Assessment on knowledge, attitude, practices and risk of infection towards COVID-19 in Ethiopia: An online cross-sectional survey

COVID-19 has ushered in a catastrophe of an unprecedented scale across all parts of the world. Conrmed cases and death toll are constantly on an upward trend. Various measures to control the disease have been adopted globally including in Ethiopia. However, people’s adherence to such control measures is affected by their knowledge, attitudes and practices (KAP) during the pandemic. This cross-sectional online survey was therefore, conducted to appraise the KAP vis-a-vis COVID-19 containment strategy during May 13-25, 2020. The online survey questionnaire consisted of demographic characteristics and interrogations, pertaining to knowledge (15 items), attitude (10 items) and practices (7 items), framed in accordance to previous studies. A total of 1,484 respondents completed the survey. The overall correct response rating and average score of the knowledge were 74.7 % and 11.2 ± 2.2 respectively. Maximum respondents (63 %) could be bracketed together with a moderate level on knowledge, attitudes while only 43 % had moderate level of practice, with signicant difference across demographic variables. Despite the moderate level, the practices were not creditable as the registered values evinced that 1 out of 5 never wore nose mask, washed hands or maintained social distance. In a similar vein, 17.6 %, and 43.2 % of the respondents were in high and in medium risk of infection, respectively. Results of our study recommended the importance and need of health education programs aimed at improving KAP, especially the practices in the milieu of COVID-19.


Introduction
COVID-19, declared as 'Public Health Emergency of International Concern' (PHEIC) on January 30, 2020 [1] and consequently, a pandemic on March 11, 2020 by World Health Organization [2] has set the entire globe out of gear. This topsy-turvy of an unparalleled scale, caused by the novel betacoronavirus, SARS-CoV-2 does not need any elaboration. Discernible by major infection of the lower airways and access via binding to angiotensin-converting enzyme 2 (ACE2) on alveolar epithelial cells, the pathogenesis is associated with 'cytokine storm' or 'cytokine cascade' -the proposed mechanism of organ damage [3][4][5]. With an incubation period of 2-14 days for the virus, the clinical symptoms of the disease include fever, dry cough, fatigue, and shortness of breath while severe stage is characterized by acute respiratory distress syndrome and pneumonia [6,7]. Albeit the current SARS-CoV-2 shares ~79% of its (RNA) genome with SARS-CoV, the former appears to be much more transmissible with human to human contact being the major transmission route. Asymptomatic transmission of the virus has been marked as the Achilles' heel in the context of the current control strategies of the pandemic [8]. As of today (29 th July, 2020), 16,741,049 con rmed cases in 188 countries and a death toll of 660,428 worldwide (the number being an upward trend daily) [9]. Albeit, the average mortality rate of ~4% is comparatively lower than that of SARS (9.5%), MERS (34.4%), H7N9 (39.0%), Ebola (25-95 %) [10,11], howbeit, COVID-19 has projected itself as a microscopic holocaust over the last few months [12].
Needless to say, researchers worldwide are toiling to develop be tting strategies to detect and target the virus [12,13]. However, to our dismay, there is neither a potent vaccine nor recommended medications to treat the disease till date. Pertinently, SARS-CoV-2 has spelled devastation in various developed countries even though they have been acknowledged for their well-structured health service time and again. Its spread in Africa may be more catastrophic in the context of lack of adequate health systems. Various measures have been adopted globally to control and contain the disease, including enforcement of 'lockdown' in various countries. Due to its global threat and alarming predictions, online courses on awareness and strategic preparedness and response plan (SPRP) around the world were initiated to protect the states with weaker health infrastructures [14]. In this backdrop, as well perceived, strong infection control practices are the key to minimize the spread of the virus in both health care settings and the community [14]. In the African context, Ethiopia, a densely populated nation without a robust healthcare infrastructure, is leaving no stones unturned to combat the viral assault. However, certain degree of panic resides in public due to the unavailability of basic protection measures. 15,200 con rmed cases and 239 deaths as on 29 th July 2020 have been registered since the con rmation of the 1 st case on 13 th March 2020 [9], however, this number may re ect a shortage of tests [15]. In this regard, besides declaration of a state of emergency (SoE) for 5 months (April-August, 2020) and ensuring timely execution of the viral detection test, Ethiopian government is beavering to combat the debacle through various suggestive measures. Some of these include maintenance of social distancing, wearing of nose masks, frequent washing of hands using soap/appropriate sanitizer and avoidance of crowded places, shutting down of schools and higher education, and door to door temperature check to stop community spreading.
