Lessons for communication strategies during health emergencies from a COVID-19 knowledge, attitudes and practices study in an informal settlement in Mumbai, India

Abstract

The COVID-19 pandemic provided lessons for health policies across the globe. We assessed the knowledge, attitudes and practices of vulnerable populations in an informal settlement in Mumbai, India, during the pandemic. We discuss the viability and effectiveness of communication strategies based on these results and offer suggestions for policy modifications regarding awareness generation and behavioral change during health emergencies. The study was conducted through a telephone survey among 460 respondents (233 men and 226 women) from April to May 2021. Television (94%) and family (70%) were the most common sources of information, but they were not the most trusted. Most respondents were aware of the causes and preventive measures of COVID-19, including vaccination. However, this awareness did not always result in changes in attitudes and behavior- 66% perceived low or no risk to COVID-19, while 93% did not consider it essential to wear masks in workspaces and 78% did not sanitize their hands before entering workspaces. More respondents were concerned about loss of employment (53%) than about their physical (10%) or mental (4%) health. The study highlights the need for context-specific communication strategies for vulnerable populations. This includes providing reliable and accessible sources of information, emphasizing accuracy and detail, and adopting a holistic and multidimensional approach to awareness and information sharing.

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Discover Public Health
Research
Lessons forcommunication strategies duringhealth emergencies
fromaCOVID‑19 knowledge, attitudes andpractices study
inaninformal settlement inMumbai, India
SupriyaKrishnan1· JenniferSpencer1· ApurvaTiwari1· SushmitaDas1· AnaghaWaingankar1· SushmaShende1·
ShantiPantvaidya1· VanessaD’souza1· ArmidaFernandez1· AnujaJayaraman1
Received: 7 May 2024 / Accepted: 15 January 2025
© The Author(s) 2025 OPEN
Abstract
The COVID-19 pandemic provided lessons for health policies across the globe. We assessed the knowledge, attitudes
and practices of vulnerable populations in an informal settlement in Mumbai, India, during the pandemic. We discuss
the viability and eectiveness of communication strategies based on these results and oer suggestions for policy
modications regarding awareness generation and behavioral change during health emergencies. The study was
conducted through a telephone survey among 460 respondents (233 men and 226 women) from April to May 2021.
Television (94%) and family (70%) were the most common sources of information, but they were not the most trusted.
Most respondents were aware of the causes and preventive measures of COVID-19, including vaccination. However,
this awareness did not always result in changes in attitudes and behavior- 66% perceived low or no risk to COVID-
19, while 93% did not consider it essential to wear masks in workspaces and 78% did not sanitize their hands before
entering workspaces. More respondents were concerned about loss of employment (53%) than about their physical
(10%) or mental (4%) health. The study highlights the need for context-specic communication strategies for vulnerable
populations. This includes providing reliable and accessible sources of information, emphasizing accuracy and detail,
and adopting a holistic and multidimensional approach to awareness and information sharing.
Keywords COVID-19· Knowledge, attitudes and practices· Health communication· Slums· Mumbai
1 Introduction
The COVID-19 pandemic provided crucial lessons for health policies across the globe. With the onset of the pandemic
and national lockdowns in 2020, attention was directed towards understanding knowledge, attitudes, and practices
(KAP) related to COVID-19. Health communication played a signicant role in generating awareness, shaping attitudes
and instilling preventive behaviors during the COVID-19 pandemic [1].
Health communication strategies aimed at enhancing health-related knowledge, behaviors, attitudes and practices
among the population were adopted by several governments to tackle COVID-19. Mass media including social media,
was widely used to accelerate and disseminate information about the pandemic [2, 3]. Studies conducted in India report
Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12982- 025-
00410-2.
* Anuja Jayaraman, anuja.jayaraman@gmail.com | 1Society forNutrition, Education andHealth Action, Mumbai, India.
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that television was a primary medium for receiving information, followed by social media [4–7]. However, some studies
have also cautioned about the misuse of social media, including the spread of misinformation, bias and fear [8–10].
Other studies have highlighted the importance of inter-personal communication (IPC) through trusted sources such
as doctors [11], and through community-based support systems [12, 13] such as non-governmental organizations and
health workers [14, 15].
Due to multiple communication sources and a diverse media environment [16], health communication strategies
faced the challenge of managing both the pandemic as well as an ‘infodemic’ [17, 18] characterised by an overload
of information from various sources, often contradictory and incorrect [19]. Communication strategies needed to be
continually evolved to tackle behavior change hesitancy and COVID-19 fatigue [20].
Some authors show how health communication related to KAP for COVID-19 needed to be diversied and customized
based on the socioeconomic and demographic characteristics of a community to be successful [21–23]. This is evident
from studies in low and middle-income countries (LMIC) which show how context-specic issues impacted KAP [2, 24,
25] including socioeconomic and demographic characteristics like age, gender, education attainment [6, 26, 27], area of
residence [28], employment status and income [8, 29].
KAP was considered especially important among vulnerable populations such as those living in urban informal
settlements or slums due to factors like high population density [2], illiteracy [5], vulnerability to misinformation [10],
unequal access to basic necessities such as water and sanitation [30, 31], and inadequate public healthcare systems [2].
Studies have shown that communication uptake diered in these settings. While television and social media continued
to be primary sources of information in slums, they were less trusted than healthcare providers and workers [32, 33].
Trust in sources of information also varied in a study related to vaccine hesitancy among underserved populations [34].
