Compliance with Covid-19 Non-Medicinal Preventive Protocol and Intent to Accept Covid-19 Vaccine Among Adults in South Eastern Nigeria

A Non-pharmaceutical public health measures are being promoted for mitigating the risk and impact of epidemic and pandemic covid-19 inuenza and the introduction of its vaccine necessitate the assessment of individual perception regarding the vaccine. This study assessed compliance with covid-19 non-medicinal preventive protocol and intent to accept covid-19 vaccine among adults in Owerri West, Imo state Nigeria. Descriptive cross sectional research design was employed in recruiting four hundred and thirty six (436) participants used for the study. Using SPSS version 23, data were subjected to descriptive and Chi-square analysis.


Introduction
It has been just over a year since the rst cases of the Coronavirus SARS-CoV-2, leading to the disease COVID- 19, have been identi ed. Over this period, much has changed in terms of knowledge about the virus and its management. It has, indeed, been a steep learning curve for all involved (1). The alarming spread of the coronavirus disease and its attendant impacts on the global economy calls for concern. The non-availability of the vaccine makes the situation more challenging. Since the rst case was reported in late 2019, it has remained a serious issue in the public health domain. This is particular in Africa where the absence of good health facilities and rising population increase the risk of disease. Coronavirus disease 2019 (COVID- 19) outbreak was rst noticed in Hubei Province, Wuhan, China in 2019 and has spread to virtually all parts of the world. It has so far affected 123 countries in the world, infecting fourteen million six hundred and seventy-four thousand, sis hundred and sixty-six (14,674,666) people and resulting into six hundred and nine thousand, six hundred and eighteen (609,618) deaths worldwide (2) (Worldmeter, 2020). The World Health Organization (WHO) declared the disease a public health emergency (3). Nigeria is categorized as one of the 13 high-risk African countries based on the poor state of healthcare system in the country (4). As of May 25, 2020, Nigeria reported about 7,839 con rmed cases and 226 related deaths (3).
Covid-19 is a disease that affects the respiratory tract and is caused by a newly emergent coronavirus, SARS-CoV-2, which was rst noticed in Wuhan, China (5). Coronaviruses are minute in size (65 -125 mm in diameter) and contain a single stranded DNA, with size ranging from 26 to 32kbs in length. The coronaviruses families include alpha, beta, gamma and delta coronaviruses (6). People who have the disease show mild or uncomplicated illness. However, about 14 per cent of the people with Covid-19 develops severe illnesses that requires hospitalization and oxygen support and 5 per cent needing admission in intensive care unit. Based on available evidence, coronavirus is basically transmitted from one person to another through respiratory droplets and contact routes (3). Droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (e.g. coughing or sneezing) and is therefore at the risk of exposing his/her mucus (mouth and nose) or conjunctiva (eyes) to potentially respiratory droplets. Thus, transmission of coronavirus can occur directly by contact with infected people and indirectly through contact with infected surfaces (3). In cases that are serious, diseases like acute respiratory disease syndrome (ARDS), sepsis and septic shock, multiorgan failure including acute kidney and cardiac injury can cause complications (6).
The pandemic has adversely impacted Africa in several ways. According to the (7), it has reduced the demand for Africa's commodities, capital ight, poor performance of tourism and aviation industries with lockdowns and closure of borders; and depreciation of local currencies. Also, the pandemic has reduced the gross domestic product of many countries in the African continent. The African Union Commission (8), predicts a negative growth from 3.4% to between 0.8% to -1.1%. Similarly, in the sub-Saharan African region, the GDP is expected to decline sharply from 2.4% in 2019 to between -2.1% and -5.1% in 2020 (9). In Nigeria, the pandemic is reported to have caused declining consumption, declining investment, increasing government expenditure and declining net exports. Restriction of movements has not only reduced the consumption of nonessential commodities but have affected the income-generating capacity of these groups, thereby reducing their consumption expenditure (10).
No cure has been discovered for Covid-19 disease despite myriads of efforts and claims, thus making adoption of preventive measures very important. (11). stated that preventive measures can save at least 20 million lives and when they are adopted early enough would save up to 38.7 million lives globally. Therefore, enforcing these measures remains a great challenge to human society. Compliance with preventive measures has signi cantly helped in the control of the pandemic in many countries. For example, many Americans were subjected to a stay-at-home measure (12) to check the spread of the disease. Similarly, in Nigeria and other countries, related measures were also undertaken in order to curtail the spread of the disease. According to (13), certain factors such as perceived threat, moral beliefs, negative emotions, practical capacity to comply and descriptive social norms in uenced compliance to preventive measures.
Prevention means averting the development of a pathological state. According to World Health Organization (14) it covers measures not only to prevent the occurrence of a disease such as risk factor reduction, but also to arrest its progress and reduce its consequences once established. The Australian National Public Health Partnership de ned prevention as action to reduce or eliminate the onset, causes, complications or recurrence of diseases (15). Preventive measures against disease outbreak promote health and prolong life through organized efforts of society. Prevention stops disease progression by reducing exposure to environmental hazards related to the disease. Prevention can be primordial (preventing the predisposing social and environmental) primary, secondary and tertiary to improve function, minimize impact and delay complications (14). Certain measures have been deployed to check the spread of the disease. Some of the preventive measures include washing of hands, coughing etiquette, use of face masks, avoidance of public gathering, restrictions on movement, disinfection, use of alcohol-based sanitizers, vaccination as well as public health measures.
In Nigeria, several measures have been taken to prevent, mitigate and respond to the spread of Covid-19 (16).
Vaccines have been a successful measure of disease prevention for decades (17)(Vaccines and immunization, 2020). Numerous channels have as well been utilized in communicating the measures among the people. The assumption has been that those measures are strictly complied with. However, the pandemic continues to spread as a second wave of the outbreak is recorded in the country. Observations have revealed the non-compliance and wrong application of the measures, making them counterproductive. Moreover, the second wave of Covid-19 outbreak is expected to ravage developing countries, exacerbating the already strained economic conditions. ACAPS (16) noted that clarity is lacking on the containment measures against Covid-19 among rural communities in Nigeria. It further maintained that the type of Covid-19 preventive measures, their degree of implementation and the populations' compliance varies across states and regions.
Research has shown that lack of knowledge is the major reason for non-adherence to precautions against diseases (18). Moreover, vaccine hesitancy and refusal are signi cant concerns globally, prompting the World Health Organization (WHO) to declare this uncertainty among the top 10 health threats in 2019 (19). The causes of vaccine hesitancy, as reported in different studies, include religious reasons, personal beliefs, and safety concerns due to wide-spread myths, including the association of vaccines and autism, brain damage, and other conditions (20).
Literature review revealed that no study has determined the compliance and non-compliance to preventive measures against Covid-19 in Imo State, Nigeria and to the best of our knowledge, no previously published work has evaluated the intent of people in Imo State to be vaccinated against COVID-19 when a vaccine is provided. This creates a gap in knowledge which may stall policy formulation against the spread of the disease. The study was therefore designed to determine compliance with covid-19 non-medicinal preventive protocol and intent to accept covid-19 vaccine among adults in Owerri West, Imo state Nigeria.

