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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 90-99

An online cross-sectional survey on knowledge, attitudes, practices and perspectives of homoeopathic practitioners towards COVID-19


Central Council for Research in Homoeopathy, New Delhi, India

Date of Submission17-Apr-2020
Date of Acceptance28-Apr-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Divya Taneja
Central Council for Research in Homoeopathy, 61-65, Institutional Area, Opp. D Block, Janak Puri, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_35_20

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  Abstract 


Background: In the light of pandemic of coronavirus disease (COVID-19), identification of level of epidemic preparedness and understanding of homoeopathic practitioners is required to utilise their services in mainstream healthcare effectively. Objective: The objective of this study was to identify knowledge, attitudes and practices of homoeopathic physicians about COVID-19. Methodology: An online cross-sectional survey was undertaken in the midst of the epidemic in India when services of homoeopathic doctors were under consideration. The ten knowledge questions were scored and analysed to identify differences with sociodemographic variables. Responses to the ten questions on attitudes and practices were analysed to identify differences in the domains, differing significantly in knowledge scores. Results: Out of 3901 responses received over 2 days, 3595 were included for analysis. Knowledge scores significantly differed with qualification (graduates – 8.60 ± 1.38, post-graduates – 8.84 ± 1.29 and other qualifications – 8.56 ± 1.31) and years of practice (<10 years – 8.57 ± 1.38 and >10 years – 8.84 ± 1.30). Gender was not identified as a variable to affect knowledge scores significantly. Attitudes and practices were also identified to be more favourable in participants with more than 10 years' experience. Conclusion: Homoeopathic physicians have largely been able to maintain a high level of currency of knowledge, purely on their own accord. Specific aspects related to patient care and practices need to be further enhanced. Practitioners affirmed that homoeopathic medicines need to be validated on a group of patients before mass treatment/prevention can be identified for which immediate access to patients is required.

Keywords: Attitude, COVID-19, Homoeopathic physicians, Knowledge, Practice


How to cite this article:
Taneja D, Khurana A. An online cross-sectional survey on knowledge, attitudes, practices and perspectives of homoeopathic practitioners towards COVID-19. Indian J Res Homoeopathy 2020;14:90-9

How to cite this URL:
Taneja D, Khurana A. An online cross-sectional survey on knowledge, attitudes, practices and perspectives of homoeopathic practitioners towards COVID-19. Indian J Res Homoeopathy [serial online] 2020 [cited 2020 Jul 10];14:90-9. Available from: http://www.ijrh.org/text.asp?2020/14/2/90/285289




  Introduction Top


The International Health Regulations (2005) Emergency Committee of the World Health Organization (WHO) declared the novel coronavirus disease (COVID-19) (initially termed novel coronavirus (2019-nCoV) a public health emergency of international concern, on 30 January 2020; the same day as India had reported its first confirmed case of the condition.[1],[2] The WHO directed all countries to prepare for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoV infection.[3]

From 30 January 2020 to 24 March 2020, there were 372,755 confirmed cases and 16,231 deaths globally and 434 confirmed cases and 9 deaths in India,[4] when India was brought under complete lockdown for a period of 21 days (up to 14 April 2020) to contain the spread of the epidemic.[5]

The Ministry of AYUSH (AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) in India had released its advisory on COVID-19 on 6 March 2020[6] detailing homoeopathic medicines which have an antiviral effect and can act as immune enhancers. The Ministry of AYUSH also initiated the process of seeking concepts and proposals from AYUSH practitioners on innovative and traditional ways to handle the pandemic through its website.[7]

The Ministry of AYUSH also issued a call inviting AYUSH practitioners including Homoeopathic physicians as volunteers to fight against the virus.[8] The precise modalities of utilisation of services of homoeopathic physicians were not detailed. However, they were encouraged to train themselves as per the guidelines/training material, a list of which was published on 1 April 2020.[9] As on 1 April, no proposal for treatment of confirmed or suspected cases of COVID-19 by homoeopathic medicines issued by the Government of India could be identified.