Government-curated mobile applications for COVID-19 awareness and information had limited usage in these settings
[24]. Implementing preventive measures, such as social distancing or regular hand washing also posed challenges in
densely populated slum settlements [12, 35]. Although specic health challenges faced in urban informal settlements
during the pandemic have been highlighted [12, 36], and overall strategies for providing immediate relief and containing
COVID-19 spread have been documented [7, 37–39]; existing studies rarely focused on analysing communication
strategies to improve KAP specically for vulnerable settlements in cities.
This study aims to analyse the knowledge and awareness, attitudes, behaviors and practices of residents in the urban
slum settlement of Dharavi, Mumbai, during the COVID-19 pandemic. It seeks to examine the sources of information,
nature of information needs, community fears and perceptions, awareness of COVID-19-related symptoms and preventive
measures, and corresponding practices and behavioral changes adopted. It also explores changes in KAP within the slum
settlement over two time periods during the pandemic. Through these analyses, the study aims to learn from experiences
during the COVID-19 pandemic to provide suggestions on the viability and eectiveness of communication strategies and
interventions for future health emergencies or crises that can be better suited to raise awareness and promote healthy
behaviors in socio-economically vulnerable settings such as slum settlements.
2 Methods
2.1 Study setting
The study was conducted in Dharavi, Mumbai, India. Dharavi is one of Asia’s largest urban informal settlements, covering
an area of 2.4 km2 [40]. It is one of the densest slum settlements in Mumbai, with an estimated population of one million
residents [41]. The area is known for housing thousands of small-scale manufacturing units, including leather, textiles,
recycling, pottery and food, attracting a signicant number of seasonal migrants for employment [42].
During the COVID-19 pandemic, Dharavi emerged as a hotspot in April 2020 with cases peaking in May 2020 (1402
cases, 101 deaths). Cases tapered by March 2021 but rose again to 1531 in April 2021 [40]. The government adopted a
stringent approach to curb the spread of COVID-19 in Dharavi using the “4T’s” strategy– tracing, tracking, testing, and
treating. This strategy, which was successful in limiting COVID-19 spread in Dharavi during the rst wave of the pandemic,
was widely reported as a model for tackling COVID-19 in slums and was replicated in other parts of the country and
beyond [3, 43].
In Dharavi, the Society for Nutrition, Education and Health Action (SNEHA), a non-governmental organization
established in 1999, implements various programs to improve maternal and child health, adolescent health and the
prevention of violence against women and children. During the pandemic, SNEHA’s Mission Dharavi project aimed to
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Research
support residents in Dharavi with necessary, credible and up-to-date information on COVID-19, including preventive
measures, testing facilities, and information on quarantine centers and hospitals [44]. The project was facilitated through
existing community volunteers working in Dharavi. The project also supported the health authorities in disseminating
information within the community and in identifying and referring cases to appropriate facilities in Dharavi. The project
ran from August 2020 to May 2021.
As part of this initiative, two cross-sectional surveys were conducted in Dharavi to assess COVID-19 perceptions, knowl-
edge and preventive practices at the start (September–October 2020) and end (April–May 2021) of the project. Results
from the rst survey have been previously published [40]. The present analysis focuses on the second survey, conducted
during the second wave of COVID-19 in April–May 2021. It also includes a comparison of changes in KAP between the
two surveys to better understand the implications for health communication strategies. Ethical approval for the study
was obtained from the Institutional Ethics Committee of Bandra Holy Family Medical Research Society, Mumbai.
2.2 Data collection andparticipants
Participants for the study were selected from a sampling universe of 15,000 households with an estimated population
of 75,000 in three administrative divisions of Dharavi. The participants were beneciaries of the Mission Dharavi project,
aged 18years and older. The phone numbers for these households were collected by SNEHA from two sources: frontline
health workers of the Integrated Child Development Services, a national child health and nutrition community-based
program that caters to vulnerable populations and community volunteers associated with SNEHA. A random sample
of households was drawn from the list of phone numbers using MS Excel. For households with more than one contact
number, one number was randomly selected for inclusion in the sampling frame.
We estimated a sample size of 382 for each survey, based on ± 5% condence interval calculation from a conservative
50% prevalence estimate, similar to Austrian etal. [12]. Considering a 15% non-response rate for refusals and erroneous
data (based on earlier surveys in the area), the nal estimated sample size required was 450. During the survey, responses
were received from 460 individuals. Since the Mission Dharavi project was implemented at the community level and not
focused on any specic group or cohort, we did not want to limit the sampling frame to only those who were interviewed
in the rst survey; therefore, participants of the second survey were not the same as the rst survey.
Data were collected through structured phone interviews due to COVID-19-related restrictions on movement imposed
by the Government of Maharashtra. A team of seven researchers, consisting of six investigators and one supervisor,
conducted the data collection. The interviews were conducted in Hindi, a common local language spoken in Dharavi.
Each interview lasted for about 15 to 20minutes. Before data collection, the investigators and supervisor underwent
training on several aspects: assigning unique identiers to households and participants, approaching household mem-
bers, best practices for phone surveys, protocols for making phone calls (such as calling the same number three times
if not answered and contacting all available phone numbers for each household), and obtaining informed consent for
participation. Investigators received detailed training on the interview process and questions, including multiple mock
sessions. The phone numbers collected by SNEHA were shared with the surveyors. Prior to conducting each interview,
informed verbal consent was obtained from respondents.
