Knowledge and Perception of the Risk of Respiration Disorders in COVID-19 Pandemic in COPD Patient: A Mixed-Method Study

shown that

2][13][14] The BE-COPD group showed poorer socioeconomic status.No significant differences were found to be associated with SARS-CoV-2 infection regarding housing conditions, poor knowledge, attitude, and risk perception toward COVID-19.Living in urban areas and perceiving risk in COVID-19 were significantly associated with increased adherence to sanitary measures and concerns of contagion.Around 40% of all patients showed poor risk perception and adherence to sanitary measures towards COVID-19. 15rception is the experience of an object, event or relationship obtained from inferring known information and interpreting it, giving meaning to the stimulus.In other studies, it is also stated that the perception is that there is no need to visit/get advice on services from prescriptions for minor illnesses, self-medication is more economical, and does not have to queue long at the clinic.Perception is proven to significantly influence someone in self-medication in the selection of self-medication.The relationship between knowledge and perception is that perceptions are influenced by knowledge.7][18][19] Previous systematic reviews on this and similar topics did not include hospitalization as an outcome, which is particularly important as healthcare resources become stretched during the pandemic.The maintenance of essential health services is a key strategic priority of the WHO COVID-19 response. 20This study aimed to explore knowledge and perception of the risk of respiration disorders in the COVID-19 pandemic in COPD patients.This research was mixed methods research with quantitative and qualitative approaches, with a phenomenological approach.

Research design
This research was mixed methods research with quantitative and qualitative approaches complementing the description of the study results regarding the phenomenon under study and strengthening the research analysis.This research design used a sequential explanatory model or combines quantitative and qualitative research methods sequentially.The location was conducted in Rungkut District in Surabaya City, East Java, from May-October 2022.
Quantitative phase: This quantitative study used a survey research method that aimed to determine the role of knowledge and knowledge and perception of the risk of respiration disorders in the COVID-19 pandemic in COPD patients.The data collection method in this study was using a questionnaire in the form of a scale obtained from previous research (Table 1).Each knowledge number was worth 1 point if the answer was correct, the maximum value was 16 (16 numbers).To assess the level of perception of the respondents, 7 questions were included to encompass individual perception of perception of the risk of respiration disorders in the COVID-19 pandemic in COPD patients.The question of perception was given a score of 0 for disagreement responses (very agree and agree) and a score of 1 for agreement responses (disagree and very disagree).The scores were summed to a total score ranging from 0 to 7. 21 Qualitative phase: This qualitative research was conducted using the interpretative phenomenological analysis (IPA) research method which aimed to determine the knowledge and knowledge and perception of the risk of respiration disorders during the COVID-19 pandemic in COPD patients.The interview method used in this research was the in-depth interview method.The data analysis technique in this research was thematic analysis such as factor analysis.

Population and sample
In this study, the research target population that will be used were stable COPD patients who live in Rungkut sub-district, Srabaya City, East Java.The research sample was adult COPD patients (17-60 years), willing to participate in research, not hospitalized >1 month, and not working in the health sector.

Data collection and analysis method
Distribution of Informed Consent and interview in in-depth interview method, using structured interview guides and semi-structured interview guides.Validation of the questionnaire was done by equating the meaning and assessment of each statement on the questionnaire.The questionnaire was translated into the Indonesian language.Language validation was done by submitting the translation results to three expert judgments in community pharmacists.The suitability score was then validated using the Content Validity Ratio (CVR), which was declared valid if CVR was >0.29.Interviews were made with the framework of thinking as in Table 1.The construct validity test used factor analysis with the Exploratory Factor Analysis (EFA) system to find factor loads in the relationship between dimensions (factors) and items.The reliability test was conducted to determine the instrument, if Cronbach alpha value >0.7 then it was reliable.The overall interpretation of the analysis was the analysis of the interpretation of the quantitative and qualitative results, namely by combining the results from the quantitative phase and the qualitative phase of the research into the overall results of the study, so that a unified conclusion was obtained.

Research implementation
A total of 116 stable COPD patients were the study sample from 124 COPD patients were encountered.A total of 7 people was not willing to be interviewed because of their busy schedules and 1 person had just been treated at the hospital, so it does not include stable COPD >1 month.