Role of Homoeopathy in prevention, control and treatment in epidemic disease conditions including influenza, Japanese encephalitis, dengue and other infectious diseases through historical, clinical and experimental evidences has been frequently reported.[10],[11],[12],[13],[14],[15] The homoeopathic physicians in India are trained practitioners, who have undergone 5 years of training with the study of subjects of both modern medicine and Homoeopathy, trained in pre-clinical and clinical subjects. Potential role of homoeopathic practitioners for imparting behaviour change modifications (in context of HIV/AIDS) has also been reported,[16],[17] which provide a model on the basis of which homoeopathic practitioners can be effectively utilised as behaviour change (for hygiene and social distancing behaviours) catalyst in the present epidemic as well.

This workforce can greatly enhance the overall availability of skilled medical resources in the country and can play a major role in the provision of general healthcare and availability of prevention and treatment modalities for patients of COVID-19.

However, to involve homoeopathic practitioners in the mainstream healthcare services, an identification of their level of epidemic preparedness and understanding of the novel disease condition was needed. It was also imperative that the perspective of homoeopathic practitioners was identified and collated at a single platform. This survey study was, therefore, designed to assess the current level of knowledge, attitudes and practices (KAP) on novel COVID-19 among homoeopathic physicians.


  Methodology Top


Survey population

A cross-sectional online survey was conducted from 2 April 2020 to 4 April 2020. The survey questionnaire prepared was circulated on the social media sites (including WhatsApp®, Facebook® and Telegram®) to homoeopathic practitioners individually and practitioner groups requesting them to forward the questionnaire to their homoeopathic colleagues.

Homoeopathic practitioners including post-graduation students of Homoeopathy from India were included in the survey. Students and interns currently pursuing bachelor's degree and non-Homoeopathy qualified persons were excluded.

No fixed sample was proposed for the study. The attempt was to reach to as many practitioners as possible through social media. However, the survey was fixed for the duration of 2 days, irrespective of the number of responders.

Questionnaire

A questionnaire was created on Google Forms comprising 4 parts. The first section was a brief about the objectives of the survey and the consent of the participants. The second section was sociodemographic information including age, gender, educational qualification, years of practice and region of practice. The third section on KAP comprised ten questions on knowledge and ten on attitudes and practices. All questions had three options: 'Yes', 'No' and 'Don't know' (with an exception of one question having the option of 'Maybe' instead of Don't know). The fourth section was on current practice in terms of clinical exposure during the lockdown days. The face validity of the questionnaire was assessed by two homoeopathic researchers: one with more than 35 years of experience and the other with 20 years of experience. Survey process was pilot tested by two experts: one homoeopathic practitioner with 25 years of experience and another, an academician with 6 years marketing research experience.

Statistical analysis

Frequencies of correct response to knowledge questions and frequency of responses to questions of attitudes and practices were described. Response of practitioners in terms of current clinical practice and exposure was collated. Knowledge scores were calculated as a total of all correct responses and compared according to demographic characteristics using independent samples t-test or one-way analysis of variance, as appropriate. Response to attitude and practice questions was compared on the basis of qualification and years of experience of the practitioners using Chi-square test. Data analyses were conducted with SPSS version® 17.0. The statistical significance level was set at P < 0.05 (two-sided). Descriptive responses to questions on number of patients treated, risk assessment conducted and referred were modified to the nearest figures to bring in homogeneity in data.


  Results Top


Responses received

A total of 3901 responses were received, out of which 306 (7.8%) responses had to be excluded due to various reasons [Figure 1], while 3595 responders were included for analysis.
Figure 1: Survey response

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The survey was conducted from 2 April 6:00 PM (IST) to 4 April 7:20 PM (IST). There was a slight delay in closing the survey due to a problem related to internet connectivity. Over a period of 49 h, the response rate was approximately 78 responses per hour, i.e., more than 1 response per minute.