Pertinently, people's adherence to and success of such control measures is affected by their knowledge, attitude and practices (KAP) towards epidemic diseases [16]. In support of this, studies conducted during SARS [17] and MERS outbreak [18] in 2003 and 2012 respectively, suggested that KAP towards infectious diseases are associated with the level of panic-emotion and dread among the population, which can further obfuscate attempts to prevent the spread of the disease. Public knowledge and attitudes towards the disease is germane to adoption of appropriate practices, which are expected to eventually Data-collection for this cross-sectional survey among Ethiopian citizens commenced on May 13, 2020 and concluded on May 25, 2020. During this period the COVID-19 cases were documented between 350 and 500 with only 5 deaths. The citizens were instructed to maintain social distance, wear mask, wash hands, and avoid large gathering and shutdown educational institutions, amongst some of the preventive measures, put forth by the Ethiopian government. It was not feasible to conduct an off-line survey during the state of emergency (SoE), therefore, data for this study was collected using an online survey tool of Google form. Relying on authors' network, a one-page poster, highlighting the survey details was circulated via various social media platforms such as Telegram, Facebook, WhatsApp and group e-mail accounts. The poster contained an introductory description, objectives of the survey, other requirements for the respondents including the voluntary participation, declaration of anonymity and con dentiality, link and QR code, as well as the invigilators' details (S1 Fig). Ethiopian citizens of 18 years and above, and with clear understanding of the content of the poster participated in the study.

Ethical considerations
All procedures performed in this study, involving human participants, complied with the institutional and/or national research committee ethical standards, and the study was designed and conducted in accordance with the ethical principles established by th "Committee on Publication Ethics (COPE)" guidelines to handle publication ethics. Con dentiality of the participants' information was ensured throughout the study. The online pages for the self-administered questionnaire could be accessed by the participants for attempting and completion, subjected to indication (through a click on 'Yes' button) of consent for voluntary participation.
Questionnaires and score A survey questionnaire was designed based on recent study on COVID-19 in Ethiopia [26] and other countries. The questionnaire consisted of four parts: demographics of participants, knowledge, attitudes, and practices of COVID-19. Demographic variables included gender, age, marital status, education status, occupation and geographical location of the respondents ( Table 1, Fig 1). The authors had developed a set of 15 questions to assess the respondents' knowledge on COVID-19 (Table 2, S1 Table). These were either multiple-choice questions or true/false queries (including the option as 'I don't know'). A correct answer was allotted 1 point while no point was awarded for an incorrect or 'I don't know' response. The knowledge-score ranged from 0 to 15; a cut off level of <7 was set as 'poor', 8-12 for 'moderate', and 13-15 was ranked as a 'good' knowledge-score. A total of 10 questions on attitude towards COVID-19 (Table 3) were supposed to be rated in the 5-point Likert's scale: strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5) for positive attitude questions. For the negative-attitude questions, respondents were allotted the lowest score of 1 in case their response was 'strongly agree', with scores increasing to 5 with responses marked as 'strongly disagree'. Scores of <25, 26-40 and >41 corresponded to 'poor', 'moderate' and 'good' attitude respectively. A total of 7 questions, pertaining to practices of the respondents (Table 4) were to be rated on the 3-point Likert scale format, ranging from never (1), sometimes (2), and always (3). In the case of negative practice question, the scores were reversed. Scores of <10, 11-18 and >19 indicated 'poor', 'moderate' and 'good' level of practices of the respondents towards the outbreak of COVID-19. The assessment on 'risk of infection' was scrutinized based on the practice skills.

