Prevention Practice and Associated Factors of Coronavirus disease 2019 (COVID-19) Outbreak among Educated Ethiopians: An online Based Cross-sectional Survey

Background: An acute respiratory disease, known as the novel coronavirus disease 2019 (COVID-19), was identied in the late 2019. As launched by World Health Organization, it is now a pandemic problem. So far there is no any vaccine or drug for treatment to this disease. The world including Ethiopia have been relying on practicing different preventive measures. As of 17-Apr-2020, the Ethiopian health minister reported 96 conrmed cases and 3 deaths of COVID-19 from the total of 6231 laboratory tests conducted. The mainstay of approach to avoid COVID-19 is applying preventive measures. Therefore, the current survey aimed to assess self-reported measures of prevention practice and associated factors regarding COVID-19 among educated Ethiopians in the early stage of this outbreak. Methods: An online based cross-sectional study was conducted to collect information from educated Ethiopians during the early stage of the outbreak from March 25 to April 4, 2020. Electronic based questionnaire developed by reviewing literature and revising from ''COVID-19 Snapshot Monitoring comprised monitoring knowledge, risk perceptions, preventive behaviors, and public trust in the current coronavirus outbreak. Data were analyzed using SPSS-25. Results were presented using descriptive and inferential statistics. To determine predictor variables for preventive practice, a binary logistic regression model was tted. Variables with a p-value < 0.05 in the nal model were declared as predictors. Results: Five-hundred and twenty-eight Ethiopians participated in this study of which 80.7% were males. The mean age of study participants was 33.2 (±7.4) years. Above one-third (34.7%) of the participants had a health-related profession. Majority (79.7%) of the respondents attended degree and above education. Overall, above half (55.9%) of the study participants had good knowledge about COVID-19. About 55.3% and 57.8% had good knowledge regarding symptoms and prevention methods of COVID-19, respectively. Overall, above half (54%) of the respondents had good COVID-19 preventive practice. Being female [Adjusted Odds Ratio (Adjusted Odds Ratio): 2.00; 95%CI (1.14, 3.50)], higher age (aged practice, a binary logistic regression model was In multivariable binary logistic regression, variables were considered as signicant at a p-value < 0.05. Hosmer and Lemeshow goodness- of -t test (p>0.05) was used to check model tness. Results were presented using descriptive and inferential statistics.

Coronavirus disease 2019  is one of the strain in the family of corona virus which affects upper respiratory tract (1) An acute respiratory disease, known as the novel coronavirus disease 2019 identi ed in late 2019. The pathogen responsible for COVID-19 is a member of the coronavirus family, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, also known as the COVID-19 virus (2). The epidemic of unknown acute respiratory tract infection broke out rst in Wuhan, China, since 12 December 2019, possibly related to a seafood market but not yet con rmed (3,4). Suggested ways of human to human transmission of the COVID-19 is through droplet, feco-oral, and direct contact and has an average incubation period of 2-14 days (5). The disease is characterized by fever, dry cough, fatigue, tiredness and di culty of breathing (6).
Transmission of SARS occurs primarily among family members, including relatives and friends who have closely encountered patients or carriers of coronavirus (3). On March 17, 2020, the WHO reported that the number of con rmed cases reached 179, 111 and 7426 deaths, the number of con rmed cases in Africa since then been 577 cases (7). In Ethiopia, the rst case was reported on 13 th March, 2020. On April 5, the number increased to 2 con rmed cases and 2 deaths (8). In response to the COVID-19 outbreak, the Ethiopian government temporarily shut down all schools and cancelled face to face education at higher education institutions. COVID-19 and its response can also be expected to evoke broader anxieties (9).
The elderly, individuals with serious chronic medical conditions such as heart disease, diabetes mellitus and lung disease are at a higher risk of COVID-19 related death. According to WHO report the case fatality rate in people with no chronic diseases was 1.4 percent, 13.2% for those with cardiovascular disease, 9.2% for diabetes, 8.4% for hypertension, 8.0% for chronic respiratory disease, and 7.6% for cancer (10).
There is presently no vaccine or speci c anti-viral drug regime used to treat critically ill patients. The management of patients mainly focuses on the provision of supportive care, e.g., oxygenation, ventilation, and uid management. Combination treatment of low-dose systematic corticosteroids and anti-virals and atomization inhalation of interferon have been encouraged as part of critical COVID-19 management (11). There are also other treatment regimens recommended these days but not yet veri ed.
The main treatment, however is supportive care.
The key components in prevention and control measures and procedures for COVID-19 includes policies and procedures (hand hygiene, sta ng, Personal Protective Equipment), routine practices and environmental and housekeeping, transporting patients, screening and surveillance, investigations of outbreaks, frequently wash your hands with soap and water for at least 20 seconds, if no water use an alcohol-based hand rub with at least 60% alcohol ,always wash hands that are visibly soiled, education and training for health care workers, avoid touching eyes, nose, or mouth with unwashed hands point of entry controls, avoid close contact with people who are sick (12)(13)(14). It has paramount effect like depression, anxiety and stress among individuals (15). Old-style public health measures, isolation, social distancing, avoidance of hand shake and community containment, are some of effective methods to prevent a disease when vaccine is not available (16). Millions of people are using different social media to gather information about COVID-19. So knowing preventive practice and factors towards Covid-19 among educated Ethiopians can pay a great role in the prevention of the disease. Misinformation is a sign of an individual's failure to inspect and verify the information they are sharing. Ideally, people need to explore the evidence and use empathy before jumping to conclusions, especially where other people and cultures are concerned. One of the challenge in ght against COVID-19 is misinformation and lack of preventive practice. The battle against COVID-19 is still continuing globally. Assessing preventive practice is an important approach to tackle health problems like Covid-19 among individuals (17,18). The lessons learned from the 2003 SARS outbreak indicate that good practice towards infectious diseases are related to the degree of fear among the population, which may complicate further efforts to prevent the spread of the disease (19,20).
The primary objective of this current study is therefore to identify the self-reported preventive practice and associated factors towards Covid-19 among educated Ethiopians using an online data collection by employing ''COVID-19 Snapshot Monitoring (COSMO): Monitoring knowledge, risk perceptions, preventive behaviours, and public trust in the current coronavirus outbreak" tool.

