Sociocultural Determinants and Behavioral Risk Factors of COVID-19: A Study of Knowledge, Attitudes, and Practices in Bangladesh

doi:10.21203/rs.3.rs-5338958/v1

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Sociocultural Determinants and Behavioral Risk Factors of COVID-19: A Study of Knowledge, Attitudes, and Practices in Bangladesh

https://doi.org/10.21203/rs.3.rs-5338958/v1

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Experts say that community transmission of coronavirus connects to sociocultural and behavioral contexts. As such, it is necessary to understand the health behaviors of local people to explore the sociocultural determinants and socio-demographic risk factors that might be responsible for coronavirus infections. A study was done in five sub-districts of Chittagong, a southeastern district of Bangladesh, to generate evidence on sociocultural and behavioral perspectives of COVID-19 risk factors. Employing a mixed-methods research approach, this study observed 555 people and administered a vaccination survey to 200 respondents to understand individuals’ knowledge, attitudes, and practices toward COVID-19 safety measures. Researchers also conducted in-depth qualitative interviews with 20 key informants. Interview data was analyzed through thematic analysis, whereas descriptive statistics were used to analyze observational and survey data. Under the framework of the KAP model, the study results show that around half of the observed people do not wear face masks, and more than three-quarters do not maintain social distancing in public. The study also demonstrates no handwashing or hand-sanitizing facilities in over half of the observed places. The vaccination survey indicates that although 60.2% of respondents have been vaccinated, 21% of respondents do not know that they might be infected by the coronavirus even after getting vaccinated, whereas 15.5% do not know that vaccinated people still need to wear masks. Qualitative data shows that individuals’ perception of coronavirus was influenced by their sociocultural context of digesting mass media-generated COVID-19 knowledge and information. Unhealthy behavioral practices and undesirable attitudes of community members are also responsible for COVID-19 infections. From this perspective, examining individuals’ attitudes and views on the causes of COVID-19 might help in proper planning, designing, and implementing risk communication and community engagement interventions and policies to encounter the pandemic in Bangladesh.

Health Economics & Outcomes Research

COVID 19

Health Behaviors

Risk Communication

Sociocultural Determinants

1.1 Background

The contagious coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is an ongoing worldwide pandemic that emerged as the most devastating outbreak in the contemporary period (Cascella, Rajnik, Aleem, et al. 2021). Almost every country in the world has become a silent victim of this deadly disease that has already been the sole cause of deaths of hundreds of millions of people worldwide since December 2019, when the disease was first identified in the city of Wuhan, in China's Hubei province (Zhu, Wei, and Niu, 2020). Later, the virus spread to almost all countries and territories around the world, resulting in a huge number of confirmed cases worldwide and establishing itself as one of the deadliest diseases in history.

The mounting concern that followed its spread to every corner of the globe and the total number of deaths led to the declaration of COVID-19 as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 (The Globe and Media, 2020) and a pandemic on 11 March 2020 by the World Health Organization (WHO) (Cucinotta and Vanelli, 2020). So far, many strains of the coronavirus have emerged and become prevalent in many countries, raising some concern among public health specialists and organizations throughout the world.

To prevent the spread of the virus, public health bodies like the World Health Organization (WHO) and the Johns Hopkins Center for Global Health recommended various controlling measures, such as maintaining social distancing, wearing face masks in public, quarantining infected people, issuing lockdowns in affected areas, imposing travel restrictions and business closures, and testing infected people and tracing affected communities (WHO, 2021a). Countries around the world, with the support of public health and humanitarian entities, have been fighting back against the deadly disease by undertaking such preventive tools and developing domestic medical facilities.

Amid the higher risks of community coronavirus transmission, experts widely credit safe and effective vaccines for reducing the spread, severity, and death caused by the virus and recognize them as an extraordinary method to control the COVID-19 pandemic (Kaplan and Milstein, 2021). Under this perspective, many initiatives were undertaken by international medical scientists and beyond to ease collaborative and accelerated vaccine research efforts.

Scientists developed many potential vaccines for COVID-19, all designed to teach the body’s immune system to recognize and block the virus that causes COVID-19 safely (CDC, 2021a). WHO approved several vaccines, and these have been distributed in various countries. Thus, authorities initiated mass vaccination campaigns in December 2020, prioritizing vulnerable and elderly people and front-line workers such as health staff and law enforcement agency officials, as some countries had limited vaccine availability (Hasan, Beardsley, Marais, Nguyen, and Fox, 2021).