Statistical analysis
The data collected from the survey were collated and the incomplete and repeated responses were excluded. The rst complete responses were counted as accurate. The descriptive statistics and one-way analysis of variance (ANOVA), or Chi-square test as appropriate were performed using Microsoft Excel to assess the differences between groups for selected demographic variables and their KAP toward COVID-19. Regression tests were applied to nd any correlation between knowledge, attitude and practice scores. The statistical signi cance level was set at p<0.05.

Demographic characteristics
Albeit, a total of 1,991 participants attempted the survey questionnaire, howbeit, 177 and 330 responses were incomplete and repeated attempts respectively.
The rst complete attempted responses were taken into consideration while the repeated attempts and incomplete responses were excluded (n=507). Thus, the nal count consisted of 1,484 responses. Among these, 87% of the respondents were male while majority of the respondents (54%) were within the age range of 18-29 years ( Table 1). The proportion of married to non-married response was almost similar. The majority of respondents were postgraduates or those enrolled in PG program (58.4%). The education-status of 54 participants was <12 th grade. In terms of occupation, majority of respondents (62.6 %), were government employees, followed by students (12.9 %), privately employed (11.6 %) and health care workers (11.1 %). The participants hailed from all the states of the country with maximum representation from Oromia (31.1 %), followed by SNNAP (17.3 %), Amhara (17.2 %), and Addis Ababa (14.6 %) whereas the least (a single respondent) was from Gambela (Fig 1). Other demographic characteristics are shown in Table 1.

Assessment of knowledge
A total of 15 questions were used to assess the participants' knowledge/awareness on COVID-19. The documented average knowledge score was 11.2 ± 2.2 (range 2-15). The overall correct answer rating for the knowledge-section of the questionnaire was ~74.7 % (11.2*100/15). As shown in Table 2, more than half the respondents selected the correct choices for expansion of the acronym 'COVID-19' as Coronavirus disease 2019 (52.6%), the place of its origin (97.4%), its spreading routes (84.9%), causal virus (57.7%), main symptoms (79.2 %) and current level of vaccine development (93.7%). Around half of the participants (48.2 %) correctly answered the minimal prescribed norms for social distancing as '6 feet' while 3 out of 10 (28.2 %) ruled out the possibility of spreading the disease by pet animals. The prescribed quarantine period of 14 days for suspected people was correctly documented by all. Pertinently, higher knowledge scores were registered for health care workers (12.6 ± 1.9), people residing in Harari state (12.5 ± 2.4), those in the age-group of 30-49 (11.6 ± 2.0), and respondents, holding or pursuing Ph.D. degree (11.5 ± 2.0). The least knowledge score was registered at 8.9 ± 3.0 and 9.6 ± 3.2 for the respondents from Somali state and participants with education only up to school level respectively. Knowledge scores signi cantly (p<0.001) differed across age-groups, education levels, occupation and residence-state of the participants and marital status (p<0.05) while no signi cant difference was observed with respect to gender of the participants (Table 5). On a general note, the majority of the participants had a moderate knowledge level towards different items as inquired in the knowledge-section of the questionnaire (Table 6). Age, education, occupation, and geographical location of the participants exerted signi cant in uence (p<0.001) on the knowledge level. There was no signi cant difference (p>0.05) in the knowledge level with respect to gender and marital status. gender of the participants. For the parameters of age and education, attitude score increased with increase in age and education level, for example maximum attitude score was observed for participants in the age group of 50-69 (3.95 ± 0.48) and postgraduates (3.90 ± 0.47) while minimum was documented for those in the age group of 18-29 (3.82 ± 0.51) and educated up to school level (3.53 ± 0.53) respectively. Health care workers recorded higher attitude score (4.00 ± 0.54) than any others in the occupation category and the least was documented by those engaged in private job (3.73 ± 0.49). The highest attitude score was recorded for the participants from the state of Benishangul-Gumaz (4.06 ± 0.54) followed by SNNAP (3.92 ± 0.42). The attitude score was signi cantly associated with age group (p<0.05), marital status, education status, occupation and state of the respondents at p<0.001 (Table 