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ORIGINAL ARTICLE Table of Contents  
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Assessment of knowledge and preventive practices towards COVID-19 among tribals living in tea gardens of Eastern India: An analytical cross-sectional study

 Department of Community Medicine, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India

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Date of Submission01-Aug-2022
Date of Decision11-Sep-2022
Date of Acceptance01-Oct-2022


Introduction: The government of India has launched large-scale health education and vaccination campaigns to combat pandemic COVID-19. However, their effects on changing behavior and practices of the very vulnerable tribal communities remain largely unexplored.
Materials and Methods: A cross-sectional study was conducted to obtain COVID-19 knowledge and practice data from 390 households of 10 representative tea gardens of Darjeeling district, chose by cluster random sampling. Heads of each household were interviewed using a questionnaire containing 19 knowledge-related questions and 9 practice-related questions, marked on a 3-point Likert scale. A multivariable linear regression model was fitted to ascertain any association between sociodemographic parameters and participants' knowledge with COVID appropriate behavioral practice.
Results: Most households were led by men and had a per capita monthly income of >INR 3000. The mean age of the respondents was 52.15 ± 10.14 years, with most being employed and having secondary-level education and above. The mean knowledge score was 30.16 ± 2.97, and practice score was 5.68 ± 1.54. The most common source of knowledge was from government and health-care campaigns. While most of the participants followed COVID-appropriate behaviors such as wearing masks and getting vaccine, hand hygiene (33.82%) and social distancing practices (32.05%) were found to be poor. Employment (P = 0.005) and knowledge about COVID-19 (P = 0.016) were significantly associated with a higher practice score.
Conclusions: Among the tribal people assessed, good knowledge about COVID-19 was observed, owing to government efforts. However, while some COVID-appropriate behavior was widely adopted, hand hygiene, and social distancing were not.

Keywords: Attitudes, COVID-19, health knowledge, health services, indigenous, practice, preventive medicine

How to cite this URL:
Samanta S, Biswas D, Sarkar P, Bandyopadhyay A. Assessment of knowledge and preventive practices towards COVID-19 among tribals living in tea gardens of Eastern India: An analytical cross-sectional study. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Oct 4]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=359958

  Introduction Top

Since December 2019, the pandemic COVID-19 has spread rapidly across the world, infecting and killing millions in its wake.[1] To prevent its spread, governments across the world have adopted different policies ranging from nationwide and regional lockdowns, mass vaccination campaigns, close monitoring and management of communities, and isolation of the infected people.[2] However, these the mainstay of these has been intense public health education campaigns, to encourage adoption of preventive practice, termed “COVID-19 appropriate behaviors” by the general public.[3]

Among the Asian countries, India has been hit especially hard in the current pandemic. As of July 2021, the country had the world's second-highest COVID-19 case burden and the third-highest number of deaths due to the disease.[4] To stave off the unfettered spread of the virus throughout the country the Indian government has conducted a massive country-wide vaccination drive. Through its robust public health infrastructure, the government has also run a pan-India information campaigns through telephone ringtones, mobile applications, and mass media campaigning.[5]

While the outcomes of these measures on the educated urban populace of the country have been studied, their effect on the hard-to-reach tribal communities of India is still largely unknown.[6] Tribal populations have very different healthcare requirements and needs as compared to their nontribal counterparts. Thus, their response to health programs and campaigns which are primarily targeted toward the general population are also different.[7] Campaigns that might work extensively well among the general population thus might work poorly or not at all among the tribal population.[8] This coupled with a chronic disenfranchisement from socioeconomic and health-care benefits make them especially vulnerable to the effects of a highly transmissible disease like pandemic COVID-19.[9] This is evident by research done a priori, which has shown that the most deprived and vulnerable populations, such as ethnic minority groups, those with low socio-economic and educational backgrounds, and those lacking access to healthcare have been affected the most by COVID-19.[10],[11] Thus, periodic assessment of the effects of health education campaigns in changing the practices of tribespeople living in remote parts of the country is essential to reduce the burden of any communicable disease, especially a fast-spreading one like COVID-19.