Area Of Study
Owerri West is a Local Government Area of Imo State, Nigeria. Its headquarters are in the town of Umuguma. Only adult household residents aged 18yrs and above at Owerri west LGA were recruited for the study.

Exclusion criteria
Adult household residents aged 18yrs and above in Owerri West LGA who refusesed to give in their consent for the study were excluded from the study.

Sample size Determination
The sample size will be determined using the ( (15) Communities in Owerri west were selected by the researcher using simple random sampling via balloting to give every community an equal chance of selection of which Ihiagwa, Obinze and Eziobodo was selected by the researcher.
Second stage: Selection of villages Two (2) villages each out of the total number of villages in Ihiagwa, Obinze and Eziobodo community respectively were selected via simple random sampling using balloting.

Third stage: Selection of Streets
A total of ve (5) streets each in the selected Six (6) villages were selected via simple random sampling (balloting) to give every street an equal chance of being selected.
Fourth stage: Selection of households A systematic probability sampling method was used to select each household in the selected streets giving each household an equal chance of selection.

Fifth stage: Selection of Respondents
The researcher selected any adult of each household or any one present at the time of study. Selection of respondents was done via simple random sampling.

2.5
The instrument for data collection consists of a semi-structured self-administered questionnaire which was administered on the 436 respondents. The structured questionnaire was validated using face-validity. Pre testing was carried out on 40 respondents in Ihiagwa Metropolis in Owerri West LGA as a trial run for the main research intended. Cronbach's Alpha was used to determine the internal consistency and degree of relationship of the test item. Prior to administration of the questionnaire to the respondents, an informed consent was obtained. Ethical clearance was obtained from the ethical review committee of School of Health Technology, Owerri. Verbal informed consent was obtained from all the participants before being allowed to participate in the study. Each of the respondents was assured of con dentiality of the information she might volunteer. Each questionnaire took about 5-10 minutes to be completed.

