Journal of Surgical Specialties and Rural Practice

: 2022  |  Volume : 3  |  Issue : 2  |  Page : 25--30

Knowledge, attitude, and practice regarding COVID-19 with emphasis on the rural: Urban divide in Tamil Nadu, India

S Suganathan Soundararajan, K Suvetha Kanppan 
 Department of Community Medicine, PSG Medical College and Research Institute Coimbatore, Coimbatore, Tamil Nadu, India

Correspondence Address:
S Suganathan Soundararajan
Department of Community Medicine, PSG Medical College and Research Institute Coimbatore, Coimbatore, Tamil Nadu


Background: There is the scarcity of population-based studies on knowledge, attitude, and practice (KAP) about COVID-19 in Tamil Nadu and no literature on the rural-urban differences in KAP about COVID-19 in Tamil Nadu. Aims and Objectives: The study was conducted with the primary objective of estimating KAP regarding SARS-COV2 virus in Tamil Nadu and secondary objectives of determining the rural-urban differences in KAP and identifying the association between KAP and certain sociodemographic factors. Materials and Methods: An analytical cross-sectional study was done on 305 participants selected from the rural and urban population of Tamil Nadu. Urban data were collected using Google Forms through social media and the rural population data were collected through simple random sampling from three villages in the outskirts of Chennai District. The study tool had ten items to evaluate the knowledge, three items to evaluate the attitude and four items to evaluate the practice regarding COVID-19. Results: The overall KAP scores had a mean of 7.88 out of 10 (78.8%) for correct knowledge, 2.51 out of 3 (83.5%) for positive attitude, and 3.68 out of 4 (92%) for good practice. The knowledge score was slightly higher in the urban region, but the mean practice score (P ≤ 0.001) and attitude score (P < 0.001) were significantly more among the rural population. There was a statistically significant association between higher knowledge score and educational status (P = 0.0000001), male gender and better attitude (P = 0.0052) and higher age (>40 years) and better practice (P = 0.014). Conclusions: The study revealed reasonably good levels of KAP in regard to COVID-19 in Tamil Nadu in both the urban and rural populations.

How to cite this article:
Soundararajan S S, Kanppan K S. Knowledge, attitude, and practice regarding COVID-19 with emphasis on the rural: Urban divide in Tamil Nadu, India.J Surg Spec Rural Pract 2022;3:25-30

How to cite this URL:
Soundararajan S S, Kanppan K S. Knowledge, attitude, and practice regarding COVID-19 with emphasis on the rural: Urban divide in Tamil Nadu, India. J Surg Spec Rural Pract [serial online] 2022 [cited 2022 Sep 27 ];3:25-30
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Full Text


On March 12, 2020, the World Health Organization declared that the COVID19 outbreak is a pandemic. The pandemic has lingered and has had a hefty toll on health-care professionals, families, communities, and the whole world.[1] It is known that COVID-19 can spread to humans through an intermediate host such as bats, or from human-to-human, through respiratory droplets and body contact.[2] With its advent in India, the Government of India declared a nationwide lockdown on March 22, 2020, intending to curb the spread of this virus in the country.[3] Large numbers of people are illiterate, isolated, migrants, live remotely and are below the poverty line, struggling hard for their daily needs and are raising the government's concern during the lockdown.[4] Knowledge, attitude, and practice (KAP) surveys are commonly used to identify knowledge gaps and behavioral patterns among sociodemographic subgroups to implement effective public health interventions.[5] As research into COVID-19 continues, a lot of the facts keep on changing and many myths are also prevalent in the general population regarding the prevention and management of the infection. In the time of widespread use of social media, these myths, along with fake news around SARS Cov-2 virus are also spreading rapidly.[6] However, the problem to break the chain of transmission of COVID-19 and mortality becomes more complex in reaction to a lack of awareness of scientific treatment line, and a lack of sound knowledge and experience among health personnel to manage such infectious diseases in the past.[7] A study done in Bangladesh suggested that compared to urban, rural residents are at a particularly high risk of COVID-19 because they were found to have significantly lower knowledge and practice levels than were urban residents.[8] Similar studies were lacking in India, especially in Tamil Nadu and hence, a study was taken up with the primary objective of estimating KAP regarding corona in Tamil Nadu and with the secondary objectives of comparing KAP regarding corona between the rural and urban population in Tamil Nadu and to determine the association between KAP and certain sociodemographic variables.

