Coronavirus disease (commonly known as COVID-19 or formerly known as the novel-coronavirus [2019-nCOV]) was first reported in Wuhan, China in December 2019 (Azlan et al., 2020). Since then, it has spread to over 200 countries and was declared a global controllable pandemic by the World Health Organization (WHO) on March 12, 2020 (WHO, 2020). Some of the common signs of COVID-19 include fever, cough, shortness of breath, and breathing difficulties (Abdi, 2020). As of June 9, 2020, more than 10 million positive COVID-19 cases have been recorded, with at least 502,000 deaths (John Hopkins University, 2020).
The first case of COVID-19 in the Philippines was recorded on January 30, 2020, while two more cases were confirmed in February 2020. Seven new patients tested positive between March 6 and March 8, 2020, including the first cases of local transmission. These cases were traced back to a mosque within a local shopping center in San Juan City in the NCR. On March 7, 2020, Philippine health authorities raised a Code Red alert after it confirmed the transmissions (ABS-CBN News, 2020). A Code Red alert is a “preemptive call to ensure that the government and public and private health care providers can prepare for a possible increase in suspected and confirmed cases" (Department of Health, 2020). The Philippine government then placed the entire country under a state of public health emergency because of the COVID-19 threat (Official Gazette, 2020).
Several days later, the government decided to raise the COVID-19 Alert System to Code Red sublevel 2 and imposed a Community Quarantine (CQ) in the entire NCR to control the spread of the virus (Panelo, 2020). The CQ restricted many non-essential activities and movements outside the home similar to lockdowns implemented in China and Italy.
However, by the second day of the CQ, the government decided to enforce a 15-day Enhanced Community Quarantine (ECQ) measure in the entire Luzon, which includes 38 provinces and the NCR, which was supposed to end on April 12 (Lopez, 2020). On April 7, the ECQ was extended in the entire Luzon until April 30 (Patag, 2020). On April 24, the government announced the extension of ECQ in the NCR, Region 4A (composed of the provinces of Cavite, Laguna, Batangas, Rizal, and Quezon), Central Luzon (except Aurora), and other areas in Luzon that were deemed high-risk for COVID-19 until May 15 (Lopez, 2020). Other provinces were placed in a less strict community quarantine category.
From May 16-31, the NCR was placed in a modified ECQ until May 30 (together with Laguna in CALABARZON and Cebu City in the Visayas), which allowed more businesses to open following strict social distancing measures. The following month, the NCR was placed in general community quarantine (GCQ), which further eased movement restrictions.
As of June 1, 2020, the Philippines has recorded more than 18,000 cases including 960 deaths and 3,979 recoveries (Tomacruz, 2020a). By June 15, 2020, the number of confirmed cases surpassed 26,000, with 1,098 deaths, and 6,252 total recoveries (Tomacruz, 2020b).
The employment sector is one of the areas most severely affected by COVID-19. More than two million Filipino workers were displaced due to the quarantine measures, according to the country’s Department of Labor and Employment (CNN Philippines, 2020a). Approximately 1.4 million of these people were displaced due to temporary closures of establishments, while more than 600,000 workers reported reduced income due to modified working arrangements. The NCR, which is considered the epicenter of the pandemic in the country, recorded the highest displacement with 687,634 affected workers (Ramos, 2020). This is the reason why thousands of workers reported back to their workplaces after the NCR transitioned to a more relaxed GCQ, despite the continuing threat of COVID-19 (CNN Philippines, 2020b).
The knowledge, attitudes, and practices (KAP) toward COVID-19 play an important role in determining a society’s readiness to receive and adapt to behavioral change measures from the government (Azlan et al., 2020). Thus, the objective of this study was to understand the KAP of COVID-19 among employed people in the NCR, Philippines. Several studies examining KAPs on COVID-19 have been conducted, but there is a need to understand it from the perspectives of the employees in the NCR who have been braving the threat of COVID-19 to meet the daily needs of their families. Assessing this would be helpful to provide insights on the level of knowledge about the virus among employed Filipinos in the NCR, and what government strategies or policies are favorable to the members of the employment sector.
Methodology
Study Design
A quantitative approach through an online survey was employed, which was deemed most appropriate considering the restrictions imposed during the GCQ. This gave easier access among target respondents, without sacrificing social distancing measures. Data collection was performed online using Google Forms, and the invitation to participate was posted and shared on social media.