The survey included 38 questions, many of which were adopted from the World Health Organization’s “Survey Tool and
Guidance: Rapid, Simple, Flexible Behavioral Insights on COVID-19” and a survey tool used by Austrian and colleagues
[12] to assess COVID-19-related KAP in informal settlements in Nairobi, Kenya. The questions were modied to suit Indian
contextual specicities and the particular situation in Dharavi during the COVID-19 pandemic. For example, questions
related to use of masks and local helplines were added and various options in the multiple-choice were tailored to the
local context. For instance, in questions about sources of information, options such as public announcements, local cable
networks, and names of local government programmes implemented in the area were included.
The survey covered sections on demographic information, sources of COVID-19 information, knowledge and aware-
ness of COVID-19 symptoms, preventive behaviors, perceived risk of the disease, fears and worries during the pandemic
and awareness, uptake and perception related to the COVID-19 vaccine (refer Annexure 1 for the complete question-
naire). The survey tool for this study was the same as the one used for the rst survey, with the addition of questions
about the COVID-19 vaccine.
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2.3 Data analysis
STATA (Version 14) was used for analysis. Survey responses were analyzed as frequencies and percentages. Responses
were examined among all respondents and by gender (male and female; ‘other’ gender not included due to small
sample size) and age group (categorized as < 35 (younger) and ≥ 35years (older), with 35 being the median age of
the sample). Chi-square tests were used to evaluate the statistical significance of differences in responses by sex
and age while Fisher’s test was used for cell counts under five. A p-value of less than 0.05 was considered statisti-
cally significant. Overall changes in responses on KAP responses between this survey and the first survey were also
examined. No adjustments were made for multiple comparisons.
3 Results
Demographic characteristics of the survey respondents are presented in Table1. A total of 460 persons were surveyed,
of whom 50% were below the age of 35 and 49% were female.
3.1 Knowledge
3.1.1 Sources ofinformation andtrust onsources ofinformation
Table2 shows that the most common source of COVID-19-related information was television (94%) followed by
family (70%) and community health workers (CHWs) (58%). CHWs included both community health workers and
community-based volunteers affiliated with the government and non-governmental organizations. More men (58%)
reported social media as a source of information than women (48%) (p < 0.05). In addition, 58% of the younger age
group reported social media as a source of information, compared to 48% of the older group. CHWs and doctors were
the most trusted sources of information (97%). Other sources, such as public announcements through megaphone
and posters, were more trusted than television and social media but were not widely reported as common sources
of information. Although there wasa gender difference in the trust placed in social media (80% of men versus 72%
of women), this was not statistically significant.
Table 1 Socio-demographic
characteristics of survey
respondents during the
COVID-19 pandemic among
Dharavi residents, Mumbai,
India (N = 460)
Characteristics n (%)
Age (years)
 < 20 19 (4)
20–34 211 (46)
35–49 187 (41)
50–64 35 (8)
 ≥ 65 8 (2)
Gender
Female 226 (49)
Male 233 (51)
Others 1 (0.2)
Sanitation facilities
Shared toilet 359 (78)
Private toilet 100 (22)
Other 1 (0.2)
Average household size 5
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3.1.2 COVID‑19 awareness: transmission, symptoms andpreventive measures
Seventy-eight percent of respondents knew that COVID-19 could spread through respiratory droplets, and 62% were
aware that it could spread through an infected person (Table3). Awareness of fever and dry cough as symptoms of
COVID-19 was over 90% and was similar among men and women, and both age groups. Awareness of less common
symptoms, such as loss of taste, fatigue, chest pain, was reported by 64% respondents, with a significant difference
between younger (69%) and older (59%) respondents. Awareness of handwashing as a COVID-19 prevention measure
was universal. Most of the respondents recognized social distancing (87%) and wearing masks (95%) as COVID-19
prevention measures. However, avoiding contact with infected persons (13%) and maintaining respiratory etiquette
(17%) were lesser-known preventive measures (Table3).
Accuracy of information related to COVID-19 symptoms and spread (> 50% correct answers) was the highest among
those who reported their source of information as doctors (79%), public announcements via megaphone (80%) and
posters (78%). It was lowest among those who received information from more commonly used sources, such as
family (61%) and television (62%) (p < 0.05) (see Annexure TableA1). Awareness of helplines was low (average 28%)
and showed a significant gender difference- 38% for males and 17% for females. Only 9% of those aware of COVID-19
helplines used them (see Annexure TableA2).
3.1.3 Vaccine awareness andperception
Most respondents (97%) were aware of the COVID-19 vaccine (Table4). At the time of the survey, nearly one-fifth of
the respondents (18%) reported taking the first or second dose of the vaccine. Among those who had not taken the
vaccine, 63% expressed a willingness to take the vaccine when made available, with significant gender and age dif-
ferences (Table4). More than one-third (37%) reported that they do not intend to take the vaccine or are uncertain
about doing so, with a significant difference between women (46%) and men (27%). Among those who did not intend
to take the vaccine, concerns about vaccine safety (34%) and the potential side effects (23%) were major factors (see
Annexure TableA3).