The coronavirus outbreak in Bangladesh was formally confirmed on March 8, 2020, when the country's epidemiology institute, IEDCR, identified the first three infected persons (Paul, 2020). Since then, the virus has spread to the whole country, and the number of affected people has been increasing. As of October 19 of this year, the virus has infected 29,410 people who have died in Bangladesh, while the country has reported more than 2 million confirmed cases, placing it as the second most affected country in South Asia, after India (Worldometers.info, 2021). The recent official data shows that as the rate of community transmission of coronavirus is declining in Bangladesh, the country is recording a low number of new COVID-19 cases and deaths. Some public health specialists state that the COVID-19 situation is being normalized in the country. However, some experts view that community transmission of coronavirus has close relations with sociocultural and behavioral contexts. Experts and professionals hold general views and opinions that certain sociocultural and behavioral practices may trigger an increase in coronavirus-confirmed cases in the country. As such, it is necessary to understand the health behaviors of local people to explore the sociocultural determinants and socio-demographic risk factors that might be responsible for coronavirus infections.

1.2 Significance of the Study

The coronavirus is transmitted primarily through droplets generated by an infected person when they cough, sneeze, or exhale. People can infect themselves by breathing in the virus if they are close to someone who has COVID-19 or by touching a contaminated surface and then touching their eyes, nose, or mouth (WHO, 2021b). However, there is widespread agreement among public health experts that COVID-19 is on the rise in this locality due to many variables, including frequent mobility of people without precautions, community transmission of reckless travel, and an increase in face-to-face activities. Moreover, misinformation has spread through social media and the mainstream media, exacerbating misperceptions about COVID-19 among individuals.

It is recognized that examining individuals’ attitudes and views on the causes of any of their health problems might help in proper planning, designing, and implementing health services. Furthermore, a better grasp of community members’ knowledge, behaviors, and socio-cultural practices is considered an effective intervention to bring positive health outcomes (Boccia, 2015). From this perspective, researchers could consider the effort to better analyze individuals' COVID-19-related knowledge, attitudes, and practices (KAP) as one of the important measures to encounter the ongoing COVID-19 pandemic in Bangladesh.

Amid the current state of COVID-19 in Chittagong, it is necessary to understand the health behaviors of the local people in the district and to explore the sociocultural determinants and socio-demographic variables that are responsible for increasing the number of coronavirus-infected people. This formative local study would help generate evidence about the root causes of COVID-19 trends, conduct behavior analysis of different audiences, and initiate coronavirus preventive program interventions.

1.3 Objectives

This formative local KAP study aimed to examine people’s knowledge, attitudes, and practices towards COVID-19 through quantitative and qualitative methods. The core objectives of this study are to:

1) Find out the responsible sociocultural causes of the increasing trend of COVID-19,

2) Describe individuals’ practices of maintaining safety measurements of COVID-19,

3) Assess individuals’ level of knowledge, attitude, and practice on COVID-19 vaccines, and

4) Analyze the COVID-19 related behavioral practices of community members

COVID-19 has been disrupting social order, not a medical epidemic. Many studies have been undertaken to explore diverse perspectives of the pandemic as COVID-19 is going through change (Teti, Schatz, and Liebenberg, 2020). This study reviewed research papers on the sociocultural and behavioral context of COVID-19.

Ferdous et al. (2020) used cross-sectional research to investigate knowledge, attitude, and practice on the COVID-19 outbreak in Bangladeshi people in 2020. They discovered that 48.3% of participants, the majority of whom were students, had more correct knowledge, 62.3% had more positive attitudes, and 55.1% had more regular COVID-19 preventive activities after a 10-day online-based cross-sectional survey. During the rapid rise of the COVID-19 outbreak in Bangladesh, the researchers advocated launching an efficient health education program to promote general knowledge, attitude, and practice (KAP).

A study was undertaken to learn how the public felt about the Bangladesh government's response to the pandemic in the early days of the outbreak in March and April 2020. The study employed qualitative and quantitative approaches with 190 participants in the survey. Many government agencies have partially failed to explain the government's policies to the general population. It underlined that adequate collaboration among all agencies will aid in the containment of the epidemic, as well as a regime of constant lockdown and social distancing. Frontline fighters should have received sufficient protection, and hospitals should have been completely equipped (Islam and Siddika, 2020).

Researchers conducted a study among 300 participants in Barisal, Bangladesh, in 2020 to assess the knowledge and awareness among the mass population. Around 31% of respondents had good knowledge, whereas around half of the surveyed participants possessed poor knowledge regarding the COVID-19 pandemic. It investigated the number of people following COVID-19 health and safety measures. It highlighted the lack of awareness and unwillingness to wear masks in the Barisal division during the pandemic (Hossen, Obaidullah, and Hosen, 2021).

After conducting an online (FEEL-COVID-19) survey on the initial psychological impact of COVID-19 and its correlates in the Indian community, some researchers discovered that nearly one-third of the 453 respondents reported significant psychological effects from COVID-19. Younger age, female gender, and comorbid physical illness were all linked to greater mental strain. They discovered the largest psychological impact on younger age groups, females, and persons with comorbid illness using an online survey with snowball sampling. The group also recommended a more systematic and long-term assessment of the population's psychological needs (Varshney, Parel, Raizada, and Sarin, 2020).