The survey was conducted in the first week of the imposition of the GCQ in the NCR, between June 4-18, 2020. Applying a systematic sampling technique was not feasible during this period due to no available data on the actual number of employed people in the NCR as of May 2020; so the researchers used non-probability sampling to conduct the survey. People who are employed and who are residing or working within the NCR and are above the age of 18 were eligible to participate in the online survey. The researchers used different strategies to reach as many respondents as possible. Facebook was primarily used to disseminate the survey online. This platform was selected as it was the most visited social media site in the country (Gonzales, 2019). Only 107 respondents took part in the survey. However, seven of them were excluded as they were not employed when they answered the survey.
Survey Instrument
The survey instrument used in the study was adapted from the questionnaire developed by Erfani et al. (2020) on the knowledge, attitude, and practice toward the Novel Coronavirus (COVID-19) outbreak in Iran. The questionnaire was composed of four main themes, namely: 1) demographic profile of the survey respondents, including gender, educational attainment, employment status, monthly income, and employment sector; 2) knowledge about COVID-19; 3) attitude toward COVID-19; and 4) practices related to COVID-19.
To measure the knowledge about COVID-19, 15 questions were adapted from previous research. These included the respondents’ knowledge of the characteristics of the disease, symptoms, and prevention of COVID-19. Three questions were multiple responses: symptoms, transmission, and vulnerable sectors. In total, there were 26 items used for the analysis (including separate items for the multiple response questions). Correct answers were assigned 1 point, while incorrect/not sure responses were assigned 0 points. The maximum total score ranged from 0-26. The knowledge scores were categorized as low (scores 8 and below), moderate (scores 9 to 17), or high (scores 18 and above).
To measure attitudes towards COVID-19, 13 items were adapted from previous research, while seven questions were added by the researchers concerning the government’s preparedness and the imposition of community quarantines. Surveyed respondents were asked to evaluate their attitude towards the disease, and the way the government handled the COVID-19 crisis. To measure practices, 10 items were adapted from previous research, and an additional question was asked about social distancing. Respondents were asked how frequently (all the time, most of the time, some of the time, occasionally, or none of the time) they took several measures to prevent contracting and spreading COVID-19. They were also asked about their source of information about COVID-19, and how many times they left of their homes in the past seven days to buy food or medicine, conduct financial transactions, or go to work.
The first part of the online survey contained the informed consent form. All the respondents were duly informed before the collection of the data that they could refuse to answer any question, withdraw from the survey at any point in time without any harm, and that all data would remain confidential. The online survey form strictly adhered to the provisions of the Data Privacy Act. Respondents who gave consent to participate in the survey were asked to click the “submit” button and were directed to the survey proper.
Statistical Approach
Frequencies and percentages were computed, while Kruskal-Wallis was used to find out if there are differences between groups for gender, educational attainment, employment status, monthly income, and employment sector. The statistical significance level was set at p<.05.
Results
Demographic Characteristics
One hundred respondents participated in the study. Of the total, 63% were women, 57% were college graduates, 85% were regular/permanent employees, 28% earned more than Php25,001 ($512US) monthly, and 84% were employed in the private sector. Other demographic characteristics are detailed in Table 1.
COVID-19 Knowledge
A total of 26 items were analyzed to measure the knowledge on COVID-19. The average knowledge score for the respondents was 20.5 (SD = 2.14, range 13-25). Based on the results of the survey, 92% of the respondents had high knowledge about the disease, obtaining scores between 18 and 24. About 8% had moderate knowledge of COVID-19 (scores 13 to 17).
As shown in Table 3, most respondents knew that an infected person must be incubated for 3 to 14 days (95%) and that the disease is more dangerous among people aged 50 and above (89%). However, there was a noticeable confusion among the respondents on how COVID-19 can be treated. About 65% of the respondents believe there is no treatment for COVID-19, while 11% answered symptomatic therapy. Around 9% said that antibiotics are a treatment for COVID-19. Although no vaccine and treatment for COVID-19 are currently available, present treatment of the disease is symptomatic (Cascella et al., 2020). WHO recommends that patients with mild COVID-19 be provided with symptomatic treatment such as antipyretics for fever (WHO, 2020).
In terms of symptoms of the disease, most of the respondents answered fever (97%), cough (94%), and sore throat (96%). About 75% of the respondents answered body pain, 66% said headache, and only 56% chose diarrhea.
In terms of transmission, 99% were able to identify physical contact such as handshaking, hugging, and kissing as a transmission route, followed by coughing (92%), and contact with infected surfaces (90%). However, 22% believed the consumption of contaminated dairy and meat was a transmission route. The results of this survey are significantly important, as the selected employees were able to appropriately identify possible transmission routes of COVID-19. In a survey conducted by the International Care Ministries (2020) among low-income households in the Philippines before the wider spread of the disease in the country, only 73% of 2,090 respondents were able to identify indirect hand contact, while 81% answered handshakes or hugs.