Table 2 Sources of information and trust on sources during the COVID-19 pandemic among Dharavi residents, Mumbai, India
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
a percent calculated among those who are users of the source of information (for example: 383/431 for television users = 89%)
Information Sources and Trust Total (N = 460) Gender Age
Male (N = 233) Female (N = 226) p-value < 35 (N = 230) > = 35 (N = 230) p-value
Source of information
Television 431 (94) 222 (95) 208 (92) 0.2 216 (94) 215 (94) 0.9
Social media 244 (53) 135 (58) 109 (48) 0.04 134 (58) 110 (48) 0.03
WhatsApp 224 (49) 121 (52) 103 (46) 0.2 119 (52) 105 (46) 0.2
Family 322 (70) 162 (70) 160 (71) 0.8 168 (73) 154 (67) 0.2
CHWs 265 (58) 129 (55) 135 (60) 0.3 139 (60) 126 (55) 0.2
Doctors 117 (25) 61 (26) 56 (25) 0.7 60 (26) 57 (25) 0.7
Posters 155 (34) 83 (36) 72 (32) 0.4 76 (33) 79 (34) 0.8
Public announcement 64 (14) 43 (19) 21 (9) 0.005 32 (14) 32 (14) 1.0
Trust in sources of informationa
Television 383 (89) 191 (86) 191 (92) 0.06 194 (90) 189 (88) 0.5
Social media 186 (76) 108 (80) 78 (72) 0.1 101 (75) 85 (77) 0.7
WhatsApp 163 (73) 84 (69) 79 (77) 0.2 86 (72) 77 (73) 0.8
Family 282 (88) 142 (88) 140 (88) 0.9 150 (89) 132 (86) 0.3
CHWs 256 (97) 122 (95) 135 (99) 0.3 136 (98) 120 (95) 0.2
Doctors 113 (97) 60 (98) 53 (95) 0.3 57 (95) 56 (98) 0.3
Posters 140 (90) 70 (84) 70 (97) 0.007 70 (92) 70 (89) 0.5
Public announcement 58 (91) 37 (86) 21 (100) 0.07 29 (91) 29 (91) 1.0
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Table 3 Knowledge of COVID-19 transmission, symptoms and preventive measures during the COVID-19 pandemic among Dharavi residents, Mumbai, India
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
a Uncommon symptoms include loss of taste, loss of speech, diarrhea, fatigue, muscle ache, chest pain and skin rash
COVID-19 Transmission, Symptoms and Preven-
tive Measures Total (N = 460) Gender Age
Male (N = 233) Female (N = 226) p-value < 35 (N = 230) > = 35 (N = 230) p-value
Transmission/spread
Droplet 357 (78) 189 (81) 167 (74) 0.06 190 (83) 167 (73) 0.01
Airborne 114 (25) 57 (25) 56 (25) 0.9 57 (25) 57 (25) 1.0
Infected person 285 (62) 148 (64) 136 (60) 0.5 151 (66) 134 (58) 0.1
Symptoms
Fever 440 (96) 227 (97) 212 (94) 0.06 222 (97) 218 (95) 0.4
Dry cough 419 (91) 214 (92) 204 (90) 0.6 211 (92) 208 (90) 0.6
Breathing diculty 325 (71) 165 (71) 159 (70) 0.9 165 (72) 160 (70) 0.6
Aches and pains 194 (42) 97 (42) 96 (43) 0.9 106 (46) 88 (38) 0.09
Sore throat 190 (41) 92 (40) 98 (43) 0.4 97 (42) 93 (40) 0.7
Headache 140 (30) 69 (30) 71 (31) 0.7 77 (34) 63 (27) 0.2
Runny nose 167 (36) 85 (37) 82 (36) 0.9 78 (34) 89 (39) 0.3
Uncommon symptoms (any one)a294 (64) 150 (64) 143 (63) 0.8 159 (69) 135 (59) 0.02
Preventive measures
Avoid direct contact with infected person 60 (13) 40 (17) 20 (9) 0.008 38 (17) 22 (10) 0.03
Respiratory etiquette 78 (17) 47 (20) 31 (14) 0.07 53 (23) 25 (11) 0.001
Social distancing 401 (87) 199 (85) 201 (89) 0.3 204 (89) 197 (86) 0.3
Wearing mask 436 (95) 219 (94) 216 (96) 0.5 220 (96) 216 (94) 0.4
Hand washing 458 (100) 231 (99) 226 (100) 0.2 230 (100) 228 (99) 0.2
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Table 4 COVID-19 vaccine awareness and perceptions during the COVID-19 pandemic among Dharavi residents, Mumbai, India
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
a Among those who have not received vaccine (Males N = 184; Females N = 194; Age < 35 N = 196; Age > = 35 N = 183)
1 India started its vaccine program in phases in January 2021. By April 2021, vaccination was available for those aged 45 and above and by May 2021 for those aged 18 and above. COVID-
19 vaccines were available in both public and private health facilities in Dharavi.
Vaccine awareness and prevention1Total (N = 460) Gender Age
Male (N = 233) Female (N = 226) p-value Age < 35 (N = 230) Age > = 35 (N = 230) p-value
Aware about the vaccine 444 (97) 227 (97) 217 (96) 0.4 218 (95) 226 (98) 0.04
Received vaccine 81 (18) 49 (21) 32 (14) 0.05 34 (15) 47 (20) 0.1
Intend to get the vaccinea240 (63) 135 (73) 105 (54) 0.001 110 (56) 130 (71) 0.007
Do not intend to take the vaccine/don’t
know whether will take vaccine 139 (37) 49 (27) 89 (46) 86 (44) 53 (29)
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3.2 Attitudes
3.2.1 Perceived risk andefficacy ofpreventive measures
Over fty percent of the respondents felt they had a low risk of contracting COVID-19, while 19% perceived a medium risk
and 8% felt they were at high risk. Most respondents considered preventive measures very eective (48%) or somewhat
eective (39%) (Table5).