In this context, the current study aims to assess the existing knowledge and associated practice regarding the prevention of COVID-19 among tribespeople living in and around the tea gardens of rural Eastern India.

  Materials and Methods Top

Study setting and study population

The present study was conducted in the hilly district of Darjeeling, West Bengal, which is home to 86 operational tea gardens. Each of these tea gardens has an associated village community adjacent to it. The families living in these villages are mostly formed of people from different tribes, who in turn form around 8.4% of the total population of the district.[12] Remoteness of these communities, difficult terrain, poor socioenvironmental conditions, and chronic lack of socio-economic and health-care infrastructure makes it very difficult to prevent and control various communicable and noncommunicable diseases once they have taken hold in the community.[13]

Study design and sample

An observational analytical cross-sectional study was conducted from August 2021 to December 2021. A cluster sampling methodology was adopted for the present study to obtain a representative sample of population the tea gardens of the district. As the 86 operational gardens are spread over large distances are separated from each other by difficult, hard-to-access terrain, and house around 120,000 people, a cluster sampling method was deemed appropriate to obtain the sample for the present study. The prevalence of good COVID-19 appropriate behavior was considered to be the outcome variable and the sample size was estimated considering a 90% confidence level. Based on a previous study done among the general population in a different state of India, the prevalence of good COVID-appropriate behavior was taken as 77%, with a 10% margin of error.[14] A complex sample design effect of 2 was applied to obtain the final sample size of 382. Each village associated with a tea garden was considered a single cluster, and 10 randomly selected tea gardens from 86 working gardens were selected as primary sampling units. From each of the selected gardens, a systematic random sample of 39 households was selected.

Data collection and statistical analyses

Responses assessing knowledge about COVID-19 were obtained from the head of the households using a researcher-administered questionnaire consisting of 19 knowledge-related questions. Each of the knowledge-related questions was scored using a 3-point Likert scale. Excepting question number 2 (causative agent of COVID-19) which was scored as virus – 2, bacteria/parasite/insects/others – 1, and do not know – 0; question 15 (does COVID-19 spread through consumption of food?) which was scored as yes – 0, do not know – 1, and no – 2; and the remaining 17 questions were scored as yes – 2, do not know – 1, and no – 0. Their practice regarding COVID-19 appropriate behavior was assessed using 9 practice-related questions, which were scored as Yes – 1 and No – 0. The questions regarding COVID-19 appropriate behavioral practices were based on the information booklets resources maintained and widely circulated by the Government of India.[15] The scores were tallied into two groups, knowledge regarding COVID-19, and practice of COVID-19-appropriate behavior. The higher the score that a household obtained on the scale, the better their knowledge and practice regarding the disease. The questionnaire was validated by three independent experts in the field, and then a pilot study was conducted in one of the tea gardens of the adjacent Jalpaiguri district.

The collected data were entered into a spreadsheet, analyzed using Statistical Package for the Social Sciences (b. 25, IBM Corp. Armonk, New York), and reported using mean ± standard deviation. A multivariable linear regression analysis was performed using the COVID-appropriate behavior practice scores as dependent variable and the various sociodemographic characteristics (age, sex, education, employment status, per capita monthly income, regularity of visiting health-care institutions, and knowledge regarding COVID-19) as independent variables. A P < 0.05 was considered to be statistically significant.

Ethical issues

Appropriate permissions were obtained from the institutional ethics committee of a local tertiary care medical college and hospital as well as the authorities of each individual tea gardens where the study was conducted. The respondents of each household provided written informed consent to take part in the study, and the information provided by them was de-identified, and confidentiality was ensured.