In another study titled "Acceptance of COVID-19 Vaccine and Its Determinants in Bangladesh," the team of researchers found that around 31% of respondents were taking the COVID-19 vaccine out of their own choice, while the remaining 47.48% of respondents were postponing their vaccination. People were unwilling to take vaccines immediately due to anxiety about the side effects or safety of the COVID-19 vaccine, doubt about the effectiveness of the COVID-19 vaccines, and skepticism about the necessity of being vaccinated (Kabir et al., 2021).

In research on hygiene and hand washing practice, the northern area of Bangladesh had the highest rate of hand washing, although it was less affected by COVID-19 infections. Central Bangladesh was the hardest afflicted by COVID-19 cases, with around 50% handwashing coverage. To establish causality, large-scale observational research is required (Ahmed and Yunus, 2020).

Paul, Chatterjee, and Bairag (2020) demonstrated that the efficacy of individual-level measures, such as hand washing and mask use, was higher in the United States and Europe than in South Asian countries. Because of the disparity in these countries' socioeconomic conditions, we could expect this. However, it's worth noting that the daily interaction in developing countries was lower than in advanced economies, with India ranking the lowest and Spain ranking the highest. One possible explanation for this outcome was that India declared a state of emergency much earlier than the United States and other countries after the first positive case was discovered. In India, this significantly reduced person-to-person transmission and broke the cycle.

The literature review shows that researchers conducted several studies about COVID-19 impact, hand washing practices, causes, KAP analyses, and vaccination in Asian countries and the world. Most studies focused on individual aspects of COVID-19's risk factors and impact. However, in this study, researchers attempted to conduct a comprehensive investigation into the sociocultural and behavioral elements, focusing on the causes of COVID-19 disease spread, vaccination intentions, and existing safety measures.

Understanding individuals’ knowledge, attitudes, and practices towards COVID-19 and associated risk factors can help to predict the outcomes of social behaviors. Further, extensive knowledge supports a positive attitude and the right practices, which helps to reduce the risks of individual infection with the coronavirus (Limbu, Piryani, and Sunny, 2020). Thus, this study adopts the Knowledge, Attitude, and Practice (KAP) model as the theoretical framework. The KAP model was first developed in the 1950s and widely employed in family planning and population studies. According to the KAP model, human behavior transformation occurs in three phases: obtaining knowledge, creating attitudes or beliefs, and forming practices or behaviors (Xie, Wei, Zheng, et al. 2017).

In the KAP model, knowledge is an individual's understanding of any issue. It is the ability to receive, retain, and apply information mixed with experience and skills. Accordingly, individuals' feelings about a topic are referred to as attitude. A person's attitude is their propensity to react in a specific way to a given situation. However, the public's way of demonstrating their knowledge and attitude is referred to as practice. It means applying the rules and knowledge to action (Badran, 1995; Kaliyaperumal, 2004).

People's motivations to use safety measures are influenced by their knowledge, attitudes, and practices towards COVID-19. So, in this study, knowledge is considered as the study participants’ understanding of COVID-19 safety measures and their uses. Attitude is participants’ positive or negative feelings towards COVID-19 public health protocols and guidelines. Similarly, practice is the participants’ actions towards using or maintaining face masks, physical distancing, hand washing, and getting vaccinated.

As a social behavior change theory, the KAP model has been used in health-related research for decades to identify the baseline knowledge, myths, misconceptions, attitudes, beliefs, and behaviors. This formative local study on the COVID-19 increasing trend also incorporated the theoretical concept of the KAP model, as it has been playing a remarkable role in disease prevention, control, and rehabilitation. In addition, it is based on the notion that increasing personal knowledge will influence health-related behavior change (WHO, 2012). Thus, the KAP model is a useful framework for exploring public health crises and creating effective awareness and intervention programs.

4.1 Study Area

The study examined 40 public places across five regions in Chittagong district, a southeastern district of Bangladesh. The regions were 1) Chattogram City Corporation area, 2) Sitakunda Upazila Sadar, 3) Raozan Upazila Sadar, 4) Fatikchori Upazila Sadar, and 5) Hathazari Upazila Sadar.

4.2 Study Design and Sampling

This study adopted both quantitative and qualitative research approaches. Mixed-method research design originated in the social sciences and has recently gained application priority in public health and medical science-related studies (Wisdom and Creswell, 2013). As the quantitative research approach, this study encompassed an observational study and a COVID-19 vaccination survey. In-depth qualitative interviews with key informants were also administered.