Characteristics of respondents
There were 116 respondents.Most of the respondents were male (107 of 116).While the average age of the respondents was 47 years and the lowest age was 32 years and the lowest age was 60 years.The biggest category is in the early elderly (57 of 116).A history of diseases other than COPD are cardiovascular disease (57 of 116), respiratory disease (27 of 116), and diabetes mellitus (24 of 116).As many as 69 respondents had been infected with the COVID-19 virus, and most needed treatment at the hospital because of quite severe symptoms of shortness of breath.The largest number of jobs are private employees (43 of 116), including working in offices, maintaining shops, and online drivers (Table 2).
Most of the respondents with male gender (Table 2).Data from most of the early studies indicated that men had a greater risk of developing COPD and dying from COPD than women, but data from developing countries show that the prevalence of COPD in men and women is similar, which may reflect changes in tobacco smoking patterns.[33] Most of the respondents' ages were in the range of 45-55 years of 49.14% (Table 2).Human lungs develop until 10-12 years of age and mature until they reach a maximum age at around 20 years for girls and around 25 years for boys.Then lung function begins to decline with age as a consequence of structural and physiological changes in the lung.Aging is defined as a progressive decline in homeostasis after the reproductive phase is complete, resulting in an increased risk of disease or death.Thus, aging is one of the main drivers of the development and increasing burden of non-communicable diseases, namely chronic diseases.Older COPD patients (geriatrics) experience a greater decline in functional status so that age is an independent risk factor for reducing functional capacity in COPD patients. 34,35

Instrument validity test
The validity test was the level of reliability and validity of the instrument or measuring instrument used.Content Validity Ratio (CVR) was the accuracy of a measuring instrument in terms of the content of the measuring instrument through rational analysis by expert judgment.The results of the data validity test showed that items 1-16 were valid so that the questionnaire can be used as a measuring tool (Table 3).
Construct Validity (CV) was used using factor analysis with the Exploratory Factor Analysis (EFA) system.to look for the Loading Factor was the relationship between dimensions (factors) and items.The condition of the loading factor was >0.5.The results of factor analysis showed the following values: Sample Sufficiency Test was tested using Kaiser-Meyer-Olkin (KMO) and Measure of Sampling Adequacy (MSA), provided that the KMO Airborne transmission with aerosol-generating procedures has also been implicated in the spread of COVID-19.Resources for contact tracing and testing must be enhanced to limit the spread of this virus.Patients must be educated and encouraged to adhere to social distancing guidelines, travel guidelines, and the use of facemasks. 22,23How long is the incubation period for COVID-19?
The average incubation time for COVID-19 was 12.5 days when the mean age of patients was 60 years, increasing 1 day for every 10 years.The potential exposure and risk of contracting COVID-19, linked with new cases and quarantine procedures being systematically introduced, are understandably higher in such places as hospitals, medical centres and diagnostic units.The deaths of people who suffer from chronic disease(s) are not related to coronavirus infection.value was >0.5.The results showed KMO and MSA values for the correlation between variables in the KMO and Bartlett's Test box showed a value of 0.661 which was >0.5.Meanwhile, the significance result from Bartlett's Test of Sphericity was 0.000.Based on the results above, it can be concluded that this instrument had met the valid requirements, so the data was eligible for further Factor Analysis.
Item Independence Test was used to test each item in the questionnaire, provided that the antiimage correlation value was >0.4.The results showed the correlation between the independent variables of each item was classified as high, namely all items had an antiimage correlation data value >0.4 so that based on the results of item validity testing, it can be concluded that all items were valid and all independent variables can be analyzed further.
Exploratory Factor Analysis was carried out to find the Loading Factor was the relationship between dimensions (factors) and items.The provisions of the loading factor that was >0.5.The following was the loading factor from item No. 1-9 (knowledge) and 10-16 (perception).
The discrimination index (DI) was the distinguishing power of the item, namely the ability of the item to distinguish a sample that had high and low score group.There were many ways to calculate the discrimination index.The technique used in this study was to use product moment Pearson correlation between items and the total.Good items were items that had item correlation -a total of >0.3.The results of the discrimination index test showed that from a total of 30 samples, all items had good discrimination with average significance of 0.000 and the total item correlation value showed >0.3.