5). Classifying the attitude level as poor, moderate and good towards COVID-19, generally speaking, the majority of the participants had a moderate attitude towards different queries, enlisted in the questionnaire (  Table 4 represents the responses recorded for practice items of the questionnaire towards COVID-19. When enquired about wearing nose mask while going out in this COVID-19 outbreak, surprisingly, 1 out of 5 participants reported that they 'never' wore a nose mask, 43 % marked 'sometimes' while only 36.2 % resorted to a nose mask every time. Notably, 67.6 % and 51.6 % participants remarked positively about washing theirs hand after going out and carrying a sanitizer 'always' in contrast to 1 out of 5 participants who neither washed their hands after going out, nor carried a sanitizer. More than half of the participants (n=777) asserted the maintenance of social distancing during the survey period. Surprisingly, 19.1 % of participants remarked that they never engaged in using a nose mask, washing hands or maintaining social distance during the COVID-19 outbreak. Around 56.3 % of the participants marked 'always' with respect to avoidance of crowded place like worship place, bus and train stations, banks and malls, while 1 out of 4 and 1 out of 5 chose 'sometimes' and 'never' respectively in the online portal. Four out of ten people supported lockdown if imposed in the country to control COVID-19 spread as against 23 % who voiced against such strategy. Almost 66 % respondents speci ed that they did not favor the Ethiopian style of greeting (involving hand shake, followed by shoulderhit for man and cheek-touch for woman) during the COVID-19 outbreak, still a considerable portion of the participants was found to second it: 8.4 % 'sometimes' and 25.1 % 'always'! On demarcating the practices towards COVID-19 as poor, moderate and good, generally speaking, the majority of the participants exhibited moderate practice level in the context of various items, inquired in the questionnaire (Table 6). Age, education status, and geographical location of the participants appeared to signi cantly impact the practice level while no signi cant difference (p>0.05) in the practices were recorded for the variables of gender, marital status and occupation. Regression tests revealed that there was a statistically signi cant) positive linear correlation between attitudes and practices (r = 0.199, p<0.001, while no signi cance correlation between knowledge and practice ( Table 7).

Assessment of Risk of infection
Risk of infection was analyzed among all the respondents based on the seven practice-questions (Table 4). Accordingly, 241 (16.24 %) were placed under high risk category, 668 (45 %) in medium risk category, and 575 (38.75 %) in low risk category (Table 6). High risk category people were those who remarked that they never wore mask or engaged in washing hands, maintaining social distance, avoiding crowded places, and preferred hand shake for greeting. By the same token, medium risk category responders adhered to the recommended practices only at times, while people in the low risk category stringently followed the advocated practices, besides avoiding the bodily contact (like hand-shake) for greeting. Relatively, females (20.2 %) were at higher risk than males ( (Fig 2). Surprisingly, even healthcare workers (18.3 %) appeared to be in higher risk in contrast to government job employees (14.9 %) and students (14.6%).  *, **, *** Statistically signi cant at P<0.05, P<0.01, and P<0.001, respectively (Chi-square analysis); 1 holding or pursuing; 2 Healthe workers-nurse, physician, pharmacist, lab assistant; 3 Benishangul-Gumaz; 4 Southern Nations, Nationalities and people.  [30,31]. The message is clear, Ethiopians must comprehend and sternly abide by the recommendations and handling strategy vis-à-vis the control and prevention of COVID-19. On the precincts of limited scienti c information on COVID-19, the WHO had suggested improving knowledge, prevention and control measures in health care and community settings [14]. The novelty of this virus, along with its uncertainties, makes it indispensable for health authorities to plan appropriate stratagems. It is therefore of paramount pertinence that the KAP of the population be studied to guide these efforts. To the best of our knowledge, this is the rst study in Ethiopia regarding general public's KAP and assessment of risk of infection towards COVID-19 among Ethiopians, albeit, some studies have been done with limited sample sizes including higher education communities [26], undergraduate students in Debre Berhan University [27], nurses in Northern Ethiopia [28] and visitors in Jimma University Medical Center [29].