3.2.2 Fear, worries andinformation needs duringCOVID‑19
Over 50% of the respondents had fears related to loss of employment which was more than their concerns about physical
(10%) or mental (4%) health. More than half of the older age group (59%) was worried about unemployment, a signi-
cant dierence compared to the younger age group (47%). As presented in Table6, women were also signicantly more
worried about being unable to pay bills, the health of their loved ones and restricted access to food supplies compared
to men. Thirty-ve percent of respondents reported no worries regarding the pandemic and related restrictions, with a
signicant gender dierence (40% of men versus 30% of women).
Sixty-nine percent of men did not want any more information regarding the pandemic and related restrictions, com-
pared to 54% of women (p < 0.05). Additionally, there were statistically signicant dierences in the type of information
desired- more women than men wanted information on vaccination, the economic impact and availability of groceries.
We analyzed whether there were dierences in information needs and fears based on the source of COVID-19 informa-
tion of the respondents; however, the dierences were not largely signicant (see Annexure TableA4). We also compared
respondents’ attitudes towards wanting more information with the accuracy of their COVID-19 knowledge. It was found
that among those who did not want more information, 43% had more incorrect answers (> 50%) regarding COVID-19
spread and symptoms; however, this relationship was not signicant (see Annexure TableA5).
3.3 Practices
3.3.1 Healthy/protective behaviors duringCOVID‑19
More than 85% of both men and women, across all age groups, reported using handwashing, masks and social
distancing as health-protective behaviors in the week prior to the survey (Table7). A detailed analysis shows that
while close to 90% of the respondents reported always wearing a mask while going out in the past week, less than
30% of men and women felt the need to wear masks while going to the market, visiting common toilets, walking on
the street, using public transport or at their workplace. Similarly, while more than 90% reported cleaning or washing
Table 5 COVID-19 related attitudes of perceived risk and perceived ecacy of preventive measures during the COVID-19 pandemic among
Dharavi residents, Mumbai, India
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
Degree of risk/eectiveness Total (N = 460) Gender Age
Male (N = 233) Female (N = 226) p-value < 35 (N = 230) > = 35 (N = 230) p-value
Perceived risk of getting COVID-19
No risk at all 53 (12) 33 (14) 19 (8) 0.09 30 (13) 23 (10) 0.9
Low risk 250 (54) 125 (54) 125 (55) 123 (54) 127 (55)
Medium risk 89 (19) 47 (20) 42 (19) 46 (20) 43 (19)
High risk 35 (8) 12 (5) 23 (10) 17 (7) 18 (8)
Don’t know 31 (7) 16 (7) 15 (7) 13 (6) 18 (8)
Perceived ecacy for COVID-19 preventive behaviors
Very eective 222 (48) 121 (52) 101 (45) 0.4 116 (50) 106 (46) 0.1
Somewhat eective 179 (39) 86 (37) 92 (41) 91 (40) 88 (38)
A little or not eective at all 59 (11) 26 (11) 33 (15) 23 (10) 36 (16)
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Table 6 Fear, worries and information needs during the COVID-19 pandemic among Dharavi residents, Mumbai, India
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
Fears, Worries and Information Needs Total
(N = 460) Gender Age
Male
(N = 233) Female
(N = 226) p-value < 35 (N = 230) ≥ 35 (N = 230) p-value
Fear and worries
No worries 162 (35) 94 (40) 68 (30) 0.02 90 (39) 72 (31) 0.08
Becoming unemployed 245 (53) 122 (52) 122 (54) 0.7 109 (47) 136 (59) 0.01
Not being able to pay bills 129 (28) 50 (22) 78 (35) 0.002 65 (28) 64 (28) 0.9
Health of your loved ones 78 (17) 28 (12) 49 (22) 0.006 40 (17) 38 (17) 0.8
Restricted access to food supplies 92 (20) 32 (14) 59 (26) 0.001 43 (19) 49 (21) 0.5
Restricted liberty of movement 57 (12) 26 (11) 30 (13) 0.5 28 (12) 29 (13) 0.9
Personal mental health 17 (4) 9 (4) 8 (4) 0.9 5 (2) 12 (5) 0.08
Personal physical health 46 (10) 18 (8) 27 (12) 0.1 16 (7) 30 (13) 0.03
Information needs
Don’t want any more information 282 (61) 160 (69) 121 (54) 0.001 143 (62) 139 (60) 0.7
Information on protecting myself and my family against COVID-19 44 (10) 19 (8) 25 (11) 0.3 23 (10) 21 (9) 0.8
Information on vaccination 91 (20) 34 (15) 57 (25) 0.004 52 (23) 39 (17) 0.1
Information on the economic impact of the pandemic 33 (7) 9 (4) 24 (11) 0.005 17 (7) 16 (7) 0.9
Information about availability of ration/groceries 33 (7) 11 (5) 22 (10) 0.04 11 (5) 22 (10) 0.05
