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 populations 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 peoples 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 peoples 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 50s 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 farmers 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 nonadoption of a recommended technology.
A similar methodology is used in the IDAF (Integrated Development of Fishery in WestAfrica) 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 dont 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

1.K
1.A

The amount of fish in the sea, what we call the fish

resource, is limited
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.
Do you allow new fishermen to start fishing here in your
fishing grounds?
When the fish you catch is getting smaller in size, it
means that the fish resource is being overfished.
The fishery resource can sustain itself without any help.

2.P
3.K
3.A
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
Do you ask the government representative for help
when you have a problem in your fishery business?

4.P

Yes, I

No, I dont

I dont

agree

agree

know

5.K
5.A
5.P

There are laws made by the government of this country,

to regulate fishing activities.
The government laws on fishery activities are of no use
to artisanal fishery activities.
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 openended 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 peoples perceptions,
willingness and ability to invest and participate in certain practices and programs.
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