In our survey, with respondents, being predominantly male and educated (68 % holding undergraduate degree or higher), we found that the average knowledge score of Ethiopians was moderate at 11.2 ± 2.2, with an overall correct-response rating of 74.7 % about COVID-19. This is in lines parallel to the results (73.8 %) observed among undergraduate students from Debre Berhan University [27] and hospital visitors in Jimma University Medical center [29]. The rating ranged widely among demographic variables indicating that some participants had satisfactory knowledge (29 %) about the disease while a poor knowledge score rating was documented for others (8 %). Ethiopians in the age-group of 30-49 recorded higher knowledge scores, plausibly due to a greater access to information intertwined strongly with the implications of higher education. Based on the limited information available to date, the risk of pets spreading the virus that causes COVID-19 in people is considered to be low. At this time, there is no evidence that animals play a signi cant role in spreading the virus that causes COVID-19 [32] however, ~60.9% answered the other way due to lack of information about the fact. On the other hand, social distancing has been projected as the key to prevent the current pandemic [30,31]. Remarkably, 45.4 % had responded as 2 feet, instead of the recommended 6 feet, which could be bracketed together with the failure of the mass to retrieve correct information. On a surprising note, equipped with the correct information about its genesis in China, 4 in 10 participants wrongly expanded 'COVID-19' as 'China originated Virus disease-2019'. By the same token, those with low education status possibly attributable to restricted access to credible and timely information about the disease in the rural regions. This variation in levels of knowledge may be re ective of the current COVID-19 information landscape in the country. Although the government and health authorities have been consistently disseminating COVID-19 information since the disease was rst detected in Ethiopia [33], there has also been a surge in false and inaccurate information [34]. This demands dissemination of correct knowledge in a timely manner to the various strata of the society.
Several surveys, conducted in other countries have indicated differences in levels of COVID-19 knowledge-score and correct response rating among the general population. A similar correct response rating (~74 %) of the general public of Ethiopia (this study) and undergraduate Ethiopian university students [27] have been documented as against higher values of 84.7 % in Sudan [21] and 80 % in Nigeria [22]. Differences have been observed in the studies conducted in other countries such as Egypt [19], Tanzania [25], Nepal [35], Malaysia [36], and Indonesia [37]. The dissimilarities in the knowledge-appraisal questionnaires do not make it possible for accurate comparisons of knowledge levels across these studies. Moreover, barring Bangladesh and our study, all the previous surveys embraced female participants as the major respondents. Interestingly, knowledge score signi cantly differed with respect to gender of the respondents in other countries, while such trend was not evident for Ethiopia and Egypt. asymptomatic individuals and low rate of detection in the country need to be addressed as well. On the other hand, around 3 out of 10 respondents averred the virus to be a potential bioweapon, while, corresponding results were 1 out of 4 in Egypt [19] and nearly 1 out of 2 (50 %) in Nigeria [38]. In the context of the current dearth of scienti c evidence, there is enormous heated discussion globally on the synthetic versus natural origin of SARS-CoV-2, responsible for COVID-19. Around 22 % of the Ethiopian respondents in our study vouched for its synthetic genesis as against 36 % Nigerians [22].