  Results Top

Of the 390 respondent households, 68.21% were headed by men. The mean age of the respondents was 52.15 ± 10.14 years. Most of them were employed (56.92%), in different capacities at the tea gardens adjacent to which they lived as well as at different jobs in other villages or towns. The per capita income for less than a third (26.15%) of the respondents' families was below INR 3000 per month (~ USD 40) or the lower socioeconomic status as per the modified B.G. Prasad Socioeconomic Classification of the Indian populace.[16] On the assessment of the educational qualifications of the participants, it was seen that most of the participants had completed secondary level education (43.85%), however, there was also a high percentage of participants who were illiterate or had nonformal schooling [Table 1].
Table 1: Sociodemographic characteristics of the participants (n=390)

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Regarding the knowledge about COVID-19, the total possible score that could be obtained by a participant was 38. The mean score obtained was 30.16 ± 2.97, with a minimum score of 13 and a maximum of 37. The participants responded that they acquired their knowledge about the disease from the governmental mass media campaigns (50.77%), through local health-care workers (63.08%), newspapers (29.74%), messages regarding the disease that were provided by all of the major mobile carriers as their caller tunes during the pandemic under the orders of the Department of Telecommunications of the Government of India (80.51%),[17] and televisions (42.05%).

While 87.69% of the participants knew about the communicable nature of the disease, only 32.56% could respond that it was caused by a virus. Regarding the symptoms associated with the disease, majority of the participants could identify fever (82.31%) and cough (96.92%) to be the primary presenting symptoms. A comparatively lesser number of participants identified sore throat (67.69%), body ache (67.69%), and loss of smell (75.64%) while very few participants knew of the gastrointestinal manifestations of the disease (27.85%). It was seen that most of the participants knew the importance of visiting the nearest health-care facility (83.85%) if identified with the infection. Furthermore, 83.85% of the participants knew about the availability of the vaccines against the disease, and 80% responded that these vaccines were effective.

Knowledge about the mode of spread of the disease was adequate among the participants, with 71.79% knowing that the disease spread via coughing, and 52.31% responding that it does not spread from food consumption. However, only 35.90% knew about the role of fomites. Therefore, expectedly, only 47.95% of the participants responded that they knew that regular hand washing helped prevent the spread of COVID-19, while on the other hand, 95.64% of them knew about the importance of wearing [Table 2].
Table 2: Score obtained by the participants in questions related to knowledge and practice regarding COVID-19 disease

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The total possible score for the COVID-19 appropriate behavior questions was 9. The mean score obtained by the participants was 5.68 ± 1.54. When asked, most participants responded that they (93.33%) and all of their eligible family members (92.56%) have taken at least one dose of the COVID-19 vaccine. Similarly, a high percentage of the respondents said that they regularly wore facemasks to prevent COVID-19 infection (96.15%).

While most respondents said that they regularly washed their hands with water (76.15%), only 44.36% said that they used soap during handwashing, and even lesser percentage (32.82%) said that they regularly practice handwashing to prevent the spread of COVID-19. Social distancing practices were similarly poor, with only 32.05% of the respondents saying that they maintain 6 feet distance while talking to another person and 36.41% saying that they avoid large crowds. Comparatively higher percentage (64.36%) of the participants, however, responded that they regularly cover their mouths and noses while coughing and/or sneezing [Table 2].

On running a multivariable linear regression model with practice scores as outcome variable and age, sex, occupation, education, and socio-economic status as predictors, it was seen that those currently employed scored significantly higher (P = 0.005) in the scale than their unemployed counterparts, as did those who scored high on the knowledge scale (P = 0.016). It was observed, however, that the model explained only 14.1% of the variations observed in the practice scores, indicating that there exist many other predictors of good COVID-19-appropriate behavior in the community that needs to be explored in further research [Table 3].
Table 3: Multivariable linear regression showing the determinants of the practice score of the participants (n=390)