 Materials and Methods

Study design

The study design was an analytical cross-sectional study. The analytical component was used to identify the association between the KAP levels regarding corona between the urban and rural populations.

Study population and sampling method

The study population was selected from both the urban and rural populations of Tamil Nadu. The stratified random sampling method was used; data collection for the urban population was done using an online survey done through Google Forms on social media and data collection from the rural population was done using simple random sampling from three villages in the outskirts of Chennai.

Sample size

A multicenter study done in five centers in Tamil Nadu and Pondicherry[9] found that the knowledge scores in percentage were 82%. The sample size was calculated using the formula:

[INLINE:1], where L = 8% of P = 6.56


Since stratification was done based on area, it was decided to study double the sample size, and finally, a sample size of 305 was achieved, of which 151 were from the rural population and 154 were from the urban population.

Study population

All adults >18 years of age were included in the study after obtaining informed consent.

Inclusion and exclusion criteria

All adults ≥18 years of age who were willing to participate in the study were included in the study. Those below 18 years of age and those with disabilities that would interfere with their participation in the study were excluded from the study.

Study period

Urban data collection was done between April and June 2021, and rural data collection was done between June and August 2021.

Study tool

A structured questionnaire was created after reviewing literature, and a pilot testing was carried out, during which time two questions that were found to be difficult to comprehend were removed from the study. The final questionnaire had 10 questions on knowledge, three on attitude, and four on practice regarding corona, and there was one picture-based question on their personal preference between cloth masks and surgical masks. The study questionnaire was translated into the regional language, which was Tamil, for use during the rural data collection. The questions either had “yes,” “no,” “I don't know options” or “agree,” “disagree” options. While calculating the overall scores, all the correct answers and positive responses were given 1 mark each, and all wrong answers and negative responses were given 0 marks. The overall knowledge score was out of 10, the overall attitude score was out of 3, and the overall practice score was out of 4.

Ethical considerations

The study was approved by the Institutional Ethics Committee of PSG Institute of Medical Sciences and Research, Coimbatore, and informed consent was obtained from all participants.

Data analysis

Data were analyzed using SPSS Version 28. Mean scores were calculated for the KAP components along with standard deviation and Pearson Chi-square values were used to find differences in KAP between rural and urban areas for individual items. t-tests were calculated to identify differences in the overall mean KAP scores between rural and urban areas. Odds ratios (OR), 95% confidence interval of the OR and P values were calculated using Epi Info version for the associations between sociodemographic parameters and overall KAP scores which were classified as above their mean value or otherwise for each component.