Ethical issues
The research followed the tenets of the Declaration of Helsinki. Ethical approval was given by the Ethical Committee of the School of Health Technology, Federal University of Technology Owerri, Nigeria. Informed verbal consent was sought and obtained from all the participants before they could take part in the study 2.7 Method of data analysis Data collected were analyzed using frequency, mean and Chi-Square. This was achieved using Statistical Package for Social Sciences (SPSS) version 21. Chi square was used to determine the in uence of demographic characteristics on compliance to covid-19 preventive measures and intent to accept covid-19 vaccine.

Socio-demographic characteristics of the respondents
As shown in Table 1 were single compared to those that were married 169(39%), co-habiting 52(12%) and separated/divorced 20(5%). A larger proportions 216(%) were not having any child as of the time of the study. Moreover, those with secondary school certi cate 301(69%) and who were unemployed 98(22%) constituted the vast of the respondents. Almost all of them 399(92%) were Christians as shown in gure 1.  Results of the participants level of perception about covid-19 are shown in Table 3 where majority of them 285(65%)perceived that covid-19 is real. Greater proportions of them 288(66%) strongly perceived the disease to be a serious one but strongly disagreed that anybody, no matter their social status can suffer it 292(67%).
However, many of them 240(55%) perceived the disease to be preventable but disagreed 303(69%) that some of those infected with the disease in the country have died. Moreover, a majority of the participants strongly perceived that regular washing of hands with soap 291(67%), maintaining of social distancing 223(51%), wearing of nose mask 204(47%) as well as cleaning and disinfecting the environment 231(54%) can prevent one from getting covid-19. Displayed in Table 4 are the results of preventive practices of the participants where there was a signi cant association (p<0.001) between respondents' perception and prevention measures of covid-19. It was shown that sometimes, greater proportions of them practice hand washing 226(52%) and washes their hands with soap for up to 20 seconds 298(68%). Sometimes when sneezing/coughing, most of them do that into their elbow 244(56%) and maintain at least one meter distance when they are with others 283(65%). Equally, majority of the 205(47%) sometimes wear nose mask when going out. In addition, most of them use disposable face mask which they never disposed after using it once 344(79%) but sometimes prefer to wash and reuse them 288(66%). Majority of the participants sometimes wash their hands before and after placing on these nose masks 281(64%). Results of Table 4   was the main reason for not wearing it 180(41%). the importance of events was noted to be the major reason most of the participants 167(38%) attend crowded events. Equally, a vast proportion of them do touch their face because of cleaning sweat 178(41%). As shown in Table 6, almost three quarter of the respondents 322(74%) said they will not accept vaccine for the disease when provided meanwhile, few 114(26%) will accept will accept it. Amongst this group, most of them 55(48%) will prefer to take the vaccine in liquid form than other forms. However, large proportions of the respondents 151(35%) strongly agreed they can accept vaccine if it is given free of charge. Also, a large proportions of them 352(81%) strongly agreed they will only accept it if they are sure of its safety. Equally, most of them 299(67%) strongly disagreed they will be willing to participate in covid-19 vaccine trial.
Prominent among the reasons for not taking the vaccine was that there is hidden agenda behind it which is not to the advantage of humanity. According to majority of the respondents 52(46%), major in uencer of accepting the vaccine was friends ( g 5) while the major reason for accepting it was to prevent them from getting the covid-19 disease 88 (77%) ( g 6). Doubt about the sincerity of the advocates of the vaccine 38 12 There is nothing like COVID-19 3 1 It can be treated easily with local remedies and there is no need for vaccine 9 3 It is in line with anti-Christ agenda 41 13 There is a hidden agenda behind it which is not to the advantage of humanity 87 27 Bill Gates and his cohort wants to rule the world with it through the concept of Arti cial Intelligence 36 11 The essence of the vaccine is to depopulate the world 67 21 Total 322 100