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Table 7 COVID-19 protective behaviors (exhibited in the week prior to the survey) during the COVID-19 pandemic among Dharavi residents, Mumbai, India
Preventive practices/behaviors Total (N = 460) Gender Age
Male (N = 233) Female (N = 226) p-value < 35 (N = 230) ≥ 35 (N = 230) p-value
Preventive practices in the past week
Handwashing 450 (98) 223 (96) 226 (100) 0.002 225 (98) 225 (98) 1.0
Use of mask 441 (96) 223 (96) 217 (96) 0.9 218 (95) 223 (97) 0.2
Social distancing 399 (87) 199 (85) 199 (88) 0.4 201 (87) 198 (86) 0.7
Disinfecting surfaces 95 (21) 41 (18) 54 (24) 0.1 53 (23) 42 (18) 0.2
In the past week have you worn a mask when leaving home
Never 17 (4) 3 (1) 14 (6) < 0.0001 11 (5) 6 (3) 0.09
Always 407 (89) 223 (96) 183 (81) 196 (85) 211 (92)
Sometimes 36 (8) 7 (3) 29 (13) 23 (10) 13 (6)
Where do you think you should wear a mask
Everywhere outside my house 336 (73) 179 (77) 156 (69) 0.06 167 (73) 169 (74) 0.8
In supermarkets/markets/shops 129 (28) 57 (25) 72 (32) 0.08 64 (28) 65 (28) 0.9
While using public toilets 114 (25) 55 (24) 59 (26) 0.5 54 (24) 60 (26) 0.5
While walking on the streets 70 (15) 37 (16) 33 (15) 0.7 39 (17) 31 (14) 0.3
When using public transport 88 (19) 49 (21) 39 (17) 0.3 46 (20) 42 (18) 0.6
At workplace 31 (7) 20 (9) 11 (5) 0.1 15 (7) 16 (7) 0.8
Type of mask used in the past week
Reusable cloth mask 423 (92) 218 (94) 204 (90) 0.2 210 (91) 213 (93) 0.6
Disposable medical mask 11 (2) 5 (2) 6 (3) 0.7 7 (3) 4 (2) 0.4
Medical surgical mask (N95) 24 (5) 17 (7) 7 (3) 0.04 17 (7) 7 (3) 0.04
 Scarfa11 (2) 2 (0.9) 9 (4) 0.03 4 (2) 7 (3) 0.4
How often was the reusable mask washed in the
past one week? Total (N = 423) Male (N = 218) Female (N = 204) p-value < 35 (N = 210) > 35 (N = 213) p-value
After every use 392 (93) 203 (93) 188 (92) 0.7 200 (95) 192 (90) 0.04
After 2–3 uses 31 (7) 15 (7) 16 (8) 10 (5) 21 (10)
Washed hands with soap/used sanitizer Total (N = 460) Male (N = 233) Female (N = 226) p-value < 35 (N = 227) ≥ 35 (N = 149) p-value
Before preparing food 192 (42) 30 (13) 162 (72) < 0.0001 110 (48) 82 (36) 0.008
Before eating 428 (93) 214 (92) 213 (94) 0.3 216 (94) 212 (92) 0.5
After using the toilet 430 (94) 213 (91) 216 (96) 0.07 210 (91) 220 (96) 0.06
After changing a baby’s diaper 61 (13) 12 (5) 49 (22) < 0.0001 43 (19) 18 (8) 0.001
After coming home from a public place 341 (74) 181 (78) 160 (71) 0.1 168 (73) 173 (75) 0.6
After coughing/sneezing 46 (10) 24 (10) 22 (10) 0.8 27 (12) 19 (8) 0.2
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Table 7 (continued)
Washed hands with soap/used sanitizer Total (N = 460) Male (N = 233) Female (N = 226) p-value < 35 (N = 227) ≥ 35 (N = 149) p-value
Before or after caring for a sick or vulnerable
person 36 (8) 15 (6) 21 (9) 0.3 25 (11) 11 (5) 0.01
Before leaving the house 97 (21) 55 (24) 42 (19) 0.2 47 (20) 50 (22) 0.7
Before entering a shop/oce 73 (16) 47 (20) 26 (12) 0.01 43 (19) 30 (13) 0.1
After entering a shop/oce 101 (22) 60 (26) 41 (18) 0.05 58 (25) 43 (19) 0.1
Numbers shown in the cells are n (%). Statistical signicance (p < 0.05) highlighted in bold
a Scarf/mask/towel/dupatta/naqaab
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their hands with soap or sanitizer before eating and after using the toilet, less than 30% reported handwashing before
or after entering the workspace or before leaving the house. Moreover, less than 15% reported washing their hands
after coughing, sneezing, changing a baby’s diaper or after caring for a sick person (Table7).
3.4 Comparing changes inKAP withthefirst survey
This section provides a brief comparison of the results from the second survey with those from the first survey, which
was previously published [40].
3.4.1 Sources ofinformation forCOVID‑19
Television, family, CHW and social media were common sources of information for COVID-19 in both the surveys. The
use of CHW as a source of information increased from 33% in the first survey to 58% in the second survey, while the
use of television as a source of information remained almost the same- 90% in the first survey and 94% in the second
survey. In both the surveys, CHWs and doctors were the most trusted sources of information, with more than 90%
respondents expressing trust in these sources. Additionally, the level of trust in the most common sources increased-
trust in television rose from 80% in the first survey to 89% in the second survey, and trust in family rose from 84% in
the first survey to 88% in the second survey (see Annexure Figure A1).
3.4.2 Knowledge
The comparison between the first and second surveys indicates and increased awareness of most symptoms (Fig.1).
