Knowledge and attitude towards home quarantine instructions and associations with history of Covid-19 infection in Malaysia

Introduction Although COVID-19 has entered the endemic phase, individuals infected with COVID-19 are required to adhere to home quarantine measures. By exploring the public’s knowledge and attitude towards recommended home quarantine measures, their readiness in containing potential COVID-19 outbreak can be determined. This study aimed to assess the public knowledge and attitude towards home quarantine instructions and their association with history of COVID-19 infections. Methods This was a web-based cross-sectional study conducted among the public in Malaysia between August to October 2022. All Malaysian adults over 18 years of age were included. Knowledge on home quarantine instructions and COVID-19 warning signs were measured using “True,” “False,” or “I’m not sure”, while attitude towards home quarantine instructions was measured using a five-point Likert Scale. The questionnaire was initially constructed in English and then translated into the national language, Bahasa Malaysia. Face and content validation were performed. The internal consistency of the questionnaire was found to be satisfactory. Results 1,036 respondents were analyzed, comprised mostly of females (743, 71.6%) with a history of COVID-19 (673, 64.9%). In the knowledge domain, more than 80% of the respondents answered 9 out of 11 home quarantine instructions statements correctly. 457 (44.1%) were unaware or unsure about the minimum distance of the infected individual’s bed from the rest of the occupants in a shared bedroom. The respondents reported relatively weaker knowledge in identifying uncommon warning signs of COVID-19 deterioration, including anuria (162, 44.5%), ingestion problems (191, 52.5%), and immobility (195, 53.6%). In the attitude domain, more than 90% of respondents answered correctly in 8 out of 9 questions. Respondents with a previous history of COVID-19 infections had better knowledge than COVID-19 infection-naïve individuals towards both home quarantine instructions and COVID-19 warning signs. Conclusion Most respondents had good knowledge and attitude towards home quarantine instructions, with those previously infected with COVID-19 showing greater awareness of uncommon warning signs. However, there was a notable lack of awareness regarding physical distancing within shared rooms, appropriate disinfectant use and mobility limitation within the household. This study highlights the knowledge gaps to be improved in future educational campaigns. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-18739-9.


Introduction
COVID-19 was declared as pandemic by the World Health Organization in March 2020 [1].The first case of COVID-19 in Malaysia was detected on January 25, 2020, and the number of confirmed cases subsequently hiked [2].Knowing that transmission of COVID-19 disease is mainly airborne via respiratory droplets and close contact with infected symptomatic cases [3], quarantine of infected individuals has shown to be an effective strategy to break the chain of transmission [4,5].In the early stage of the pandemic, individuals who tested COVID-19 positive, regardless of severity, were admitted to the ward or quarantine centres [6].
As Malaysia entered the "transition to endemic" phase since April 2022, the majority of COVID-19 positive individuals no longer needed to undergo involuntary detention.Based on the Ministry of Health Guideline on Home Monitoring and Management of Confirmed COVID-19 case at COVID-19 Assessment Centre, only adult patients clinically diagnosed with COVID-19 category 3 to 5, having uncontrolled comorbidities, immunocompromised, or found to present with warning signs of COVID-19 during evaluation were hospitalized for close monitoring [7].Whereas, COVID-19 patients that were asymptomatic (Category 1) or minimally symptomatic (Category 2a) were mandated to undergo home surveillance order (HSO) and report their health status twice a day through an electronic home quarantine self-assessment survey on the national contact tracing surveillance application, MySejahtera [7].
As of October 2022, 95.5% of the 23,038 active cases in Malaysia were given HSO [8].However, there is no direct surveillance and guidance by the health authority on the adherence to home quarantine instructions and monitoring of the warning signs of COVID-19 deterioration during the home quarantine period.In other words, individuals who undergo home quarantine could only rely on their own initiatives to search for information regarding home quarantine instructions and self-disciplines to adhere to them.
A systematic review revealed that overall public knowledge, attitude, and practice regarding COVID-19 were satisfactory across most countries during the early stage of outbreak [9].Studies conducted in China and Australia indicated that the general public exhibited appropriate practices in adhering to preventive measures [10,11].Similarly, local investigations carried out in Malaysia indicated that the public possessed adequate knowledge and displayed positive attitude toward adhering to mitigation strategies aimed at curbing COVID-19 [12,13].However, there is a lack of research examining the knowledge, attitude, and practice of the public regarding home quarantine.
As COVID-19 is entering the endemic phase, it is important to educate the public regarding proper home quarantine instructions in accordance to guidelines adopted by the government to prevent future outbreak.In addition, empowering the public in recognizing warning signs of COVID-19 during the period of home quarantine will help them to recognize needs to seek for timely medical attention.This study aimed to assess the public knowledge and attitude towards home quarantine instructions and its associations with history of COVID-19 infections.