Sociodemographic profile

Age, gender, qualification, years of practice [Table 1] and place of practice [Table 2] were the sociodemographic variables identified for the respondents. Although mandatory, the questions had open responses, and therefore, random digits or typographical errors were identified in some responses, which could not be included in the sociodemographic profile. Responses from participants where the sociodemography could not be ascertained in more than two variables were excluded as doubtful responses and not included in the analysis.
Table 1: Sociodemographic profile of responders

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Table 2: State/union territory-wise number of responders

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Age of the participants was between 23 and 78 years, and 94.7% were below 50 years. There were an equal number of both male (49.86%) and female (50.14%) participants. A large number of participants were graduates (60.18%) in Homoeopathy. More than 50% of the participants had <10 years of practice (n = 1318).

Place of practice

Responses were received from all over India with the exception of union territories (UTs) of Ladakh and Lakshadweep. Three thousand five hundred and seventy-six participants were practicing in single states, 7 in two states and 12 participants were either not practicing or did not respond to the question.

Response to knowledge questions

Response to KAP questions was mandatory in the survey and had fixed choice [Table 3]. Most of the responders (more than 80%) had a fair knowledge about the novel coronavirus infection and related information except on the first question, i.e., the other respiratory syndromes caused by coronaviruses. The response to the question if the novel virus can survive over plastic for 3 days was average, with 35% of the participants responding in negative or don't know to the question.
Table 3: Response to knowledge questions

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Gender was not identified as a variable to affect knowledge scores significantly, implying that both male and female participants fared equally. Participants were segregated into two groups with 10 years or more of practice and <10 years of practice to identify the difference between knowledge scores. Knowledge scores significantly differed with qualification and years of practice [Table 4]. Post hoc test identified a significant difference between graduates and post-graduates but no difference between other qualifications with either graduates or post-graduates. Age was not used as a variable since it was presumed that age will have a dependent effect on both qualification and years of practice.
Table 4: Knowledge score by demographic variables

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Attitude and practice

Attitudes and practices were identified for all participants using mandatory questions with fixed responses [Table 5]. A large number of responders (47.37%) could not differentiate between quarantine and social distancing and considered them as the same.
Table 5: Response to attitude and practice questions

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Further, attitudes and practices were identified in terms of the variables where knowledge scores differed significant, i.e., for qualification [Table 6] and years of practice [Table 7].
Table 6: Variation in attitude and practice response by qualification

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Table 7: Variation in attitude and practice response attitude and practice by years of experience

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Current practice

Most of the practitioners were able to continue with their clinical practices, whereas 38.29% of the practitioners stated that they had to discontinue practice because of lockdown, leading to movement restriction. Only 12.29% of the respondents said that their practice was discontinued due to factors other than lockdown. No details on these factors were, however, identified [Table 8].
Table 8: Current practice

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Treatment of patients with cough and fever

In response to the question of number of patients treated for cough and fever in the past 10 days, i.e., since the beginning of the lockdown period [Table 9], 533 practitioners did not respond; whereas 1404 (39.05%) responded to this query as 0 or none; 55 did not give any figure and rather responded as few or many or as yes. In case of rest of responses, the range of number of patients treated was from 1 (91 responders) to 701 (1 responder). These included consultations both face to face and through telephone.
Table 9: Treatment of patients with cough and fever

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Eleven responders gave patient figures in 1000s, which did not appear to be plausible for a single practitioner to treat over a period of 10 days.

In terms of response to number of patients in whom risk identification for COVID-19 has been done [Table 10], 555 practitioners did not respond to the query and 2367 responded 0; 35 responded as few, not many or many or yes, without giving any figures. The range of patients was 1 (119 responders) to 555 (1 responder).
Table 10: Practitioners conducting risk assessment for coronavirus disease

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Two responders gave figures in 1000s which were again implausible.