Seventy-eight percent of respondents in the second survey reported that COVID-19 could spread through droplets,
compared to 69% in the first survey. In contrast, 62% of the respondents in the second survey reported that it could
spread from infected persons, compared to 76% in the first survey.
Fig. 1 Change in awareness of COVID-19 spread and symptoms between the rst and second surveys among Dharavi residents, Mumbai,
India (gure shows percentage)
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3.4.3 Attitudes
Unemployment (44% in the rst survey and 53% in the second survey) and inability to pay bills (26% in the rst survey
and 28% in the second survey) were the main reasons for worry among the respondents and increased between the two
surveys (Fig.2). In contrast, worries related to health of loved ones decreased from 26% in the rst survey to 17% in the
second survey. Also, over one-third of the respondents expressed no worries at all in both surveys.
There was an increase in the proportion of respondents who required no further information related to COVID-19, a
10% increase among men and a 5% increase among women between the two surveys (see Annexure Figure A2).
3.4.4 Practices
In both surveys, more than 80% of respondents reported practicing handwashing, using masks and maintaining social
distancing as measures to prevent COVID-19 (Fig.3). However, the proportion of respondents who felt the need to wear
masks on the street fell from 24% in the rst survey to 15% in the second survey. Similarly, the proportion of respondents
who washed their hands or sanitized before leaving their homes also decreased, from 29% in the rst survey to 21% in
the second survey. (Fig.3).
4 Discussion
The study analyses KAP during the second wave of COVID-19 in the slum settlements of Dharavi, Mumbai. When the
pandemic broke out in Mumbai, the state and local governments expressed concern about increasing cases in the densely
populated slum settlements of the city. This led to stricter measures of tracing, tracking, testing and treating (“4T” pro-
gram), which helped curb the spread of COVID-19 in Dharavi [31, 43]. Studies on COVID-19 strategies in Dharavi have
primarily explored the implementation of this model [14, 45, 46], and the need for improved services such as sanitation
[47]. However, our results reveal that challenges in awareness, such as incomplete information, fears and worries, and
inconsistent adherence to preventive behaviors persisted, highlighting the need for better communication strategies.
Based on the insights from this study, we oer recommendations for designing and implementing more eective com-
munication strategies in crises such as health emergencies, especially in socio-economically vulnerable settlements.
The ndings emphasize various channels for crisis communication, which includes mass media such as television and
social networking platforms, mid-media sources such as posters and local public announcements on megaphones, and
Fig. 2 Change in fears and worries related to COVID-19 pandemic between the rst and second surveys among Dharavi residents, Mumbai,
India (gure shows percentage)
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IPC channels like information exchange within families, with doctors, and through CHWs. In our setting, television and
family, followed by CHWs and social media, emerged as the most frequently utilized sources of COVID-19 information,
aligning with the results of prior research studies [12, 32, 48]. Our study showed that the sources of information varied
between dierent groups based on accessibility; for example, social media was used more by males and younger respond-
ents. Primary sources of information, such as television and family, were less trusted compared to mid-media sources
like posters and public announcements on megaphones, while IPC, especially through government sources, was most
trusted. The accuracy of responses related to COVID-19 symptoms and preventive behaviors was higher among those
who trusted doctors and public announcements. They also reported fewer worries than those who accessed information
through mass media such as television.
This highlights two considerations for developing crisis communication strategies. First, there is a need for commu-
nication strategies to be designed through mediums that cater to diverse groups. Public announcements on megaphones
Fig. 3 Change in protective behaviors for COVID-19 between the rst and second surveys during the COVID-19 among Dharavi residents,
Mumbai, India (gure shows percentage)
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or interactions with government health workers and doctors in the local language are more feasible in our setting
than information shared through social media, which was less accessible, especially to women and older respond-
ents. Second, health-related information must be disseminated through trusted sources in the community to ensure its
reliability and effectiveness, as highlighted by other studies [11, 14, 49]. In our case, CHWs and doctors providing
information through IPC and information shared by government sources, was much more trusted than the media
sources. Health workers and volunteers were also crucial for implementing the “4T” program in Dharavi [31, 43]. IPC
from government health workers appears to be an effective and trusted means of crisis communication. However,
it is often challenging for health workers to reach large populations individually. This can be supplemented by com-
monly used media with broader and faster reach, while ensuring its accuracy and reliability through information
sourced and verified by the government, such as government-led advertisements on television. The importance of
such trusted sources of information has also been highlighted in similar contexts [12, 50].
The study highlights that, while multiple sources of information led to high levels of awareness, this did not trans-
late into improved attitudes and practices within the population, also reflected in other LMIC contexts [51]. Awareness
was almost universal for the most common symptoms and general preventive practices but lacked in-depth, detailed
information. For instance, awareness regarding the need for handwashing before meals or after using the toilet may
have continued from pre-pandemic routines. Specific preventive measures, such as handwashing before and after
entering workplaces or shops, or after caring for an infected person, were rarely practiced. Similarly, while aware-
ness of wearing masks as a preventive measure was almost universal, it was not consistently practiced insituations
such as in community toilets or workplaces. Furthermore, wearing masks and handwashing were more commonly
known preventive measures compared to advice such as avoiding contact with infected individuals or practicing
respiratory etiquette.