Observational Study

It was conducted to know social practices regarding COVID-19 safety measures. For quantitative observation, eight (8) public places from each of the five (5) regions of the Chittagong district were chosen. The selected places are as follows

1. Local Markets,
2. Tea Stall,
3. Public Transportation Station (bus/rail),
4. Traffic Square,
5. Hotel/Restaurant,
6. Public Transports,
7. Shopping Malls and
8. Religious Places

Table 1 Description of observed time and people

Five Regions	Time Used for Observation (In Minutes)		People Observed
Five Regions	Minutes	%	Numbers	%
Chattogram City	104	17.42	102	17.75
Sitakunda Upazila Sadar	93	15.58	87	15.13
Raozan Upazila Sadar	155	25.96	182	31.65
Fatikchori Upazila Sadar	112	18.76	88	15.30
Hathazari Upazila Sadar	133	22.28	116	20.17
Mean	119.4		115.0
Total	597 Minutes	100%	575 People	100%
Per individual average observation time	1.04 minutes (approx.)

In that way, forty (40) public places [5 regions * 8 public places = 40] from the district were selected for the observational study (see Table 1). Using random time sampling, people gathered in a single public place were observed for 10 to 25 minutes. In total, 597 minutes (nearly 10 hours) were used for the observation. An average of 14.927 minutes was allocated for observing a single place (see Table 1).

Further, employing event sampling, individuals’ behaviors of wearing face masks, sanitizing and washing hands, and keeping social distance were observed. This study also observed the arrangements of COVID-19 social awareness guidelines or announcements in the selected places. In total, 575 people were observed describing their behavioral practices toward maintaining safety measures for COVID-19. It took approximately 1.04 minutes to observe an individual during the observational study (see Table 1). Besides, out of the total observed people, most were male (71.65%), whereas 28.35% were female.

Table 2

Locality-wise sample distribution and its proportion
Localities	Sample Size (N = 202)	Proportion of Sample (%)
Chattogram City	40	19.80
Sitakunda	38	18.82
Raozan	44	21.78
Fatikchori	40	19.80
Hathazari	40	19.80

Vaccination Survey

It comprised 202 individuals from the five localities of Chittagong district (see Table 2). Out of the total respondents, the majority were male (61.88%), whereas just under two-fifths (38.12%) were female respondents. The sample demonstrates that most of the respondents live in semi-urban areas (37.1%), followed by urban areas (32.7%), and rural areas (30.2%). The majority of the respondents are in the 26–35 age group (31.7%), followed by 18–25 (22.8%), 36–45 (18.8%), 55 + age group (13.9%), and 46–55 age group (12.9%). On average, respondents are 36.30 years old (SD = 11.79), indicating that most middle-aged people participated in the vaccination survey.

Table 3

Frequencies and proportion of key informants’ demographic characteristics
Key Informants’ Demographic Characteristics	Frequencies (N = 20)	Proportion
Gender
Female	7	35%
Male	13	65%
Living Areas
Urban	9	45%
Semi-urban	8	40%
Rural	3	15%
Educational Status
Below secondary	0	0%
Secondary	0	0%
Higher Secondary	5	25%
Graduation	11	55%
Post-graduation	4	20%

In-depth Interview

Administering purposive sampling, twenty (20) qualitative in-depth interviews with key informants hailing from the five localities of the district were conducted to know people’s profound knowledge and behavioral attitudes and practices regarding COVID-19 safety measures. Demographic characteristics show that out of 20 key informants, 65% and 35% were male and female respectively. The sample reveals that key informants’ ages ranged from 23 to 53 years, and the average age was 28.1 years. From an educational perspective, they mainly hold graduation degrees (55%), followed by higher secondary (25%) and post-graduation (20%). It points out that most of the key informants live in urban areas (45%), followed by semi-urban (40%) and rural areas (15%) (see Table 3).

4.3 Data Collection

As a mixed-methods study, this study used quantitative and qualitative data. Data were collected from primary and secondary sources. The researchers and a group of trained volunteers collected data between October 22 and November 5, 2021. To know people's practices towards COVID-19 health protocol, an observational questionnaire was designed by researchers following Risk Communication and Community Engagement (RCCE) observation survey guidelines.

The questionnaire encompassed thirty (30) questions on background information, mask-wearing and hand-sanitizing practices, social distance maintenance, and COVID-19 social awareness guidelines or announcements. Further, a vaccination survey questionnaire was administered to get a real picture of people's knowledge, attitudes, and practices toward COVID-19 vaccines. The questionnaire adopted socio-demographic and COVID-19 vaccination-related questions. To get a comprehensive panorama of COVID-19 risk factors, the behavior of different audiences, and preventive program interventions, a thematic in-depth interview questionnaire was also employed by the researchers.

