Concepts and challenges in the use

of Knowledge-Attitude-Practice surveys:

Literature review

Ellen Vandamme, August 2009

Department of Animal Health, Institute of Tropical Medicine, Antwerp, Belgium

SUMMARY

A KAP survey is conducted to investigate human behaviour related to a certain topic. It

identifies what people know (Knowledge), how they feel (Attitude) and what they do

(Practice). When browsing through literature, three different but partially overlapping

objectives of this type of studies can be identified. KAP studies can be used for

diagnostic purposes for which they describe the population’s current knowledge, attitude

and practice. Secondly they can be implemented to increase insights in a current situation

and help design appropriate specific interventions. Thirdly, they can be used as an

evaluation tool to evaluate the effectiveness of certain interventions or programmes.

When studying the different methodologies used in the past to implement KAP surveys it

becomes clear that a standardized methodology is nonexistent. Therefore we might state

that the KAP survey should be perceived more as a conceptual framework to study

human behaviour instead of a specific methodology. A general problem related to KAP

surveys is the difficulty to obtain reliable data and information on people’s knowledge

and attitudes. This is a general problem related to quantitative studies. However a KAP

survey or questionnaire still remains a very useful tool in development studies because

measuring local people’s mindset and behaviour should always be a first step in the

development or evaluation of any kind of program or intervention.

This literature overview considers definitions and objectives of the KAP survey, explains

the used methodologies and limitations described in literature.

DEFINITIONS KAP stands for Knowledge, Attitude & Practice. It is used to investigate human

behaviour concerning a topic:

• What the respondents know about it (K)

• How the respondents feel about it (A)

• What the respondents do about it (P)

(IDAF, 1994)

A KAP survey is a representative study of a specific population to collect information on

what is known, believed and done in relation to a particular topic (Wood & Tsu, 2008).

The KAP survey was developed in the 50’s and was originally designed to research

family planning in the Third World. These sample surveys were very popular during the

fifties and sixties: several hundred KAP studies were carried out in several dozen

countries (Bulmer and Warwick, 1998).

OBJECTIVES

In literature three different objectives of KAP studies can be found. The first objective is

to assess KAP towards a concept. The second objective is to use it for problem

identification and intervention planning. Thirdly KAP studies can be used as an

evaluation tool.

In human health research, many studies can be found were KAP studies were used for the

first objective: to assess the KAP towards a disease. These studies help to understand

what people know about the diseases: transmission, symptoms, ability to diagnose,

intervention necessity, risk behaviour… In addition, KAP surveys show how people feel

towards the disease: are they scared of getting infected, are they willing to protect

themselves against it and are they aware of the danger of the disease? The practice

questions give an idea on how they protect themselves against the disease and whether

they engage in any risk behaviour. This gives an idea of the danger of an outbreak or of

the spreading of the disease. Three different examples are given below.

Mfinanga et al. (2003) used a KAP survey to research knowledge, attitude and practice

towards tuberculosis in different tribes in Tanzania. They found the knowledge of

tuberculosis to be limited in all tribes. Secondly they concluded that all tribes had habits

and beliefs that might expose them to both bovine and human tuberculosis but that some

tribes practice more such habits then others. These results allow for a prioritisation of the

sites for tuberculosis control.

Matibag et al. (2007) performed a KAP study in Sri Lanka to determine the level of

knowledge, attitude and practice (KAP) of rabies management and control. They found

the level of awareness of rabies and the level of receptiveness to rabies control measures

to be high. According to them inaccessibility to facilities and lack of services explains

attitudes and practices of the respondents.

Rwiza et al. (1993) discovered a lot of wrong beliefs and attitudes towards epilepsy in

rural Tanzania. Respondents mentioned various causes of epilepsy including heredity,

witchcraft, infection of the spinal cord, hernia. Others believed epilepsy was infectious

through physical contact, flatus, breath, excretions, sharing food. There was equal

misconception about the control of epilepsy as some respondents stated it could not be

cured and others believed it could not even be controlled at all. They concluded that there

is a need for health education on epilepsy in Tanzania and that these results should form

the basis for design and execution of a health education and a primary health care

program in epilepsy control.