Study design, area and period
This online based cross-sectional study design was employed on educated individuals who had been using social media (such as Facebook, electronic mail, and telegram) and currently residing in Ethiopia.
The survey was carried out from March 25 to April 4/ 2020.

Population and inclusion criteria
All educated social media users living in Ethiopia and who are Ethiopian nationals were used as study population. We included all educated social media users who were volunteer to ll the survey.

Sample size determination and sampling technique
It was di cult to determine the minimum sample size for this study. We included all individuals who were volunteer to ll the online survey from March 25 to April 4/ 2020. It was practically di cult to get su cient response rate in internet based studies and increasing the sample size was essential. So we let the online survey for 10 days active to allow more participants' involvement. Preventive Practice: Respondents were asked if they practiced 12 preventive practices (proper and frequent handwashing using soap and water, use of sanitizer in the absence of soap and water, staying at home while having cough/cold, not travelling to abroad or risky areas, covering mouth and nose while sneezing or coughing, avoid touching face, nose and mouth with unwashed hand, consumption of balanced diet, avoiding contact with someone infected or suspected, use of facemask, regular physical exercise, physical/social distancing and, self-quarantine) and those who scored the median and above (≥8 out of 12 questions) were considered as having good preventive practice.
Knowledge: Respondents were asked 27 questions (6 questions about identi cation of people at greater risk of COVID-19 (pregnant women, people with chronic heart problem, people with asthma, people with pneumonia, people with diabetes mellitus and elderly), 9 questions about symptoms of COVID-19 (fever, cough, shortness of breath, sore throat, runny or stuffy nose, muscle/body aches, headaches, fatigue/tiredness and diarrhoea), 12 questions about prevention methods of COVID-19 (mentioned above under preventive practice)). Those who have answered the median (22 out of the 27 questions) and above were considered as having good overall knowledge.
Variables of the study Dependent/ outcome variable Preventive practice about COVID-19

Independent variables
Socio-demographic variables (sex, age, educational status, profession), presence of under-18 years children in house, source of information, self-rated overall health condition, history of psychiatric disease, knowledge about symptoms, prevention methods and people at higher risk, perceived susceptibility, perceived severity, perception about re-infection by COVID-19, self-rated awareness about COVID-19, primary source of information, and accepting authorities' recommendations to prevent COVID-19

Data collection instrument
We used a revised Germany COVID-19 Snapshot Monitoring (COSMO) questionnaire (21) containing socio-demographic variables, knowledge, attitude, and practice about COVID-19 symptoms, transmission routes, incubation period, prevention methods, and misconceptions. The primary variable of interest in this study was preventive practice about COVID-19. The knowledge, attitude and practice were measured as a composite variable computing the responses given for each knowledge, attitude and practice questions respectively.