4.4 Data Processing

Collected quantitative and qualitative data were edited, categorized, and tabulated systematically. Quantitative data were processed and graphed using Statistical Package for the Social Sciences (SPSS) software and the Microsoft Excel application. Quantitative observational and survey data was analyzed employing various descriptive statistical tools and strategies (e.g., frequency distribution, proportion, mean, standard deviation, etc.).

A thematic analysis adopting five primary themes and fourteen sub-themes, the in-depth interview data were analyzed. Thematic analysis is a method of analyzing qualitative data that is usually applied to a set of texts, such as interview transcripts. The researcher closely examines the data to identify common themes—topics, ideas, and patterns of meaning that come up repeatedly (Caulfield, 2019). The primary themes included:

COVID-19 related awareness and information

Social Perception towards the spread of coronavirus

Attitude towards local administration, NGOs, and medical systems

Practices in health related behaviors

Behave to motivate others

Key informants' Knowledge, Attitude, and Practices (KAP) towards COVID-19 were identified following these themes. Interviewees’ comments that support the themes were studied carefully to know the risk factors of COVID-19.

5.1 Quantitative Findings: Observational Study

The observational study found that people’s practices towards COVID-19 health safety measures were not up to the accepted level as a significant portion of the total observed people did not practice wearing face masks, keeping physical distance, and following handwashing and sanitizing. The key quantitative findings are as follows:

5.1.1 Mask Wearing Behavior of Observed People

A substantial portion of people in public places do not wear masks

The findings on mask-wearing practices indicate that out of 575 observed people, over half (52.52%) wore face masks, whereas 47.48% were without face masks (See Fig. 1).

Females have good practice toward wearing face masks

Out of 412 observed males, only 45.87% wore masks as a COVID-19 preventive measure, while out of 163 observed females, 69.33% wore masks. The result specifies that females have a good practice toward wearing face masks compared to their male counterparts (See Fig. 2).

Some people wear masks in crowded places whereas most ignore them

No mask-wearing practices were mostly observed in tea stalls (16.85%), followed by religious places (15.02%), and hotels/restaurants (12.45%). It indicates that most people ignore mask-wearing practices in public places where they come into direct contact with the public.

Most people show a positive attitude to surgical masks

The study reveals that people wore diverse types of face masks in the observed areas. Out of the total people who wore masks, 59% used surgical face masks, followed by cloth masks (29%), N95 or KN95 masks (6%), and other types of masks (5%) (See Fig. 3).

More than one-third of people did not wear masks in the proper position

More than one-third (33.44%) did not wear masks properly as they wore masks dangling or hanging during the observation. However, this study found that more than three-fifths (63.58%) of masked people wore masks correctly covering the nose, mouth, and chin (See Fig. 4).

5.1.2 Handwashing or Hand Sanitizing Practices

During the COVID-19 pandemic, people should additionally wash their hands with soap and water for at least 20 seconds or use a hand sanitizer to prevent germs before and after touching eyes, nose, mouth, or face masks, entering and leaving public places and gatherings, and touching door handles, tables, gas pumps, shopping carts, or electronic gadgets (CDC, 2021b). However, this study reveals no hand sanitizing or handwashing options in more than half (52.5%) of 40 observed public places. On the other hand, 47.5% of places had these sorts of facilities (See Fig. 5). The findings also indicate that local authorities had less awareness or concerns about facilitating handwashing and hand sanitizer options for the general masses.

5.1.3 Practices towards physical or social distancing

The results show that people did not practice physical or social distance around four-fifths (78%) of the 40 observed public places. Moreover, no mechanisms or strategies for physical or social distancing were undertaken by local authorities in more than four-fifths (82.5%) of public places.

However, out of 8 public places where strategies were set for the distancing, 6-foot distance queues were maintained in 4 (57.14%) places, while local authorities used circle or square signs in 3 (42.86%) places to keep social distancing (See Fig. 6).

5.1.4 COVID-19 awareness messages, announcements or guidelines

The findings indicate there were no messages, announcements, or guidelines to increase social awareness of COVID-19 by promoting public health in two-fifths (40%) of the total observed public places. Out of total awareness strategies, more than two-fifths (42%) were posters, followed by health safety notices or guidelines (25%), awareness signposts (17%), awareness leaflets (13%), and awareness stickers (4%).

Adversely, out of the total observed public places, no campaigns with posters were found in 30 areas, followed by health safety notices or guidelines (34), awareness signposts (36), awareness leaflets (37), and awareness stickers (39) (See Fig. 7).