Methods
This was a cross-sectional study conducted among the general public in Malaysia.All Malaysian citizens over 18 years of age were eligible for this study.Those who could not read or understand English or Malay language were excluded.
The study sample size was estimated using the Raosoft sample size calculator (http://www.raosoft.com/samplesize.html).Assuming an infinite study population among the general public of Malaysia, where 50% have good knowledge regarding home quarantine instructions, with 95% confidence level and 5% margin of error, the minimum sample size required was 377.
The questionnaire was initially constructed in English and then translated into Bahasa Malaysia using a Conclusion Most respondents had good knowledge and attitude towards home quarantine instructions, with those previously infected with COVID-19 showing greater awareness of uncommon warning signs.However, there was a notable lack of awareness regarding physical distancing within shared rooms, appropriate disinfectant use and mobility limitation within the household.This study highlights the knowledge gaps to be improved in future educational campaigns.
Keywords COVID-19, Home quarantine instructions, Home surveillance order, Knowledge, Practice, Attitude, Warning signs forward-backward-translation approach to ensure linguistic and conceptual equivalence.Face and content validation were performed by a panel of two subject matter experts: one senior academic specialized in public health pharmacy, and one senior clinician specialized in internal medicine.Subsequently, it was pre-tested among five lay persons to examine clarity and relevance.A pilot test was conducted among 30 respondents to check the reliability of the questionnaire.The internal consistency of the questionnaire was found to be satisfactory: Knowledge towards home quarantine instructions (α = 0.618); warning signs of COVID-19 deterioration (α = 0.765); attitude towards home quarantine instructions (α = 0.768) [14].
To measure knowledge about home quarantine instructions and signs of COVID-19 deterioration, the respondents were required to answer whether the item was "True, " "False, " or "I'm not sure." In terms of attitude, the respondents were asked on a five-point Likert Scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree) about their likelihood to practice the home quarantine instructions recommended.The overall knowledge and attitude were categorized using Bloom's cut-off point, as good if the score fell between 80% and 100%, moderate if the score ranged between 60% and 79%, and poor if the score was below 60% [15].

Data collection
Data collection was performed online using Google Forms.The survey was opened for three months between August and October 2022.The link (URL) of the Google Form online questionnaire was distributed to the potential respondents via social media platforms (e.g., Facebook, Twitter, WhatsApp).To ensure anonymity, subjects were not required to sign in to an account to complete the survey.
The respondents were initially directed to the online Participant Information Sheet (PIS).Further details of the study and consent to participate were given on the PIS webpage.Should they choose not to participate, their intentions were acknowledged, and a "thank you" note expressing the researchers' respects for the participants' decision.Should they agree to participate, they were asked to click on a link to proceed with the questionnaire.

Data analysis
All study variables, including the respondents' demographic characteristics, knowledge, and attitude, were descriptively analyzed and presented.For the knowledge sections, responses were dichotomized into correct and incorrect/unsure.Responses were categorized and reported as agree and disagree/neutral for the attitude domain.Chi-square tests were used to stratify the knowledge and attitude of the respondents based on their history of COVID-19 infections.The analysis was performed using SPSS version 27; a p-value of less than 0.05 was considered statistically significant.
This study was registered with National Medical Research Registry (NMRR), and ethical approval was obtained from Medical Research Ethical Committee (MREC).

Knowledge towards home quarantine instructions
80% of the respondents answered correctly in 9 out of 11 statements related to knowledge towards home quarantine instructions.220 (21.2%) of the respondents were unaware or unsure whether a shared bathroom should be disinfected with 0.1% Chlorine solution after each use.Moreover, 457 (44.1%) of the respondents were unaware or unsure about the minimum distance of the infected individual's bed from the rest of the occupants in a shared bedroom (Table 2).
We performed Chi-square tests and found that respondents who have a history of COVID-19 infection had better knowledge in terms of needs of daily health status reporting (98.4% vs. 95.6%,p = 0.008) and room separation requirements (98.4% vs. 96.4%,p = 0.048) compared to those who were not infected with COVID-19 before (Table 2).