Needless to state that the possession of adequate knowledge and apt attitude towards the disease may not su ce, the requisite is to employ and engage in appropriate practices to prevent and combat the viral assault. 36.2 %, 52.4 %, 56.3 %, and 67.6 % of the respondents asserted the use of nose mask, maintenance of social distancing, avoidance of crowded places and regular washing of hands respectively as against a quarter of the participants who continued to resort to the unique Ethiopian style of greeting, involving bodily contact. This was suggestive of a low willingness of the participants to make behavioral changes towards COVID-19 with respect to some of the day to day practices. A number of factors associated for the poor practices, such cost of the mask, sanitizer, and low availability of the protection materials, and culture (greetings, eating together). Another survey in Ethiopia showed 56 % of undergraduate students and 66 % hospital visitors not maintained social distance [27,29] during March 18-24. During this period 8 out of 10 people not wearing nose mask when leaving home [29], but it has improved to 1 out 5 in this study during May. The similar percentage of people wearing mask was observed in neighboring country of Egypt [19]. Whereas, another African peoples of Tanzanians shows 80 %, Sudanese at 49.3 %, and Nigerians at 65 % [25,21,22]. In case of Chinese study almost all used face masks when they go out during the current pandemic [10], that may be the reason they got succeeded in the disease spread.
Most importantly, a considerable fraction of the participants (17.6 %) seems to be least bothered and consequently non-adherence to these precautionary measures. Speci cally, this encompassed females, young aged responders, unmarried, those with lower education status, self-employed and unemployed, and participants with poor knowledge and those hailing from Somali and Afar region. Previous studies in other countries have attested the correspondence of higher risk taking behavior with younger age, low education levels and lifestyle in rural areas [10,39]. In contrast with our results, Zhong et al., (2020) found a greater correlation of non-recommended/dangerous practices to the male participants in China [10]. On the other hand, lockdown was imposed in many countries for certain number of days. However, no lockdown protocol has been enforced in Ethiopia till the date of drafting this manuscript. Although, the number of con rmed cases and deaths are considerably low in Ethiopia in contrast to rest of African countries, there seems to be a gradual increase in recent weeks (9,503 on 19 th July, 2020) [9]. In this regard, less than half of the participants (~41 %) in our survey stood in support of a lockdown in Ethiopia. There was a positive correlation between attitudes and practices while no correlation between knowledge and practices. This might be explained as government strict action on prevention practices and peoples willingness towards the action. While previous studies in other countries found positive correlation between knowledge and practices [10,40].
With regard to risk of infection, around 18 % people could be bracketed under high risk category, it means around 19.5 million peoples are in high risk in Ethiopia. Considering the limited representation of various sections of the population and the fact that >95% of the participants in our survey had college education, the numbers in the high risk category could be plausibly much more in the real scenario. Among gender, we found women's are at high risk than man. In many settings, women and girls are highly vulnerable and at increased risk during an epidemic or crisis, because they are responsible not only for caring for the elderly and children, but because they often make up more than half of the healthcare workforce [41]. Surprisingly, healthcare workers were in higher risk (18.3 %) than the students (14.6 %), even though the former group exhibited adequate/good knowledge (55 %) than the latter counter parts with 26 % and 20 % knowledge score, respectively. At this juncture, it would be relevant to mention that healthcare workers in Ethiopia had demonstrated an insu cient knowledge and perception but positive attitude during Ebola outbreak in 2015, thereby, vouching for an intense training for the healthcare professionals [42]. These ndings clearly evince the signi cance of improving the various practices of the Ethiopian citizens towards COVID-19 through timely health education and dissemination of correct information in various nook and crannies of the country, which are also envisaged to contribute in improving the attitude, knowledge and perception of the mass towards COVID-19.

Limitation of the study
The authors had solely relied on their online/social media networks (Telegram, Facebook, WhatsApp and email accounts) for circulation of the survey link. As a result, considerable fraction of the population could not participate in the survey. Moreover, when compared to current population in Ethiopia, the surveysamples were over representative of male respondents, below the age of 50, those with university level education and mostly employed in the public sector. A more systematic, community based, inclusive sampling method with local language is recommended to improve representativeness and generalizability of the ndings. The survey questions were generally used and modi ed based on previously published KAP assessment carried out on COVID-19 in Ethiopia. Despite these limitations, our ndings provide valuable information about the KAP of Ethiopians during a peak period of the COVID-19 outbreak.