5.2 Quantitative Findings: Vaccination Survey

The vaccination survey indicates that respondents’ comprehensive knowledge and awareness of COVID-19 vaccines was high, attitudes to getting vaccinated were positive, but practices towards vaccination were low. Key survey findings are presented as follows:

5.2.1 Knowledge

Participants’ knowledge of vaccination and protection from infection is mostly assertive

The findings show that out of 202 participants, an overwhelming majority of the participants (84.6%) know that getting vaccinated against COVID-19 protects them from being infected with the virus.

Table 4

Frequencies and proportion of sources of vaccines information [Multiple answers were given]
Sources of Vaccines Information	Frequencies (N = 201)	%
TV/Radio	138	68.66
Newspapers	93	46.27
Posters	37	18.41
Health Service Providers	53	26.37
Social Media (e.g. Facebook, Whatsapp)	123	61.19
Micing	63	31.34
Family member	96	47.76
Website	46	22.89
Friends	67	33.33
Religious Person	43	21.39
Others	18	8.96

Sources of information on COVID-19 vaccines

The most common information source of COVID-19 vaccines was broadcast media. The findings show that 68.66% of respondents knew about coronavirus vaccines either from television or radio (See Table 4 for more).

Knowledge of immunization centers

The survey indicates that 15.3% of participants did not know where their nearest COVID-19 immunization center was situated, whereas 84.7% were informed about the centers.

5.2.2 Attitudes

The vaccination survey exposes individuals’ various attitudes towards COVID-19 vaccination. Results present as follows:

Individuals’ positive attitudes towards vaccination

More than one-fifth (21%) of participants do not think that after getting vaccinated they might be infected with coronavirus (See Fig. 8).

The majority think only vaccines will not turn off the pandemic automatically

An overwhelming majority of respondents (84.5%) thought that only vaccines would not turn off the pandemic automatically, although a substantial portion (15.5%) of individuals’ negative attitudes towards vaccination and other health safety measures (See Fig. 9).

Respondents have some misperceptions about vaccination

The results indicate that 29.4% of respondents think that after being vaccinated it is not important to maintain COVID-19 health safety protocols.

Reasons behind the unwillingness to health safety measures after getting vaccinated

33.8% of respondents think that only vaccines can protect people from being infected with coronavirus forever, whereas 25.4% believe that vaccines create antibodies in humans so vaccinated people need not maintain COVID-19 health protocol (See Fig. 10).

5.2.3 Practices

Practice towards getting vaccinated is mostly positive

The study found that more than three-fifths (60.2%) of respondents have been vaccinated either fully or partially. By contrast, almost two-fifths (39.8%) of participants have not been vaccinated yet.

Table 5

Frequencies and proportion of reasons behind not practicing COVID-19 vaccines [Multiple answers were given]
Reasons	Frequencies (N = 155)	%
Could not register for vaccines (for technical crisis or age range)	40	25.8%
Registration completed, but have not received vaccine taking message	80	51.6%
Afraid to take injections	19	12.3%
Vaccination will be harmful physically, this thought	11	7.1%
No national identity card	22	14.2%
Do not believe in Vaccine	10	6.5%
Vaccination center away from home	8	5.2%
It takes money to get vaccinated	2	1.3%
What about vaccines? Life and death are in the hands of the Almighty	15	9.7%
Others	11	7.1%

Associated factors with not practicing COVID-19 vaccines

The study presents that a majority of people, more than half of the respondents (51.6%), completed vaccine registration, but had not received vaccine-taking messages from respective authorities. Some risk factors were interconnected to the socio-behavioral perspective. The results demonstrate that 12.3% of participants did not take vaccines as they were afraid to inject vaccines into the body, whereas 7.1% thought that vaccination would be harmful physically (See more from Table 5).

Motivating community to take vaccines

the survey found that a majority of people, almost three-quarters of the respondents (74.5%), stated that they motivate others in their community to take COVID-19 vaccines. However, 25.5% of participants responded that they do not make efforts to influence others to get vaccinated.

5.3 Qualitative Findings: In-depth Interview

The qualitative findings have been presented here focusing on the theoretical framework of the KAP model. The findings are as follows:

5.3.1 Theme 1: COVID-19 related Knowledge, awareness and information

The study, by thematic analysis of interviewees’ opinions regarding in-depth questions, found that people had mostly positive knowledge of COVID-19. Many interviewees are informed about the health risks of COVID-19, and they are mostly familiar with clinical symptoms of COVID-19. Interviewees have mainly affirmative views on the information of COVID-19 preventive measures.

Do you know about the health risks of coronavirus? Can you point out the risks? While answering this in-depth question, a key informant Morshedul Islam, an opinion leader in Chittagong City, stated:

I know the risks of coronavirus. COVID-19 can cause high fever, throat soreness, muscular or body aches, and shortness of breath. The virus can cause organ failure and possibly death if it infects the lungs.

While asking a question- how people can prevent themselves from being infected with the virus, Mr. Ariful Islam, a student hailed from Hathazari, said: ‘People should wear masks, wash hands and keep social distance always to prevent themselves from corona infections.’