The differences in the medians among different demographic characteristics were analyzed using the Kruska-Wallis test (Table 4). Since the research utilized non-probability sampling, the non-parametric test was used. Results of the Kruska-Wallis test showed that there are significant differences in the knowledge scores in terms of the respondents’ educational attainment but not across other demographic characteristics (Table 4).
COVID-19 Attitudes
The respondents were asked 19 questions to assess their attitudes. The questions were divided into two themes: the respondents’ attitude towards COVID-19 as a disease, its prevention, and effects (9 questions); and their attitude on how the government is handling the crisis (10 questions).
For the first theme, the majority of the respondents agreed that COVID-19 is a serious disease (98%), that health education can help prevent COVID-19 (95%), that early detection of COVID-19 can improve treatment and outcome (94%), and that COVID-19 is a curable disease (77%).
At the same time 67% believed that an available vaccine for the disease should not be used if there are not yet enough studies (trials) for it. About 54% of them do not agree that there is sufficient social awareness of COVID-19, and 60% do not believe that that COVID-19 results in death in all cases. Also, 49% do not believe that COVID-19 can be transmitted through household pets to humans. Interestingly, although 56% do not agree that COVID-19 can be treated at home, 37% believed otherwise, and 7% did not have any idea (Table 5).
In terms of how the government handles the on-going crisis, a large percentage of the respondents agreed that authorities should restrict travel to and from areas with high numbers of COVID-19 cases to prevent contamination (95%); and 92% said that authorities should quarantine COVID-19 patients in special hospitals. The same number (92%) also agreed that if there is still an increase in the number of cases of COVID-19 in the next two to four weeks, the government should not allow educational centers to open within the next six months; while 94% believe that the government should continue restricting/prohibiting access to churches, religious sites, and shrines if the number of COVID-19 cases does not decrease in the next two to four weeks.
Although 74% agreed that the NCR should be placed under enhanced community quarantine (ECQ), when the same respondents were asked if the government must place the NCR under a General Community Quarantine, 46% answered in the affirmative, while 46% disagreed.
There was also a large number of respondents (91%) in this study who believe that the government must conduct massive testing (test more people aside from health workers, front liners, and persons suspected of having COVID-19) to control the spread of COVID-19.
When the respondents were asked if the Philippine government is doing enough to control the spread of COVID-19 in the country, only 44% agreed, while 49% disagreed. There was also a negative attitude towards the Department of Health, as 58% believe it is not effective in addressing the problems brought by COVID-19. Only 29% agreed with this statement, while 13% did not have any idea.
Last, the respondents were also asked if their companies are prepared to implement government policies concerning COVID-19. About 79% or 8 of 10 respondents agreed, while 15% answered negatively.
Results of the Kruska-Wallis test showed that there are significant differences in the attitude scores in terms of the respondents’ educational attainment but not across other demographic characteristics (Table 6).
COVID-19 Practices
Practices toward COVID-19 were measured using 10 items. Respondents were asked to answer how often they did the specific actions in the last seven days upon answering the survey.
Based on the respondents’ answers, a majority paid more attention to their hygiene (80%), used disinfectant and solutions such as alcohol (82%), wore a face mask when in public (87%), practiced social distancing when in public (78%), and washed their hands with soap after being in public all the time (75%). Around 56% drank vitamin supplements all the time, while 21% drank herbal products and traditional medicines. Moreover, very few went out of their homes in the past seven days (63% occassionally or none of the time), and fewer went to work (53% none of the time), which can be attributed to the strict quarantine measures in place when this survey was conducted. Most of the respondents said that they avoided physical contact (71% none of the time), and did not use public transportation (59% none of the time) (Table 6).
Results of the Kruska-Wallis test found that the practice scores were not statistically different across all demographic characteristics included in this study (Table 7).
Discussion
COVID-19 is a relatively new virus that has become a global health emergency within just a few months after it was first detected in Wuhan, China. However, there has been limited published data on the knowledge, attitudes, and practices toward COVID-19 among Filipinos, especially among the local workers. The novelty of this pandemic, with many issues that have been observed, will likely become worse if these issues are not properly addressed. Therefore, it is critical for those in authority to come up with appropriate strategies to help mitigate the impact of the disease and prepare the public for worse scenarios. This study, although very limited in terms of the sample, still provides important and timely insights into how workers in the NCR understand the situation that will guide government efforts.
The average knowledge score of the selected Filipino workers from the NCR who were included in this study was high at 92%. This is important to highlight since limited knowledge about the pandemic will bring additional burden to the government in terms of communicating basic information about the disease. When the survey was administered to the respondents, it had been almost four months since the first local transmission was recorded, and three months since the ECQ was imposed in the NCR. Despite the surge in misinformation and disinformation on social media, it is a positive sign to be able to note that workers have correct knowledge about the disease.