In uence of demographic variables on compliance to covid-19 preventive measures
Depicted in Table 7    The ndings of this study showed that the participants had a good understanding of the sources of COVID-19 infection and its transmission routes. Results showed that almost all of them 433(99%) have heard about covid-19 especially from radio 151(35%) than other source of information. This was similar to the study by (23) in Jazan and Aseer regions of South-West Saudi Arabia where majority of the respondents 987 (98.7%) have heard of COVID 19. The use of social media (55.7%) and TV (27.5%) constitute the major sources of information about COVID-19 in the study of (24) in North-Central Nigeria. Contrarily, (25) in their study in Nigeria found that majority of the respondents (80.1%) got their information of COVID-19 from social media.
In addition, Knowledge about coronavirus disease has been through numerous avenues with various social media platforms as well as internet dominating as the main sources of information about this disease (26;27;28). Nevertheless, social media often carry misinformation and anti-vaccination sentiments, like heightened side effects, machination theories, and poor e cacy that may expand vaccine hesitancy (29).
A vast number of them 423(98%) know that the disease was rst reported in 2019 in China and they also know the cause of the disease 397(92%). According to (30), COVID 19 disease is a recent infectious disease emanating from Wuhan China and is caused by the CoV. As regards the route of covid-19 transmission, many of them were aware that the disease is transmitted through respiratory droplet and it can enter the body through the nose, mouth and eyes. Moreover, almost all of them know that the disease has no cure 398(92%).
Similarly, (30) reported that the spread of this disease can through small droplets from the mouth or nose of the patient during sneezing or coughing. On falling on surrounding objects and someone else touching this objects contaminated with the droplet, then that person touches the mouth, nose or eyes (facial triangle), then the person can be infected with the disease. (31) in their study reported that more than 80% of participants knew COVID 19 to be transmitted by person to person, handshake and contact with infectious droplets only.
In terms of the perception of the respondents about covid-19, majority of them strongly agreed that the disease is real and is a serious disease but not in Nigeria where most of the participants strongly disagreed that people did not die from the disease, know or have seen someone who suffered from the since the disease can be prevented through regular washing of hands with soap, maintaining social distance, wearing of nose mask, cleaning and disinfecting the environment. (32) in their study found that 4/5 of the respondents perceived there are con rmed cases of the disease in Nigeria and other parts the world.
Understanding the people's perception of risk is important in ensuring adequate health protection practices during virus upsurge (33).
Moreover,covid-19 prevention guidelines was provided by WHO and these included washing hands with detergent under running tap, cough protocol, use of alcohol-based hand sanitizers, maintaining 1m -1.5m social distancing, restrain from social gatherings and wearing of the N95 mask (for medical professionals) among others [34;35], to reduce the infection spread.
Preventive practices taken by the participants, it was found that most of them never used disposable nose mask only once before discarding them. However, most of them sometimes wear nose mask when going out of the house, wash their hands with soap up to 20 seconds and maintain at least one meter distance when with others. Also, the participants sometimes wash cloth nose mask before reuse but never share nose mask with any other person. Public mask wearing according to (3;36) is effectual in stopping the spread of COVID 19 when worn appropriately with high compliance especially when combined with other preventive measures like hand hygiene. Moreover, most of the respondents sometimes touch face with ngers, clean and disinfect door handles, tables and chairs. It was also found that when sneezing/coughing, most of them sometimes do that into their elbow and dispose tissue paper used for sneezing/coughing into a closed bin. It was further showed that sometimes a large number of the respondents travel in a crowded vehicle, attend events with more than 50 persons in attendance and in general sometimes follow all the recommended preventive measures resulting larger proportions of them 197(45%) observing low level of compliance. In the study of (35) 698 (53.7%), participants showed high compliance to recommendations, suggesting that interventions like continued strict implementation of isolation policies, psychological counseling as well as health education should be inculcated, as these may improve compliance (35).
Globally, preventative procedures enacted by national, state, and local governments is now affecting normal routines of many people, and this rules include social distancing and restriction of movement within and outside the countries (37;38). These adjustments are necessary to combat the disease and protect health systems (39). Previous study has shown that the present most appropriate and e cient public health interventions can only be achieved when they are duly accepted by the public (40). However, preliminary ndings showed so many variations in people's eagerness to implement measures that can mitigate pathogen transmission (41;42). Findings from this research also revealed that the major barrier for not observing the preventive measures was that majority of the respondents could not wash their hands with soap for up to 20 minutes due to lack of time, they feel uncomfortable with wearing of nose mask, they attend crowded events because it is crucial and they usually touch their face in the process of cleaning sweat. (43) reported that some measures like wearing of face mask are seen as causing social discomfort, that can be stressful but at the same time if not worn will expose one high risk of the infection. Similarly, when the participants in the study of (44) were asked their reason for their unwillingness to undertake preventive standards, almost 2/5 of them reported that the condition does not apply to them, and more than one-quarter were of the opinion that the measures demands so much effort (time, cost, etc.) and others were likely not to adhere to these measures.
On the intent to comply with the proposed covid-19 vaccine, only few of the participants 114(26%) were willing to accept it especially if it given free of charge and its safety trusted and this decision to accept the vaccine was prominently in uenced by friends. This gure is similar to 29.0% acceptance recorded by (24 Highest level of compliance was maintained by the female respondents who were within the age bracket of 52-61 years. This is in agreement with the ndings of (51) in which females in Saudi public were more likely to keep preventive and precautionary standards than males (53.6% versus 40.6%, respectively) and with the ndings of (52) in which female students from Egypt were 3.6 times more likely to avoid crowded places than male students. Age has been reported to have strong association with compliance, such that younger adults less likely to adhere.
Equally, highest level of compliance was mostly kept by those who are married with no child. Being married has also been reported have strong relationship with higher rates of compliance with quarantine measures during avian in uenza outbreak (54). Level of education also had strong in uence on level of compliance such that those who had tertiary education were most likely to keep high compliance compared to other levels of education. Other workers (55; 56) have shown that higher education level correlates with higher knowledge of coronavirus, which is in line with the present results. This suggests that higher level of knowledge of COVID-19, especially precautionary and control standards and prognoses, results to better behavioural compliance and a higher response to coronavirus prevention and control standards. Higher level of compliance was also maintained by the participants who are public/civil servants with signi cant association (p<0.05). This is in line with the nding of (57) who reported close association of the participants' occupations with preventive compliance, with professional and technical personnel, o ce and management personnel having better scores compared to outdoor workers.
Furthermore, all the demographic variables had signi cant association with the respondents' intent to accept covid-19 vaccine when provided. Acceptance was higher among female respondents within the age group of 52-61 years. Also, acceptance was higher among married respondents who had 1-2 children and who had secondary school as their highest level of education. Higher level of vaccine acceptance was also shown in participants who are small/medium traders and who are Christians with signi cant association (p<0.05).
Socio-demographic attributes were also shown to be strong predictors of pandemic vaccine acceptability in UK, France, Australia, US, and Japan (46; 58; 59). Only age and marital status were recorded as substantial factors in predicting the acceptability of coronavirus vaccines in Saudi Arabia (60).