Instrument reliability test
The reliability test was conducted to determine whether the instrument, in this case the questionnaire, could be used more than once, so as to produce data that was consistent with the condition that Cronbach's alpha was >0.7.From the item reliability test with Cronbach's alpha, the results of the reliability test get a value of 0.866 so that it can be said that the items in the questionnaire were reliable or reliable used in data collection tools.

Quantitative phase
Profil answers from knowledge and perception of the risk of the risk of respiration disorders in the COVID-19 pandemic in COPD patients was shown in Table 4. On the knowledge question, the most correct answers were number 1 which asked whether the COVID-19 virus was contagious (112 of 116).While the most wrong answers were asking whether there is any similarity between COVID-19, SARS-CoV, and MERS-CoV (21 of 116) and whether medications for COPD increase the risk of getting sick of COVID-19 (38 of 116) (Table 4).On the perception item, the answer with the most positive level is a question no. 15 (We should not be afraid to interact with COVID-19 patients as long as we keep our distance and wear masks).While the answer with the most positive levels is question no. 13 (Coronavirus may survive outside the human body for a couple of hours) (Table 4).
Some respondents had a low knowledge category (54 of 116), and the most positive perception category (57 of 116).Respondents with high and very high levels of knowledge were 48 of 116 (Table 5).

Qualitative phase
The results of this study were obtained by using in-depth interviews with informants as a form of searching for data and direct documentation in the field which were then analyzed by researchers.The results of the interview findings can be seen in Table 6.
The respondent's knowledge of the COVID-19 virus showed that the respondent knows that the COVID-19 virus was a contagious disease and was transmitted through the air (can be through coughing and sneezing). 22,36,23However, during the incubation period of the virus, many respondents answered variously and thought that if someone is in contact with someone who is positive for COVID-19, they should take a test after 3-4 days (Table 6).The average incubation time for COVID-19 was 12.5 days when the mean age of patients was 60 years, increasing by 1 day every 10 years.