They have opined that COVID-19 public health information sources are mass media and social media. In their comments, initiatives for COVID-19 awareness campaigns by authorities and NGOs are not at an accepted level.

How do you receive information on health risks and preventive tools for Covid-19? In response to the question, Mr. Forkan Sikder, a working person in Raozan, answered:

" I get COVID-19 information from mass media, social media, and doctors."

Another key informant Mrs. Shipra Sen, a Fatikchori housewife, expressed her view by saying,

" We obtain most COVID-19 information from television and our neighbors."

5.3.2 Theme 2: Social perception and attitude towards the spread of coronavirus

Thematic analysis of key informants’ opinions also found that their perception of the spread of coronavirus was influenced by some social and behavioral causes. What are the main causes behind the increasing trend of Covid-19 in your locality? What is your observation? While answering these questions during the study, Mrs. Anjana Rani Das, a primary school teacher from Sitakunda, said:

People's unawareness to maintain social distance and participating in social events without wearing masks are the responsible causes for COVID-19.

In response to the question of people’s attitudes to taking action against the rising trend of COVID-19, a Chittagong City opinion leader expressed his thoughts as follows:

People used to say if you watch the news at the start of COVID-19 in Bangladesh, COVID-19 is a disease that only the wealthy suffer from. People who stay in air-conditioned rooms may be affected. This type of superstition, as well as a lack of awareness, may be contributing to the disease's spread.

While answering the question- ‘do people think that wearing masks, sanitizing hands, keeping social distance, and getting vaccinated can prevent the transmission of the virus?’, Aynul Farid, a student from Raozan Upazila, told:

It is now clear to everybody that wearing masks, sanitizing hands, keeping social distance, and getting vaccinated can protect from being infected with the Coronavirus.

On the other side, while they were asked, ‘Are the people of your locality reluctant to wear masks, sanitize hands, keep social distance, and get vaccinated?’, a working person from Raozan Upazila said:

Rural people, especially aged residents, do not believe in COVID-19.

Meaningfully, another opinion leader from the same area opined:

Some people do not have clear ideas and believe in rumors of coronavirus.

5.3.3 Theme 3: Attitude towards local administration, NGOs, and medical systems

As part of controlling the spread of the virus, local authorities have been taking different steps to combat the coronavirus. Promoting health protocols and vaccination in local communities can be an effective strategy to prevent corona. They also believe that mainly NGOs and public health bodies can contribute more to COVID-19 interventions/programs. Further, doctors, nurses, and other staff can do their best to provide COVID-19 health treatments and save lives.

In-depth interviews also found that controlling the virus depends on effective actions by local people and local administration, NGOs, and medical systems towards COVID-19. While asking the key informants ‘Are these enough to reduce the spread of coronavirus’, Md. Mujib, a student from Sitakunda, stated:

The steps like issuing lockdown, making people aware, distributing reliefs and mass vaccination initiated by local administrations were as effective as these activities made the people concerned about the pandemic.

A student from Hathazari, however, emphasized providing sufficient resources and medical equipment for the smooth operation of COVID-19 treatments. He said:

Local medical system is doing better but there is a lack of adequate manpower, equipment, and system.

5.3.4 Theme 4: Practices in health-related behaviors

Key informants opined that practicing COVID-19 preventive measures at personal and societal levels is mostly influenced by some public health behaviors. Interviewees have their hygiene system maintaining handwashing and sanitizing whenever in public contact. Most interviewees stated that they are taking vaccines as a preventive tool. They are also urged to ensure more vaccines for mass people. Personal indifference and misperception of following health safety measures were major reasons for not practicing such health behaviors.

Focusing on health safety measures, such as properly washing hands and mouths, key informants were asked, “Do you maintain personal hygiene?” In response to the question, most of the informants opined that when they are in public interaction, they maintain their hygiene, which includes handwashing and sanitizing. However, there are also opposite views.

“I tried to maintain it earlier, but now it is not being followed in public places”, said a student from Hathazari named Mohammad Salauddin.

While answering the question ‘What personal preventive measures have you already taken or are you practicing’, A working person Mr. Akibul Islam from Hathazari, urging the authorities to ensure more vaccines for mass people, said:

I have already taken two doses of the Corona vaccine. I always wear face masks when I go outside of my home.

‘Do you find people in your locality to practice COVID-19 preventive healthy behaviors and get vaccinated?’ While responding to the question key informants showed a typical view as many people are now conscious and some are practicing preventive health measures. There are also some different views. A working person from Raozan Mr. Forkan Sikdar opined:

I think that 60 percent of people in my locality follow these guidelines. Educated persons are practicing these preventive measures more compared to the uneducated people.