Secondly KAP surveys can be used as a tool for problem identification and intervention

planning.

In a paper by Swanson et al. (1994) the Strategic Extension Campaign (SEC)

methodology programme is explained. This program states to employ a primary analysis,

based on a participatory needs assessment for problem identification of the target

audience, for the development of appropriate intervention strategies and tactics to

increase agricultural productivity. The SEC programme follows a system approach: it

starts with a farmer’s Knowledge, Attitude, and Practice (KAP) survey whose results are

used as planning inputs and benchmark-baseline. Moreover a KAP survey is generally

used to identify and describe critical elements, negative attitudes and reasons for non-

adoption of a recommended technology.

A similar methodology is used in the IDAF (Integrated Development of Fishery in West-

Africa) program of FAO in cooperation with DANIDA (International development

cooperation of Denmark). This program is concerned about the development of African

fishery. In this program a KAP study was used to indicate people's behaviour concerning

the natural fishery resources available (IDAF, 1994). With this method a large group was

interviewed simultaneously, on sensitive issues in relative privacy. The results of this

KAP study are then used as a background to create appropriate recommendations for

fishery resource management.

Finally the use of KAP surveys as an evaluation tool was identified as a third objective of

this type of studies. Halawa et al. (1995) studied the effects of a new training program for

nurses on family planning in Egypt. The objective of the study was to assess the impact

of this training on nurse performance in the clinic and on clients' family planning

knowledge, attitudes and contraceptive use. Salazar-Lindo et al. (1991) report the

evaluation of a training programme on clinical management of infantile diarrhoea. The

outcome of this training programme was assessed by pre- and post-tests, knowledge,

attitude, and practice (KAP) questionnaires, and observational surveys.

Sarti et al. (1997) conducted a comprehensive study in a rural community in the state of

Morelos, Mexico to evaluate health education as an intervention measure against Taenia

solium infections. An educational program was developed to promote recognition and

knowledge of the transmission of the parasite and to improve hygienic practices and

sanitary conditions that foster transmission. The effects of this educational intervention

were evaluated by measuring changes in knowledge and practices and prevalence of

human taeniasis and swine cysticercosis before and after the campaign. A questionnaire

was designed and used before, immediately after the intervention, and six months later.

Statistically significant improvements occurred in knowledge of the parasite, its life

cycle, and how it is acquired by humans. However changes in behaviour related to

transmission were less dramatic and persistent.

METHODOLOGY

In literature no clear methodology to develop a KAP questionnaire can be found.

Different studies use different question formats and sometimes even contradict each

other. Mostly different KAP questions are posed on different subjects. Every question is

then evaluated separately and this provides information on the subject.

The Nurses' Research Knowledge, Attitudes, and Practices of Research Survey© (KAP)

consists of a 33-items listed self-report (Witzke et al. 2008). For every item the

respondent indicates their level of knowledge, willingness to engage (attitudes) and

ability to perform the specific activity (practices). Three different responses are possible:

“low”, “moderate”, and “high”. Responses were coded as follows: low = 1, moderate = 2

and high = 3 and summary scores for each subscale were calculated by totalling

responses for each question and dividing the total score by 33. Scores from 1.0 to 1.66

were considered “low,” those from 1.67 to 2.33 were “moderate,” and those from 2.34 to

3.0 were “high.” In this survey an index was thus created and according to this index the

knowledge, attitude and practices of every nurse was evaluated separately.

In the IDAF (Integrated development of fishery in West-Africa) project on natural fishery

resource management in West-Africa 5 questions were asked for every concept:

Knowledge, Attitude and Practice (IDAF, 1994). This leads to 15 closed-ended questions

which are formulated as hypotheses or ‘vignettes’ and the possible answers are: I agree,

no opinion or I don’t agree. The KAP survey used is given in table 1 as an example.

Table 1: KAP survey on fishery resource management in Cameroon (IDAF, 1994)

Statements or questions Yes, I

agree

No, I don’t

agree

I don’t

know

1.K The amount of fish in the sea, what we call the fish resource, is limited

1.A Our fishing community is able to take care of its fishery resource itself.