Understanding of the COVID-19 virus
The COVID-19 virus was highly contagious "I think it's very contagious because the news has talked a lot about COVID, right?" "It's very contagious, yes, because many people have been affected by corona and died.""It's very contagious, because there are many schools and companies that work from home, right?"The COVID-19 virus was spread through coughing and sneezing.
"infected if someone else has corona and then coughs" "through sneezing and the virus is carried in the air" The COVID-19 virus was spread through the air, it can even be infected when talking close together.
"The virus can be infected when chatting close together, so you have to keep your distance, because you can get the saliva" The incubation period is between 3-4 days.
"As far as I know, when I come in contact with someone who has Corona, I was asked to take a test 34 days after that" Caused by different diseases.
"different possible causes of the disease" Don't know "oh I don't know what it is" "I have never heard of " "same seems yes" A person with a chronic illness and the elderly.
"Parents, yes, because there are many diseases and the immune system has gone down, right?" "Patients with diabetes and heart disease" "old age people, because the incidence of death and severe generally occurs in old age people" COPD link with COVID-19 COPD patients were more at risk of experiencing COVID-19 infection "It's more risky, yes, because the virus is attacked in the lungs, the place is the same in the breath" "more at risk with impaired lung function because the symptoms of shortness of breath are more severe" COPD patients were not more at risk of experiencing COVID-19 infection."same y seems" "Maybe it's the same because it's a virus so it can attack anyone" COPD patients need to see a doctor if symptoms appear or are positive for infection.
"You need to see a doctor if shortness of breath appears, because the danger can cause death" "if symptoms appear when positive for corona" There was no effect of treatment on the risk of being infected with COVID-19 "It's the same, I've had COVID, and pulmonary medicines are still being used as usual" A strong immune system can help increase the body's resistance, thereby reducing risk in the midst of the COVID-19 pandemic. 37,38][41][42] Chronic lung diseases (COPD, asthma, pulmonary fibrosis, and lung cancer) are at high risk of developing serious conditions if infected with COVID-19.Patients with severe and/or uncontrolled asthma/COPD are at increased risk for more severe infections. 37,38e COPD treatment associated with COVID-19 is inhaled corticosteroids (ICS).ICS are the mainstay of therapy for airway disease and provide beneficial effects including protection against exacerbations.In addition, ICS can reduce the risk of viral acquisition or alternatively suppress viral inflammation and prevent symptom manifestation.However, there is also a theory that ICS has an adverse effect of suppressing the innate immune response against rhinovirus and influenza infection, leading to increased viral replication, although an opposite (protective) effect of ICS has been reported in vitro for seasonal coronavirus 229E11 and SARS-CoV2. 6The COPD treatment guidelines (Global Initiative for Chronic Obstructive Lung Disease or GOLD) recommend that patients with COPD should follow basic infection control measures and wear a mask whenever possible.In most cases, a loose-fitting face covering, or even a face shield is tolerable and effective, but wearing a surgical mask does not appear to affect ventilation even in patients with severe airflow limitation. 43,44The use of inhaled corticosteroids (ICS) in the treatment of COPD during the COVID-19 pandemic is still controversial.ICS had an overall protective effect against exacerbations in COPD patients with a history of exacerbations; however, its use is also associated with an increased risk of pneumonia.A more recent study suggests the use of ICS in COPD does not protect against coronavirus infection.and raises the possibility that it increases the risk of developing COVID-19, but the results are likely to be confounded by indications for ICS.The GOLD report concludes that there are no conclusive data to support changes to maintenance COPD pharmacological treatment including ICS, either to reduce the risk of developing COVID-19 or otherwise because of concerns that pharmacological treatment may increase the risk of developing COVID-19. 44harmacognosy Journal, Vol 15, Issue 5, Sep-Oct, 2023 Some respondents had a low knowledge category (54 of 116), and the most positive perception category (57 of 116).Respondents with high and very high levels of knowledge were 48 of 116 (Table 5).There has been no previous research regarding knowledge and perceptions of the risk of respiration disorders in the COVID-19 pandemic in COPD patients.A similar earlier study, by Mortiel-Lopez et al. (2021), who examined prevalence, attitude, knowledge, and risk perception towards COVID-19 in COPD patients associated with biomass exposure.No significant differences were found to be associated with SARS-CoV-2 infection regarding housing conditions, poor knowledge, attitude, and risk perception toward COVID-19.Living in urban areas and perceiving risk in COVID-19 were significantly associated with increased adherence to sanitary measures and concern for contagion.Around 40% of all patients showed poor risk perception and adherence to sanitary measures towards COVID-19.Another previous study assesses knowledge, attitude, and practice toward COVID-19 among patients with chronic disease.The prevalence of poor knowledge and poor practice was high.[47] CONCLUSION Some respondents had a low knowledge category (54 of 116), and the most positive perception category (57 of 116).Respondents with high and very high levels of knowledge were 48 of 116.The respondent's knowledge of the COVID-19 virus showed that the respondent knows that the COVID-19 virus was a contagious disease and was transmitted through the air (can be through coughing and sneezing).However, during the incubation period of the virus, many respondents answered variously and thought that if someone is in contact with someone who is positive for COVID-19, they should take a test after 3-4 days.But many respondents do not know about the type of COVID-19 virus.
Lorensia A, et al.Knowledge and Perception of the Risk of Respiration Disorders in COVID-19 Pandemic in COPD Patient: A Mixed-Method Study

Table 1 : Interview guidelines for knowledge and perception of the risk of respiration disorders in the COVID-19 pandemic in COPD patient. Pharmacognosy
Journal, Vol 15, Issue 5, Sep-Oct, 2023

Table 3 : Results of the CVR (Content Validity Ratio) questionnaire.
Lorensia A, et al.Knowledge and Perception of the Risk of Respiration Disorders in COVID-19 Pandemic in COPD Patient: A Mixed-Method Study Lorensia A, et al.Knowledge and Perception of the Risk of Respiration Disorders in COVID-19 Pandemic in COPD Patient: A Mixed-Method Study 23,25even types of Betacoronoviruse genus well-known for their respiratory illness caused in humans and are capable of co-evolving, which enhances their pathogenicity and the property of long term adaptation to human host.SARS-CoV, MERS-CoV, and SARS-CoV-2 are the potential members of the Betacoronoviridae family that are very well known for their pandemic outbreak of lethal respiratory infections in humans whereas the other types are associated with mild respiratory illness.23,25