In response to the query as to number of patients of cough and fever referred for laboratory or radiological investigations in the past 10 days [Table 11], 582 responders did not respond and 2382 mentioned 0; 22 responded as few, many, rare and yes. The range of patients referred was from 1 (151 practitioners) to 582 (1 responder).
Table 11: Practitioners referring patients with cough and fever for laboratory/radiological investigations

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55.41% of the responders had either not treated any patients with cough and fever or did not respond to this query in specific numbers. Furthermore, 83.05% of the practitioners had not conducted any risk assessment.


  Discussion Top


Homoeopathic practitioners in this cross-sectional survey presented a high response rate, expressing their willingness to participate in the survey. These physicians have been able to maintain a high level of currency of knowledge, purely on their own accord. Level of disease-based knowledge and prevention of the condition is highly satisfactory, although a better understanding of the viruses in the family of coronavirus is needed. Physicians with higher qualifications, beyond the basic graduation, fared better in all aspects, i.e., KAP. The same is true for physicians with higher years of experience.

Questions related to attitudes and practices identified the preventive and treatment-related aspect of the disease condition, both in terms of public health and Homoeopathy. In most of the questions, practitioners exhibited a favourable attitude and practices as governed by current regulatory requirements in the light of evolving discernment of the novel viral disease. Persons with post-graduation and additional qualifications beyond mandatory graduation required for practice fared better than only graduates in knowledge scores, reflected in attitudes and practices as well. The years of experience also enhance an understanding of disease conditions and necessary requirements for prevention and treatment, implying their more practical approach.

The concept of differentiating between social distancing and quarantine is an area of further deliberation as the response was mixed (with only 51.99% affirming that both are different). Although post-graduates and high experience practitioners fared better in this response, a large proportion of practitioners are not aware of this very essential preventive aspect along with its legal and social implications.

How far do droplets carry the infection and survival of the virus on different surfaces can possibly create confusion as new knowledge about the virus is coming every day,[18],[19] which could be distinct from previously existing knowledge about coronaviruses.[20],[21]

Severity of disease was another question to which mixed response was received, largely due to lack of exposure to clinical cases by homoeopathic physicians and dependency on newspaper reports and social media presenting a grim picture of the epidemic. Severity of cases, beyond media reports, requires an understanding of clinical picture from both disease and homoeopathic perspectives.

Where, on the one hand, 80.72% of the practitioners acknowledged that there is currently no effective cure for the conditions, 44.37% were of the opinion that Homoeopathy is a confirmed treatment. This is in spite of the fact that 98% affirmed that the medicines need to be validated on group of patients, and as yet, no such study has either been conducted, nor are such data currently available in public domain. Graduates were more convinced about Homoeopathy being a confirmed treatment, rather than post-graduates, although both groups fared equally in response to need for validation.

A mere 18.83% were of the opinion that only nosodes can be used for prevention, implying that validation of existing medicines can be focused on, and there need not be a race to develop new nosodes. Significant difference existed between the responses of graduates from that of post-graduates in this regard. It needs to be emphasised on the practitioners, particularly the graduates, that development of nosode is a time-consuming process, involving a high level of technological involvement for isolation and standardisation of starting material and the finished product, i.e., the mother tincture to prepare a nosode with a high safety profile.[22] Most of them might not be aware about the requirement of establishing pre-clinical safety before human use.

In spite of the lockdown in the past week of March 2020, about half of the practitioners were able to continue with their clinical practices. However, no treatment of patients with fever and cough by half of the practitioners and no risk assessment of patients by more than 80% was reported, which could probably be due to lack of specific guidelines available to homoeopathic practitioners for risk assessment, before the lockdown. This aspect needs special consideration, when devising strategies for healthcare delivery by any practitioner, during the pandemic. There is a need to develop explicit understanding of practical aspects of isolation, social distancing and quarantine. Furthermore, specific guidelines on how and in whom risk assessment needs to be done, at what stage of the pandemic, need to be imparted to practitioners.