Attitude towards home quarantine instructions
More than 90% of the respondents uttered their agreement towards eight out of the nine attitude statements regarding home quarantine instructions.Notably, 97.9% of the respondents agreed to practice all the basic preventative measures during home quarantine, including wearing a face mask, regular hand washing, and practicing cough etiquette.Compared to the other home quarantine instructions, relatively fewer respondents reported agreement (867, 83.6%) in limiting their movement in the house during home surveillance orders (Table 4).There was no significant association in attitude between those with and without COVID-19 history.

Discussion
This study represents one of the earliest attempts to evaluate the general public's knowledge and attitude regarding home quarantine measures in response to COVID-19 endemic.Overall, the majority of respondents exhibited good understanding and positive attitude towards home quarantine instructions.Furthermore, individuals with a prior history of COVID-19 infection notably displayed enhanced knowledge, particularly in areas such as health status reporting and implementing room separation measures throughout the isolation period.
Respondents who were older and married have better knowledge towards home quarantine instructions, although a local study conducted six months after COVID-19 was declared pandemic among a similar population reported better knowledge among middle-aged people [13].Older individuals and those who were married may have had more exposure to health information and guidelines through traditional media channels or healthcare providers.Additionally, their life experiences and responsibilities, such as caring for families or managing households, may have heightened their awareness and adherence to home quarantine protocols.
Additionally, female and those who were vaccinated have better attitude towards home quarantine instructions.Interestingly, men were less knowledgeable about the symptoms of COVID-19 than women in Pakistan [16].This gender disparity in knowledge and attitude could be attributed to societal norms which influenced men to downplay health concerns or exhibit a sense of invulnerability, leading to lower levels of knowledge and negative attitude to health protocols.The higher likelihood of positive attitude towards quarantine instructions among vaccinated individuals suggests that this group of respondents took a proactive approach to manage their health and inherently had a greater understanding of the importance of preventive measures in mitigating the spread of COVID-19.
More than two-fifth of the respondents in this study were not aware about the minimum distance between beds in a shared room, revealing knowledge gaps to focus on in future public health education on COVID-19 preventive measures.In fact, a study reported that at least three to six feet away is critical in reducing transmission of COVID-19 [17].While it is highly advisable for individuals infected with COVID-19 to be isolated, this could be impossible for settings with limited domestic space.In fact, a few clusters involving immigration detention centres, prison, factory dormitories and construction sites were identified for contracting COVID-19 during the pandemic in Malaysia.Hence, health authorities may contemplate the provision of temporary quarantine facilities as a proactive measure to mitigate the risk of outbreaks.
On the other hand, a local study revealed that more than 50% of COVID-19 cases were due to cross-infection among household members [18].In our study, about one in five respondents were unaware of the need to limit movement in the house.In terms of attitude, we also found a relatively lower level of agreement with this instruction compared to the others.This phenomenon may stem from the belief that individuals under HSO were solely required to refrain from leaving their homes, without any restrictions on mobility within the household.This misconception warrants attention and clear correction, as it has the potential to contribute to crossinfection among household members.
In consistent with previous local and international studies [13,19,20], most respondents reported good knowledge of common warning signs of COVID-19 deterioration.Notably, less common warning signs of COVID-19 infection such as diarrhoea, reduced urine output, immobility, and ingestion individuals were better known in respondents with a history of COVID-19.At present, individuals undergoing HSO no longer have direct supervision from healthcare workers and are monitored only through the national contact tracing surveillance application (MySejahtera).This approach relies heavily on community solidarity and responsibility to self-report their infection status and daily This study was adequately powered to reflect knowledge and attitude regarding home quarantine instructions in the Malaysian population.Other than determining the preparedness of Malaysians in the era of COVID-19 endemic, it also addressed the knowledge gap in educating the public about home quarantine measures to prevent future outbreak.However, as we did not perform stratified sampling, we observed an underrepresentation of the elderly, men, and non-healthcare workers.Due to data collection time lapse, respondents may inaccurately report their past experiences due to recall bias.Respondent bias may also present as participants might have provided socially desirable responses.

Conclusion
The respondents demonstrated a good understanding of most home quarantine instructions, with those who had previously contracted COVID-19 showing better awareness of uncommon warning signs COVID-19 deterioration.Generally, participants displayed positive attitude towards home quarantine instructions.However, there was a notable lack of awareness regarding the importance of physical distancing within shared rooms and the necessity of using suitable disinfectants as well as mobility limitation within the household.These underscore the need for future educational campaigns to address the knowledge gaps identified.

Table 2
Knowledge of respondents towards home quarantine instructions (n = 1,037)

Table 4
Attitude towards home quarantine instructions