1.P Our community is currently doing something to regulate fishing activities in this community.

2.K There is always enough fish in the sea for every fisherman to have a good catch.

2.A If we are not careful now about how much fish we catch, later our children might not catch enough fish to be able to make a living out of it.

2.P Do you allow new fishermen to start fishing here in your fishing grounds?

3.K When the fish you catch is getting smaller in size, it means that the fish resource is being overfished.

3.A The fishery resource can sustain itself without any help.

3.P Are you doing something to prevent the fishery resource from being overfished?

4.K The government has created fisheries institutions that are represented in our community by the fisheries extension officer.

4.A The fishery extension officer can help us to solve the problems that occur in our fishery

4.P Do you ask the government representative for help when you have a problem in your fishery business?

5.K There are laws made by the government of this country, to regulate fishing activities.

5.A The government laws on fishery activities are of no use to artisanal fishery activities.

5.P When you fish, do you always make sure you follow government regulations?

Kaliyaperumal (2004) developed a clear methodology for assessing KAP towards

diabetes and diabetic retinopathy. He beliefs that knowledge questions should be open-

ended questions and that multiple-choice questions should be avoided because they can

result in guessing and therefore give a false impression of the knowledge of the

population. The attitudes should be measured by providing statements and respondents

should be asked to indicate the extent to which they agree with those statements, on a

pre-determined scale (strongly disagree, moderately disagree, neutral, moderately agree,

strongly agree). The practice questions again should be open-ended questions, to prevent

false information as a result from guessing.

We might conclude that the KAP survey is not really a specific methodology but more of

a conceptual framework for analyzing human behaviour. The KAP concept, with its three

key pillars, can be used as a suitable framework to develop a concrete methodology be it

qualitative or quantitative, to analyse and understand specific human behaviour such as

human or animal health behaviour and agricultural technology adoption.

LIMITATIONS The KAP survey is the most used sample survey methodology in social research,

especially in family planning research. However considerable doubts have been

expressed about the validity of this research method. Mauldin (1965: cited in Bulmer and

Warwick, 1993) states that KAP surveys exhibit two major deficiencies. Firstly they have

failed to include adequate efforts to study the reliability and validity of their data and

secondly they have failed to make adequate efforts to obtain measurements of the

intensity of the opinions or attitudes reported. These are general remarks related to the

quality and application of attitude surveys in general (Browne-Nunez & Jonker, 2008).

As a solution for the first deficiency Bulmer and Warwick (1993) refer to the inclusion of

several proxy indicators. One of the most useful techniques used for this is the ‘random

probe’ technique. This is done by using follow-up probes for a set of items. By asking the

respondent to ‘explain a little’ of what he or she had in mind in answering a closed

question, the random probe elicits information on whether the question was understood at

all and whether the meaning perceived by the respondent was the same as that intended

by the study designers. This is how the probe answers shed qualitative light on the

responses from close-ended questions. Other methods of checking reliability and validity

include a combination of open-ended and close-ended questions and intensive probing on

key items.

Grace et al. (2009) report on a KAP survey to characterize and validate farmers’

knowledge and practice of cattle trypanosomosis management in the cotton zone of West

Africa. They combined a KAP questionnaire with qualitative studies and the actual

empirical testing of farmer knowledge and skills. This increases the reliability and

validity of the information provided.

Another limitation is of course as stated above the absence of a standard methodology

that can be used in every KAP survey. This disables comparison between different KAP

studies related to the same topic.

CONCLUSION In a KAP survey a certain level of populations’ knowledge, attitudes and practices related

to a specific issue is assessed. This literature review showed that KAP surveys can be

implemented for various reasons. It can be useful as a diagnostic tool, as a development

or as an evaluation tool. As no clear cut methodology for a KAP survey is available it

might be more suited to refer to KAP as a conceptual framework to analyse human

behaviour and its impact on specific actions and interventions. Limitations of this

framework were mainly found in social science research. In this research field the lack of

validity measurement of the information provided and the inability to measure intensity

of certain answers are put forward as general constraints related to this type of research.

However the KAP survey remains an important tool in assessing people’s perceptions,

willingness and ability to invest and participate in certain practices and programs.

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