Many practitioners, in their general remarks, also expressed their willingness to treat patients, and identify preventives, which at larger scale requires directions from the Ministry of AYUSH, Government of India. A large number of practitioners believed the Central Council for Research in Homoeopathy and the Ministry of AYUSH should come up with treatment guidelines for using homoeopathic medicines in COVID-19, implying that the treatment should be based on validated strategies.

Further enhancement of attitudes and practices with a background of a good level of knowledge can be conducted by streamlining treatment guidelines, practical trainings, exposure to patients, facilities providing isolation and quarantine, a first-hand experience in identifying severity of disease condition, on the basis of which this workforce can be included in the healthcare delivery system, for both public health measures enforcement and treatment as well as prevention strategies.

Homoeopathic practitioners form a valuable, well-trained human resource which can be optimally utilised in the healthcare delivery system in the country, in the wake of the present pandemic, with due consideration of practical aspects of risk assessment, triage, clinical care and prevention strategies.

The survey had a mass outreach by electronic media, and the practitioners were easily available and ready to complete the survey, probably due to the complete lockdown and there being a larger emphasis on electronic communication rather than personal, face-to-face interactions. The strengths of the study are that real-time data could be collected in a short period of time on digital platform.

The study limitations are that the survey was conducted only for a period of 2 days. The practitioners who were active on social media are, therefore, more likely to be responders, rather than those who had limited activity on social media. Although presently there are no means to identify the same, there is a possibility that these persons had a larger exposure to COVID-19-related information coming on social media and more interactions with other practitioners than others. Furthermore, although participants were from all age groups, number of participants dwindled with age, which could be due to technological challenges, or other practical limitations.


  Conclusion Top


Homoeopathic physicians have largely been able to maintain a high level of currency -of knowledge, purely on their own accord. Practitioners affirmed that Homoeopathic medicines need to be validated on a group of patients before mass treatment/ prevention can be identified for which immediate access to patients is a must. Further recommendations for inclusion of practitioners in COVID – 19 related patient and population care strategies are given.

Recommendations

  1. Homoeopathic practitioners have been largely able to keep themselves updated about the current pandemic, but need to be trained on practical aspects of the condition, including its presentation in various stages. Training modules need to have a flexible approach to accommodate both graduates and PGs and persons with varied years of experience
  2. In the practitioner resources, specific guidelines for risk assessment and subsequent modes of social distancing, isolation and quarantine need to be emphasised, which the practitioners are required to follow in their clinical practice
  3. Homoeopathic practitioners can be involved in the healthcare delivery system during this pandemic as screeners, behaviour change counsellors and treatment providers. However, standard treatment guidelines need to be formed for homoeopathic treatment, using drugs validated on patients
  4. There is a potential for homoeopathic practitioners to contribute significantly in control and treatment of pandemic
  5. Larger outreach of authentic sources of information will further enhance the KAP of the practitioners and better utilisation as medically trained human resources for pandemic treatment and control.


Acknowledgement

We are thankful to Ms. Nitika Sharma, Independent Marketing Consultant and Assistant Professor, Maharaja Agrasen Institute of Management Studies, Delhi, for providing technical guidance and conducting the statistical analysis of the study. We acknowledge the contribution of Dr. Renu Mittal, RO (H.), CCRH, for conducting pilot testing of the questionnaire, conducting data review and validation and providing inputs into the manuscript. We are thankful to Dr. Chetna Deep Lamba, RO (H), CCRH, for her review and guidance in questionnaire development. We are thankful to all homoeopathic practitioners who willingly decided to be part of the survey.

Financial support and sponsorship

This study was financially supported by the Central Council for Research in Homoeopathy, Delhi, India.

Conflicts of interest

None declared.

 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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