOR = 5.29, P = 0.001).
|Table 4: Multivariate logistic regression predicting negative attitude and bad practice (n=214)|
Click here to view
| Discussion|| |
Since the announcement of COVID-19 as a pandemic by the WHO, the KAP toward this disease has been growing gradually.
Janitors and housekeeping staff are one of the frontline warriors to challenge the COVID-19 pandemic. Thus, their lack of awareness may adversely affect the preparedness to meet this periodic phenomenon. This cross-sectional study was an attempt to understand the insight into their KAP regarding COVID-19 and to the best of our knowledge, this is probably the first study carried out in West Bengal among janitors and housekeeping staff.
In the present study, 53.3% of the study population had adequate knowledge about COVID-19, which was in line with a study by Roy et al. among general population in a pan India online survey. However, it was far lower than the study by Zhong et al. in Wuhan among Chinese residents (90%); by Azlan et al. in Malaysia among general public (80.5%); by Ayinde et al. among Oyo State health-care workers which included housekeeping staff (78.6%); by Rios-González in an online survey conducted in Paraguay among general population (62%); by Acharyya et al. at Murshidabad, West Bengal, India, among hospital staff (77%); and by Kartheek et al. among Indian residents (74%).
Only 18.2% population regarded fever as a symptom in the study by Roy et al., whereas it was high in our study. Cough as a symptom was reported correctly by 76.6% of the population in this study, whereas it was only 17.3% in the study by Roy et al.
Overall, all the correct symptoms were reported by only 23.4% of our study population, whereas it was 86.7% in the study by Azlan et al., 93.1% by Ayinde et al., 79.8% of general population in the UK and the USA in an online survey by Geldsetzer, 94.38% by Dkhar in Jammu and Kashmir, and 42.9% in a study by Pandey et al. all over India. About 81.9% of the participants knew the correct modes of transmission (via respiratory droplets and personal contact) in the Malaysian study, 74.8% in the UK and the USA study, and 89% in Jammu and Kashmir study, while it was only 62.6% in our study. However, it was higher than the findings at Belgaum, Karnataka, in which the correct response was only 48.8%. About 38.3% of the participants of the present study population responded that COVID-19 infection is fatal, in contrast to 11.8% by Roy et al. and 68.5% by Pandey et al.
In the Malaysian study, about 83.2% reported that persons with COVID-19 can infect others even if they do not have fever, whereas only 20.6% reported the same in our study. About 71% of the respondents in this study reported that people aged 60 years and above and those having co-morbidities (such as diabetes, hypertension, and chronic obstructive pulmonary disease) are more at risk of COVID-19 infection, which was less than the finding by Geldsetzer (96.3%).
In our study, about 95.3% of the study population regarded frequent handwashing as a method of prevention, which was corroborative with the findings by Roy et al. (97%), Ayinde et al. (93.4%), Geldsetzer (86%), and Dkhar et al. (76%). This may be because of effective awareness campaigns conducted within the Institute, State, and Country. On the contrary, this finding was only 23.3% in the study by Pandey et al. Regarding the knowledge of social distancing, we found it was 85%, which was lower than that of pan India online study (95.8%) and Malaysian study (96.7%) but higher than that of Indian population study (16.9%).
About 56.1% of our study population had positive attitude, which was lower than the study by Azlan et al. (83.1%), Ayinde et al. (64%), and Acharyya et al. In the pan India study by Roy et al., 60% of the study population felt that patients who had recovered from COVID-19 infection should not be allowed to stay within the community, whereas it was only about 23.3% in our study. It could be attributed to the spread of myths and misinformation driven by fear, blame, and stigma.
About 62.6% of the study population had good practice in the present study, whereas it was higher (95%) in the study by Mukhopadhyay at a Kolkata slum. Majority (98.1%) of the participants practiced frequent handwashing in our study (following recommended guidelines for ≥20 s), which was slightly higher than the findings observed in Malaysian study (87.8%), Nigerian study (95.3%), and Jammu and Kashmir study (87.17%).
Regarding wearing face masks regularly, about 94.4% of the respondents of this study reported that they do the same, whereas it was 51.2%, 74.3%, 86%, and 73.38% in Malaysian study, Paraguay study, West Bengal study, and Jammu and Kashmir study (73.38%), respectively.
All our study population (100%) followed social distancing in contrast to 83.4% in Malaysian study, 88.3% in Paraguay study, and 86.61% in Jammu and Kashmir study. It was probably due to the government and media emphasizing more on the preventive measures.
Though information about hydroxychloroquine (HCQ) prophylaxis for COVID-19 was circulated among the masses, in our survey, 96.3% did not purchase HCQ, similar to pan India online study (96.2%). There is increasing concern of participants toward personal hygienic measures and awareness about COVID-19. This reflected in their practice as most of the participants reported social distancing, avoiding travel, and practicing hand hygiene. However, their fear, apprehension, panic, and stigma were seen when they were asked about the inclusion of recovered COVID-19 patients to the mainstream of the society (13.1%).