Attitudes towards the need for more information and specic practices, such as handwashing before and after enter-
ing workspace, shops or home also declined between the two surveys. Further, respondents believed in the ecacy of
the general preventive measures, while their perceived risk of contracting the disease was low. Excessive information
from multiple sources, a belief in achieved immunity and the perception that media as over reporting and exaggerat-
ing information, as reported through our qualitative ndings [40], may have contributed to the low perceived risk and
reluctance to seek more information related to COVID-19. This shows how a lack of adequate and in-depth information
impacts attitudes and, consequently, preventive practices. It highlights the need for crisis communication strategies
and awareness messaging that provide accurate, in-depth and detailed information. Mid-media sources, such as posters
and pamphlets, can serve as eective visual aids for detailed awareness messaging, especially when shared by trusted
sources such as CHWs.
The study also found that most respondents primarily feared unemployment and nancial hardship more than their
health, which corresponds with ndings by Kuang and colleagues [2] in Tamil Nadu, India. Dharavi was declared a success
story due to the containment and control of COVID-19. However, the loss of jobs during pandemic-related restrictions
led to persistent and even increased fears related to livelihood and food security between the two surveys. Information
needs focused more on livelihood and food security than on health. This highlights the need to adopt context-specic and
need-based communication strategies that are more holistic and multidimensional. Although COVID-19 was a health crisis,
there was a need for information not just on the disease and its prevention or health services but also on other daily life
functions that were disrupted due to the pandemic. Therefore, awareness and information messaging needed to address
community needs such as livelihood and food insecurity, to alleviate fears and provide assurance. Addressing stigma, fear
and discrimination also needed to be a crucial part of IPC and messaging. Context-based strategies are also essential for
improving preventive practice and behaviors. As an example, promoting the importance of frequent handwashing may
not be practical in areas with limited access to clean water and sanitation facilities [47]. In such cases, a more eective
approach could involve the government distributing hand sanitizers that do not require water.
The study thus provides information on residents’ KAP in a dense slum settlement during the second wave of the
COVID-19 pandemic in Dharavi, Mumbai. It highlights several ways in which government communication strategies
during crises such as the pandemic, can be context-specic, multidimensional, focused, in-depth and trustworthy to
eectively create awareness, drive behavior change and alleviate fears. This study oers an opportunity to learn from
the pandemic experience and to adopt context-based and holistic response mechanisms in case of future crises and
emergencies, especially for vulnerable populations.
By using a survey tool adapted from a standardized one, our findings can be compared with those in various other
community settings. We achieved a balanced representation of male and female respondents across different age
groups, making the results a reliable reflection of the community perspective by age and gender. The well-established
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trust and relationships between SNEHA and the Dharavi community allowed us to conduct the survey telephonically,
even during the second wave of the pandemic. However, the study does have some limitations.
4.1 Limitations
Firstly, conducting a survey during the pandemic presented several logistical challenges. Due to restricted movement,
we could not conduct face-to-face interviews and were limited to phone-based data collection. This may have led to
a biased sample, as we could only reach those with a phone or whose phones were available and reachable. Secondly,
because of the increased stress levels caused by the pandemic, we intentionally kept the questionnaire brief and did not
collect detailed demographic data, including information on income, education, and occupation. This decision limited
the depth of analysis possible with the data. Additionally, the Hindi language was predominantly used to conduct the
interviews; it is possible that this may have resulted in missing respondents who were more comfortable speaking a
dierent language. Thirdly, the study sample included only beneciaries of the Mission Dharavi project. We recognize
that including individuals who were not part of SNEHA’s project could potentially inuence the study’s ndings. Lastly,
because Dharavi was initially highlighted as a COVID-19 hotspot and later as a success story, the responses may have
been inuenced by a social desirability bias.
In summary, despite overcoming signicant challenges and vulnerabilities posed by the COVID-19 pandemic and
subsequent lockdowns, it is likely that we will face similar situations in the future unless we learn valuable lessons from
past experiences. This study oers insights into one such lesson- adopting holistic and multidimensional approaches to
design context-specic responses and information strategies tailored to the needs of vulnerable communities during
crises and emergencies.
Acknowledgements We thank all our participants for taking their time to answer our questions and share their views with us. We are grateful to
the donors of the project for all their support. We appreciate the work done by SNEHA sta and community volunteers during the pandemic.
Finally, we are grateful to the members of the SNEHA Research Group for their valuable inputs on the study.
Author contributions Study conceptualization: SK and AJ. Design and data collection: AJ, AT, SD, AW, SS, SP, VD, AF. Data analysis, manuscript
preparation and editing: SK, JS and AJ. Reviewing and approving the nal manuscript: All authors.
Funding This research was funded by the Epic Foundation and the Mission Dharavi project was funded by Give Foundation. None of the
funders had any role in study design, data collection and analysis, publication decisions, or manuscript preparation.
Data availability The datasets generated during and/or analysed during the current study are not publicly available due to the data-sharing
policies of our organization, SNEHA, which restrict public access to protect participant anonymity. However, data are available from the cor-
responding author upon reasonable request.
Code availability Not applicable.
Declarations
Ethics approval and consent to participate The authors conrm that the research was conducted in accordance with the Declaration of Helsinki.
Ethical approval for the study was obtained from the Institutional Ethics Committee of the Bandra Holy Family Medical Research Society in
Mumbai. All respondents provided informed verbal consent to participate in the study.
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which
permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modied the licensed material. You
do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party
material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If
material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds
the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco
mmons. org/ licen ses/ by- nc- nd/4. 0/.
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