In terms of attitudes, the present study found that a large number of respondents had positive attitudes about the need for health education and the seriousness of COVID-19. In terms of government measures, the respondents have a more positive attitude toward stricter measures such as the implementation of community quarantines, closure of schools and religious sites, and massive testing. However, they have negative attitudes toward the government’s general response and the effectiveness of the Department of Health.
In terms of practice, respondents in this study follow strict measures such as the washing of hands using soap, maintaining proper hygiene, using disinfectants and alcohol, wearing face masks, and maintaining proper social distancing when outside the home. They also avoid physical contact and taking public transportation. Overall, respondents in this study are practicing good measures to avoid contracting or spreading COVID-19.
There are several limitations in this study that the researchers acknowledge. First is the sample size. Sampling was done using convenience non-probability sampling through the networks of the researchers using only a single social media platform – Facebook. This resulted in a small number of respondents. As a result, there is a strong possibility of selection bias and the respondents may differ from other members of the population of employed individuals in the NCR. Moreover, women were over-represented in the sample (Philippine Statistics Authority, 2020), as well as those earning Php20,001 (US$411) and above monthly, as nearly three-fifths of Filipinos belong to the low-income class who earn below Php20,000 (US$410) monthly (Albert et al., 2018). Thus, results cannot be generalized to the wider population of employed workers in the NCR. Future researchers must conduct a more systematic, probability-based sampling method to come up with more representative and generalizable results. Additionally, the measurement of KAP has been limited to several items, which did not include the health-seeking intentions of the respondents. Future studies should include possible factors contributing to the respondents’ KAP, as well as their sources of information. Researchers may also conduct a thorough assessment of the validity and reliability of several instruments and come up with a standardized one for future reference.
Conclusion
Thus the study was able to provide a benchmark of the KAP of selected employed people in the NCR, Philippines toward COVID-19. As more workers go back to work with the lifting of strict quarantine measures in the capital region of the Philippines, it is important to understand how some of them perceive this issue, and in particular, apply appropriate preventive measures. The respondents showed a high level of knowledge of the causes and preventive measures against COVID-19. The challenge now is to sustain this high level of knowledge, and future researchers can validate whether this is true of the general population. Respondents also have a positive attitude toward the need for health education and the seriousness of COVID-19. Also, the respondents have become more aware of preventive practices, taking measures that will prevent further spread of the virus. A highlight of this study is the favorable attitude of the respondents toward stricter government measures against COVID-19, and their less favorable attitude towards Philippine government response against the disease. A majority of the respondents feel that the government is not doing enough, specifically the Department of Health. Likewise, seven out of ten respondents were in favor of placing the NCR in ECQ. The government should consider its policies in light of these results, including conducting massive testing of health workers, front liners, and persons suspected of having COVID-19, in order to control the spread of COVID-19.
Biographical Notes
Angelito P. Bautista Jr., MCM is the general manager of Blue Chips Research and Consultancy Co., a market and opinion research company founded in 2018 and based in Navotas City, Metro Manila, Philippines. He completed his Master in Communication Management degree from the Asian Institute of Journalism and Communication, with distinction. He can be reached at Blue Chips Research and Consultancy Co., 20 L.R. Yangco St., Brgy. Navotas East, Navotas City, Philippines or by e-mail at bluechipsconsultancy@gmail.com.
Dianne Balibrea is the co-founder of Blue Chips Research and Consultancy Co. She graduated from the Polytechnic University of the Philippines (PUP) with the degree Bachelor of Arts in Communication Research. She was formerly a market research assistant in an international financial services research company. She can be reached at Blue Chips Research and Consultancy Co., 20 L.R. Yangco St., Brgy. Navotas East, Navotas City, Philippines or by e-mail at dbalibrea.bluechips@gmail.com.
Doris G. Bleza, LPT, MPA, is a Master in Public Administration graduate from the Polytechnic University of the Philippines. She serves as an administrative officer in the human resource department at PUP. She is also co-founder of the Blue Chips Research and Consultancy Co., and member of the Board of Directors of TEACHERS, INC., a non-government organization for teachers and non-teaching personnel in the academic sector. She can be reached at Polytechnic University of the Philippines 3/F South Wing, HRD, Main Building PUP A. Mabini Campus, Anonas St., Sta. Mesa Manila, Philippines or by e-mail at doray.bleza@gmail.com.
Date of Submission: 2020-07-05
Date of the Review Result: 2020-07-31
Date of the Decision: 2020-08-07