Our study had a few limitations. First and, most importantly, training status of the janitors and housekeeping staff could not be assessed. Second, the study was conducted in one institute only. Third, there is a possibility of reporting bias (as the responses were dependent on the participants' honesty) and social desirability bias (as some participants may have given socially favorable answers). Furthermore, the study was conducted over a short period of time.
The strengths of our study are: (1) There is a dearth of studies about COVID-19 among janitors and housekeeping staff in our country specially in the eastern part and most probably, this is the first and only study carried out in West Bengal among janitors and housekeeping staff regarding this new pandemic. (2) Large sample size. (3) Our findings provide valuable information about the KAP of an important group of frontline workers during this period of pandemic.
| Conclusion|| |
More than half of the janitors and housekeeping staff had adequate knowledge on COVID-19, their attitude was mainly positive, and almost two-thirds had satisfactory practice, which may be as a result of the efforts made by local authorities to sensitize all hospital staff. However, the proportion of adequate knowledge, positive attitude, and satisfactory practice should have been higher. Posting in medicine and allied departments was found to have a statistically significant association with inadequate knowledge. Current residence within institution premises was found to be associated with negative attitude. Nevertheless, as the global threat of COVID-19 continues to increase, greater efforts through campaigns that target frontline workers and the wider population are urgently needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al
. A new coronavirus associated with human respiratory disease in China. Nature 2020;579:265-9.
Riou J, Althaus CL. Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020. Euro Surveill 2020;25:2000058.
Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91-8.
Tang D, Tou J, Wang J, Chen Q, Wang W, Huang J, et al.
Prevention and control strategies for emergency, limited-term, and elective operations in pediatric surgery during the epidemic period of COVID-19. World J Pediatr Surg 2020;3:e000122.
Sarkar A, Kundu M, Venkataramana P, Chakraborty P. SARS-CoV-2/2019-novel corona virus: An epidemic to pandemic. Int J Res Pharm Sci 2020;11:37-42.
GOI.COVID-19 INDIA as On: 01 November 2020, 08:00 IST (GMT+5:30). Ministry of Health and Family Welfare. Home Page. Government of India. Available from: https://www.mohfw.gov.in/index.html
. [Last accessed on 2020 Nov 01].
Al-Hanawi MK, Angawi K, Alshareef N, Qattan AM, Helmy HZ, Abudawood Y, et al.
Knowledge, attitude and practice toward COVID-19 among the public in the kingdom of Saudi Arabia: A cross-sectional study. Front Public Health 2020;8:217.
Chirwa GC. “Who knows more, and why?” Explaining socioeconomic-related inequality in knowledge about HIV in Malawi. Sci Afr 2020;7:e00213.
Podder D, Paul B, Dasgupta A, Bandyopadhyay L, Pal A, Roy S. Community perception and risk reduction practices toward malaria and dengue: A mixed-method study in slums of Chetla, Kolkata. Indian J Public Health 2019;63:178-85.
] [Full text]
Macfarlane SB. Conducting a descriptive survey: 2. Choosing a sampling strategy. Trop Doct 1997;27:14-21.
Debnath DJ, Kakkar R. Modified BG Prasad socio-economic classification, updated – 2020. Indian J Comm Health 2020;32:124-5.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety and perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.
Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al.
Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci 2020;16:1745-52.
Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. PLoS One 2020;15:E0233668.
Ayinde O, Usman AB, Aduroja P, Gbolahan A. A cross-sectional study on Oyo state health care workers knowledge, attitude and practice regarding corona virus disease 2019(COVID-19). Adv Infect Dis 2020;10:6-15.
Acharyya A, Ghosh S, Ghosh M, Sarkar K, Ghosh S, Bhattacharya A, et al
. Knowledge, attitudes, and practices towards COVID-19 among hospital staff of West Bengal during COVID-19 outbreak: A hospital based cross sectional study. Asian J Med Sci 2020;11:1-7.
Kartheek AS, Gara KH, Vanamali DR. Knowledge, attitude and practices towards COVID-19 among Indian residents during the pandemic: A cross-sectional online survey. JNTR Univ Health Sci 2020;9:107-15.
Geldsetzer P. Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey. Ann Intern Med 2020;173:157-60.
Dkhar SA, Quansar R, Saleem SM, Khan SM. Knowledge, attitude, and practices related to COVID-19 pandemic among social media users in J and K, India. Indian J Public Health 2020;64:205.
] [Full text]
Mukhopadhyay J. Optimism under the holocaust of COVID-19 in Kolkata slum. J Community Health Manage 2020;7:44-50.
[Table 1], [Table 2], [Table 3], [Table 4]