An analytical cross-sectional study was conducted among the rural and urban populations of Tamil Nadu to measure and compare the KAP regarding COVID-19 between the two populations and to compare the differences between the two populations and the following observations were made. A little more than two-thirds of the population belonged to the18–40 years of age group and there was a significant difference between the age distribution of the rural and urban population. The urban population had an equal number of men and women, but in the overall population, there were more men (58.7%) when compared to women. Illiterates were more among the rural population (13.9%), whereas professionals were more among the urban population (41.6%). It was seen that a greater number of unmarried people were from the urban population (40.3%). Details are shown in [Table 1]. It was seen that the mean scores were quite high for correct knowledge (7.88 out of 10), positive attitude (2.51 out of 3), and good practice (3.68 out of 4). Knowledge scores were slightly higher among the urban population (79.8%) when compared to the rural population (77.8%), but the attitude and practice scores were significantly higher in the rural population when compared to the urban population. Details are shown in [Table 2] and [Table 3]. [Table 4] shows the differences between rural and urban populations in the individual question correct responses for the various items in the knowledge section. Knowledge on main symptoms was significantly higher (P < 0.001) among the rural population when compared to the urban population as was knowledge on noninfluence of nonvegetarian diet (P < 0.001), the role of mask use (P = 0.01), and the importance of avoiding crowded places (P = 0.045). Knowledge on the high-risk groups was significantly higher among the urban population (P < 0.001). [Table 5] shows that the rural population had a more positive attitude regarding corona control when compared to the urban population. [Table 6] shows that the rural population was better with regard to avoiding crowded places (P = 0.004), frequent hand sanitization (P = 0.023) and leaving the house less frequently when avoidable (P < 0.001). [Figure 1] shows the results of the picture-based question on the preference of cloth mask versus triple-layer surgical mask and the rural population preferred cloth mask more than the triple-layer surgical mask; in the urban population, there was almost equal number of preferences for both masks and this difference between the rural and urban population was statistically significant (P = 0.002). [Table 7], [Table 8], [Table 9] show the association between sociodemographic profile and the overall population KAP scores were calculated by dividing the scores based on the mean value as above mean score or less than or equal to the mean score. It was seen that there were higher knowledge scores (above mean score, >7.88) was 3.69 times more among those with higher qualifications (≥high school) and the association was statistically significant (P = 0.0000001). Better attitude scores (above mean, >2.51) were 1.96 times more among males (P = 0.0052) and better practice scores (above mean, >3.68) were 2.13 times more (P = 0.014) among higher ages (>40 years) when compared to the younger age group. Better practice scores (above mean, >3.68) were 3.99 times more (P = 0.0000056) than people with lower education (<high school) when compared to those who had more education.{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Figure 1}


This analytical cross-sectional study done on the rural and urban population of Tamil Nadu revealed that the overall KAP was quite high at 78.8%, 83.5%, and 92%, respectively. The results were comparable to a study done in Rajasthan[10] among the urban population, which found that 81.12% and 76.15% of the participants had average and good knowledge and practice. The rates of the current study are more than that found by a study done in Ethiopia among Hospital visitors, which found that 69.3% had good knowledge, 62.6% had a positive attitude, and only 44.6% had good practice with regard to corona, the difference could be because of the difference in population types, the current study was done in Tamil Nadu which has high literacy rates in both Urban (87.04%) and Rural (73.54) as per the 2011 census[11],[12] results. When it came to rural-urban differences, the current study showed that though the knowledge was slightly higher in the urban population, positive attitude and good practices were significantly more among the rural population; this was different from the results of a study done in Bangladesh[8] that concluded that the knowledge levels and practice levels were significantly lower among the rural population (P = 0.001 and P = 0.002, respectively). A study done in Pakistan[13] also concluded that knowledge was 2–7 times higher, and practice was 4–5 times better among the urban residents when compared to the rural residents and a study done in China[14] found that good practice was significantly higher among the urban residents when compared to the rural residents. The differences could be because of the difference in population types. The current study showed that there was a highly statistically significant association between educational status and higher knowledge scores (P = 0.0000001), and this was comparable with a study done on antenatal women in Northwest Ethiopia[15] also found that those with college education and above 7.78 times more likely to have good knowledge scores and also a study done on the urban population of Rajasthan[10] found a statistically significant association between good knowledge scores and educational status of higher secondary and above which was also similar to the findings of the current study. According to the current study, 76.5% of the rural population and 67.5% of the urban population stated that the Indian Government was handling the crisis well; the rates were slightly lower than those found by a study done in Malaysia,[16] in which 89.9% were happy with the way the Malaysian Government was handling the crisis. A study done in Indonesia[17] revealed that only 48.7% of the participants agreed that the Indonesian Government was handling the crisis well; this was lower than the rates found in the current study.


The socioeconomic status and the sources of information regarding COVID could not be used in the current study as there was a lot of missing data in the online data collected as the participants revealed that they were not comfortable revealing their salary in an online survey.


The study showed that the overall KAP scores regarding COVID-19 were quite high and that positive attitude and good practice were significantly higher in the rural population when compared to the urban population. The study showed that educational status was significantly associated with higher knowledge scores.