Conclusions
Findings of this research showed that almost all the participants have heard about covid-19 from radio and they have good knowledge of the disease in terms of the cause, routes of transmission and seriousness of the disease in other parts of the world other than Nigeria since most of them did not know or have seen anyone who neither suffered nor died from the disease. Most of them believed the disease can be prevented through regular washing of hands with soap, maintaining social distance, wearing of nose mask, cleaning and disinfecting the environment. Nevertheless, it was found that the participants follow all the recommended preventive measures sometimes, resulting in larger proportions of them observing low level of compliance.
Major barrier for not aobserving the preventive measures was that they believed that hand washing with soap for up to 20 minutes is not necessary, they feel uncomfortable with wearing of nose mask, they attend crowded events because it is crucial and they usually touch their face in the process of cleaning sweat. Only a few of them were willing to accept covid-19 vaccine especially if it given free of charge, its safety trusted and it's in liquid form. Major reason for not taking vaccine was there is a hidden agenda behind it which is not to the advantage of humanity while major reason for accepting it was to prevent the recipient from getting the disease. With the exception of religion, all the demographic characteristics had signi cant in uence on the level of compliance to covid-19 preventive measures. Moreover, all the demographic variables had signi cant association with the respondents' intent to accept covid-19 vaccine when provided. Finally, to motivate people to receive the vaccines, scienti c evidence on the vaccine e cacy, safety, and side effects must be made available to the public.

Declarations
Competing interests The authors declare that they have no competing interests.
Author's contribution SNOI and UWD conceived the study, contributed in drafting the study and designed the questionnaire, CRN, CJN, UMC, OUG and INSD: Study design, synthesized the analysis and revisited the manuscript and critically evaluated the intellectual contents collection, NDO and CDI and participated in data collection and performed the statistical analysis. All authors read and signed the nal version of paper

Ethical considerations
Ethical issues (including plagiarism, data fabrication, double publication) have been completely observed by the authors.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on request.

Consent for publication
Not applicable. Level of compliance to preventive measures Figure 6 Reason for accepting the vaccine