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  Discussion Top

COVID-19 has had hampered the lives and the livelihoods of millions of people across India, including those in the tribal communities. Given the massive infection and death tolls it has exacted, proper knowledge about the disease and prompt adoption of preventive measures by members of all social strata is essential in stymying the progression and preventing resurgence of the pandemic. The current study assessed the knowledge and practice regarding COVID-19 and its prevention among the rural tribal population of Eastern India, who, historically have lived in the remotest parts of the country and have suffered from a chronic lack of socioeconomic support and health-care services.[9] This study therefore indirectly ascertains the effects that the governmental behavioral change communication (BCC) campaigns have had on the knowledge and practice of the rural tribal populace, who have been a major target of these interventions so as to prevent the endemicity of the disease and further outbreaks in these areas.[18]

The mean knowledge score of 30.16 ± 2.97 out of a possible 38 among the study participants indicates that most of the participants were quite knowledgeable about the disease and preventive behaviors. This can be attributed to the regular BCC campaigns conducted in these areas by the local health-care workers and the governmental telephonic advisories, which were the two major sources of information regarding the disease.[18] Good knowledge regarding COVID-19 owing to intensive government and health-care campaigns is not uncommon, as have been evidenced by research done in other parts of the world as well as in studies exploring the knowledge, attitudes, and practices of the Indian general population.[19],[20] However, the participants lacked details of the disease, particularly about the cause of COVID-19, and gastrointestinal manifestations of the disease. Furthermore, one important area where majority of the participants lacked knowledge was the utility of handwashing in the prevention of the spread of COVID-19. This needs immediate remediation, as handwashing is one of the most important prevention modalities for COVID-19, and the relevance of it in the global control of the pandemic cannot be understated.[21]

Practice regarding COVID-19 appropriate behavior was also observed to be adequate, which was directly correlated with the good knowledge of the participants. An important finding of the study was the relationship between the knowledge about the effectiveness of COVID-19 vaccine among respondents, and associated practice regarding it. Most of the participants knew that the vaccines were effective, and they and all eligible members of their families had taken at least one dose of the same. Furthermore, even when 16.67% of the participants responded that they did not think that vaccines against the disease were effective, 93.33% of participants still took the vaccine, providing evidence as to the effectiveness of the vaccination campaign launched and sustained by the health-care workers in the area.[22] Important to note, however, was the lack of proper handwashing and social distancing practices among the respondents. Poor hand hygiene practices can be explained by the poor knowledge about the same.[21] The observed lack of social distancing practices despite intensive education campaigns has to be addressed, as it creates an avenue of further outbreak and spread of the disease in the community. This is especially true for the new and emerging strains of the virus, which might not always be prevented through vaccination.[23] Poor hand hygiene, poor social distancing along with a comparatively poorer cough etiquette practice may further lead to the spread of other infectious diseases such as tuberculosis, influenza, soil-transmitted helminths, and feco-orally transmitted diseases like diarrhea, which have also been quite prevalent among rural tribal communities historically.[24],[25]

Finally, it was observed excepting employment status, none of the other socio-demographic factors were significantly associated with COVID-appropriate practice behavior. This might be due to the community characteristics of the population. As mentioned earlier, tribal people from this hilly region of India live in close-knit communities in remote villages and therefore have significantly less exposure to the outside communities as compared to their nontribal counterparts except through employment, for which some have to travel to the nearby villages and cities sometimes.[12] Thus, employment provides a proportion of the population with more exposure to governmental and other health-care campaigns as well as with other communities that have adopted more stringent COVID-appropriate behaviors. In turn, they and their families might also adopt such behavior, which was reflected in the current study.

  Conclusions Top

The study found that among the tribal people living in the remote hilly areas of Eastern India, the majority had good knowledge regarding COVID-19 disease, which along with employment was positively associated with better adoption of COVID-19 appropriate behavioral practices. While most of the participants scored adequately on the COVID-appropriate behavior scale overall, important preventive measures such as hand hygiene practices and social distancing norms were not adopted by many in their daily life, which needs sustained and targeted action from the local and the national levels of administration.

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Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Alapan Bandyopadhyay,
Woodland Park Apartments, Sushruta Nagar, Darjeeling - 734 012, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_69_22


  [Table 1], [Table 2], [Table 3]


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