Thanks to the Department of Community Medicine for making This study successful The article was not presented in any meeting as oral or paper presentations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Naser AY, Dahmash EZ, Alsairafi ZK, Alwafi H, Alyami H, Jalal Z, et al. Knowledge and practices during the COVID-19 outbreak in the Middle East: A cross-sectional study. Int J Environ Res Public Health 2021;18:4699.
2Abazid H, Basheti IA, Al-Jomaa EE, Abazid A, Kloub WM. Public knowledge, beliefs, psychological responses, and behavioural changes during the outbreak of COVID-19 in the Middle East. Pharm Pract (Granada) 2021;19:2306.
3Quansar R, Dhkar SA, Saleem SM, Khan SM. Attitude and practices related to coronavirus disease (COVID-19) pandemic among pregnant women attending family welfare clinic amid Phase-2 lock down. J Family Med Prim Care 2020;9:6085-90.
4Singh AK, Agrawal B, Sharma A, Sharma P. COVID-19: Assessment of knowledge and awareness in Indian society. J Public Aff. 2020 Aug 27:e2354. doi: 10.1002/pa.2354. Epub ahead of print. PMID: 32904779; PMCID: PMC7460945..
5Lee M, Kang BA, You M. Knowledge, attitudes, and practices (KAP) toward COVID-19: A cross-sectional study in South Korea. BMC Public Health 2021;21:295.
6Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.
7Kumar R, Singh V, Mohanty A, Bahurupi Y, Gupta PK. Corona health-care warriors in India: Knowledge, attitude, and practices during COVID-19 outbreak. J Educ Health Promot 2021;10:44.
8Rahman MS, Karamehic-Muratovic A, Amrin M, Chowdhury AH, Mondol MS, Haque U, et al. COVID-19 epidemic in Bangladesh among rural and urban residents: An online cross-sectional survey of knowledge, attitudes, and practices. Epidemiologia 2020;2:1-13.
9Christy JS, Kaur K, Gurnani B, Hess OM, Narendran K, Venugopal A, et al. Knowledge, attitude and practise toward COVID-19 among patients presenting to five tertiary eye care hospitals in South India – A multicentre questionnaire-based survey. Indian J Ophthalmol 2020;68:2385-90.
10Pareek S, Kaushik NK, Verma D, Pareek A, Ramawat Y, Kumawat N, et al. Assessment of knowledge and practices of urban population regarding COVID-19: A cross-sectional study in Bikaner, Rajasthan. Int J Community Med Public Health 2020;7:3095.
11Belete ZW, Berihun G, Keleb A, Ademas A, Berhanui L, Abebe M, et al. Knowledge, attitude, and preventive practices towards COVID-19 and associated factors among adult hospital visitors in South Gondar Zone Hospitals, Northwest Ethiopia. PLoS One 2021;16:1-18.
12Singh V. Urban and rural literacy in India : A geographical analysis. Int J Res Analytical Reviews 2019;6:437-43.
13Fatmi Z, Mahmood S, Hameed W, Qazi I, Siddiqui M, Dhanwani A, et al. Knowledge, attitudes and practices towards COVID-19 among Pakistani residents: Information access and low literacy vulnerabilities. East Mediterr Health J 2020;26:1446-55.
14Yue S, Zhang J, Cao M, Chen B. Knowledge, attitudes and practices of COVID-19 among urban and rural residents in China: A cross-sectional study. J Community Health 2021;46:286-91.
15Degu A, Nibret G, Gebrehana H, Getie A, Getnet B. Knowledge and attitude towards the current pandemic corona virus disease and associated factors among pregnant women attending antenatal care in Debre Tabor General Hospital Northwest Ethiopia: An institutional-based cross-sectional study. Int J Womens Health 2021;13:61-71.
16Azlan 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.
17Sulistyawati S, Rokhmayanti R, Aji B, Wijayanti SP, Hastuti SK, Sukesi TW, et al. Knowledge, attitudes, practices and information needs during the COVID-19 pandemic in Indonesia. Risk Manag Healthc Policy 2021;14:163-75.