5.3.5 Theme 5: Behave to motivate others

Interviewees also opined that many people did not follow COVID-19 preventive protocols in their community. Several informants mentioned that they often encouraged their colleagues, family members, and friends to wear masks and get vaccinated. However, they were frustrated that community members sometimes ignored these suggestions.

Mr. Zeaul Haque, a banker from Chittagong City, shared his thoughts on how to motivate people and raise social consciousness. He said,

I encourage my customers, relatives, and neighbors to wear masks, wash their hands, and maintain social distance, but maintaining distance in public places is challenging in our heavily crowded country. Coordination between the general public, the government, and concerned citizens is necessary to raise public awareness of COVID-19 illnesses.

Ms. Nuzhat Tabassum, a student and visual artist from Chittagong, proposed making designable and safe masks so that people can be interested in wearing them. She stated,

We should make it a habit to follow COVID-19 health safety rules as part of our daily routine. We may sell colorful and creative masks to appeal to people of all ages, as well as encourage them to use masks to protect themselves from corona.

It is recognized that examining individuals’ attitudes and views on the causes of COVID-19 public health problems might help in proper planning, designing, and implementing risk communication and community engagement interventions. Furthermore, a better grasp of community members’ knowledge, behaviors, and socio-cultural practices is considered an effective intervention to bring positive health outcomes. Under this perspective, the study has better-analyzed individuals' COVID-19-related knowledge, attitudes, and practices (KAP) to encounter the COVID-19 in Bangladesh.

Knowledge is an essential predictor of attitude and behavioral practices. Besides, individuals’ knowledge of COVID-19 contributes to the further development of program plans to promote and maintain public health preventive behaviors in the context of the COVID-19 pandemic. The study has found that a significant portion of people in the studied area have a fair knowledge of COVID-19. However, some gaps in general understanding and practice of the disease have also been revealed. The study shows that several socio-cultural and socioeconomic factors are responsible for that.

Some demographics, especially poorly educated people and people living in rural areas, are less favored than others in getting access to public health benefits such as vaccination and health care. Findings suggest that unequal distribution of COVID-19-related knowledge and unhealthy attitudes and behavioral practices of community members, health service providers, and policymakers mainly discourage individuals from performing expected COVID-19 health behaviors. In this context, the current study provides critical and timely insights into the need for targeted, inclusive, and culturally sensitive health communication strategies to improve COVID-19-related knowledge, attitudes, and practices.

The authors declare that the information provided in this paper is accurate to the best of their knowledge. There were no competing interests in the writing of this article.

Acknowledgements:

The authors are grateful to UNICEF Bangladesh and Bangladesh Betar for coordinating in the work and providing support through granting a fund for the study. The authors are also thankful to research assistants and study participants for their efforts and valuable time.

Data availability:

The data used for this study is available from the corresponding author upon reasonable request.

Ethical Approval

This study adhered to the principles of the Helsinki Declaration—a set of ethical principles for research that involves human subjects. The protocols of the study received approval from the review board established by UNICEF Bangladesh to review the paper and address ethical issues.

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Sociocultural Determinants and Behavioral Risk Factors of COVID-19: A Study of Knowledge, Attitudes, and Practices in Bangladesh

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Abstract

Figures

1 Introduction

1.1 Background

1.2 Significance of the Study

1.3 Objectives

1) Find out the responsible sociocultural causes of the increasing trend of COVID-19,

2) Describe individuals’ practices of maintaining safety measurements of COVID-19,

3) Assess individuals’ level of knowledge, attitude, and practice on COVID-19 vaccines, and

4) Analyze the COVID-19 related behavioral practices of community members

2 Literature Review

3 Theoretical Framework: KAP Model

4 Methods

4.1 Study Area

4.2 Study Design and Sampling

4.3 Data Collection

4.4 Data Processing

5 Findings and Analysis

5.1 Quantitative Findings: Observational Study

5.1.1 Mask Wearing Behavior of Observed People

5.1.2 Handwashing or Hand Sanitizing Practices

5.1.3 Practices towards physical or social distancing

5.1.4 COVID-19 awareness messages, announcements or guidelines

5.2 Quantitative Findings: Vaccination Survey

5.2.1 Knowledge

5.2.2 Attitudes

5.2.3 Practices

5.3 Qualitative Findings: In-depth Interview

5.3.1 Theme 1: COVID-19 related Knowledge, awareness and information

5.3.2 Theme 2: Social perception and attitude towards the spread of coronavirus

5.3.3 Theme 3: Attitude towards local administration, NGOs, and medical systems

5.3.4 Theme 4: Practices in health-related behaviors

5.3.5 Theme 5: Behave to motivate others

6 Conclusion

Declarations

Acknowledgements:

Data availability:

References

Additional Declarations

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