Data processing and analysis
As this was an online data collection in the form of CSV (excel le), there was no need of data entry. The excel form data were imported into SPSS version 25 for statistical analysis. All assumptions for binary logistic regression were checked. To determine predictor variables for preventive practice, a binary logistic regression model was tted. In multivariable binary logistic regression, variables were considered as signi cant at a p-value < 0.05. Hosmer and Lemeshow goodness-of -t test (p>0.05) was used to check model tness. Results were presented using descriptive and inferential statistics.

Characteristics of study participants
In the current study 528 respondents participated. Four hundred and twenty-six (80.7%) were males and the mean age of the study participants was 33.2 (±7.4) years. Above one-third, 183/528(34.7%) of the participants had a health related profession. Two hundred and thirty-two (43.9%) respondents had at least one child below age 18 years. Most of the study participants (170/528, 32.2%) reported health and health-related institutions as their primary source of information regarding COVID-19 followed by Facebook (138/528, 26.1%). Majority (421/528, 79.7%) of the respondents attended Bachelor degree and above education (table 1). Table 2 shows the study participants' overall knowledge, knowledge about groups at high risk to COVID-19, symptoms of the disease, methods of prevention, vaccine none availability, transmission routes, reinfection and incubation period. Overall, above half (295/528, 55.9%) of the study subjects were knowledgeable about COVID-19. One hundred and eighty-three (34.7%) had poor knowledge about people at risk of COVID-19 infection. About 55.3% (292/528) and 57.8% (305/528) had good knowledge regarding symptoms and prevention methods of COVID-19, respectively. The three mostly mentioned symptoms by respondents were fever (96.8%, 511/528), shortness of breath (94.3%, 498/528) and cough (94.1%, 497/528). Nine out of ten (90%, 475/528) respondents know that physical/social distancing can help prevent the spread of COVID-19. Almost all (515/520, 99.04%) know that the disease has no vaccine for prevention or drug developed for treatment yet. Ninety seven point three percent of the respondents know that the disease is transmissible from person to person. While 20.8% (110/528) reported that they did not know whether a person who has recovered from the disease is immune to COVID-19 or not majority (346/528, 65.5%) reported that COVID-19 can re-infect a person who recovered from the illness. Almost all (500/528, 94.7%) respondents reported that the incubation period for the development of symptoms from the time of infection is 14 days. Table 3 depicts the perception of the respondents regarding probability of getting infected by, susceptibility to, severity if infected with, and acceptance of governmental authority's recommendation regarding COVID-19. Only one hundred and eighty-one (34.3%) respondents believe that their probability of getting infected is extremely likely. When respondents were asked how severe would contracting the COVID-19 be for them, about two-third (350/528, 66.3%) believe that it would be somewhat severe. Only one-fth (109/528, 20.6%) and a few number of respondents (22/528, 4.2%) believe that avoiding COVID-19 infection is easy and extremely easy, respectively. While asked whether they follow the recommendations from authorities in their country to prevent spread of COVID-19, only 32% (169/528) responded that they were most likely to adhere to the recommendations. When asked whether they know how to protect themselves from COVID-19, ninety-ve participants (18%) responded that they know very much and ten (1.9%) reported that they do not have the know-how at all. Table 4 shows COVID-19 preventive practice reported by study participants. Overall above half (285/528, 54%) of the respondents had good COVID-19 preventive practice. About nine out of ten (469/528, 88.8%) study subjects reported that they were washing their hands for 20 seconds at 20 minutes intervals.
Seventy-ve percent (397/528) respondents reported that they have avoided touching their eyes, nose, and mouth with unwashed hands. Two hundred and sixty (49.2%) reported that they have ensured balanced diet to protect themselves from COVID-19 infection. Seventy-three (13.8%) reported that they have avoided consuming meat to protect themselves from COVID-19. About two-fth (211/528, 40%) reported that they were wearing facemasks. Above one-fourth (139/528, 26.3%) reported that they were consuming a mixture of Ruta chalepensis, ginger, lemon, garlic and honey to protect themselves from COVID-19. Only 72.9% (385/528) and 36.2 % (191/528) reported that they practiced physical/social distancing and self-quarantine, respectively. Table 5 shows factors associated with COVID-19 prevention practice. During the bivariable binary logistic regression, sex, age, type of profession, self-rated physical health problem, having a child below 18 years, self-rated awareness about COVID-19, knowledge about people at higher risk of the disease, knowledge of symptoms, prevention methods and re-infection, perceived susceptibility, perceived probability of getting infected, perceived severity, perceived self-protection knowhow, and acceptance of authorities' recommendations were variables with p-value <0.2. These variables were candidates for the nal multivariable binary logistic regression analysis. Variables with p-value<0.05 were declared as signi cantly associated with the outcome at the nal model. Being female, higher age, knowledge of symptoms, knowledge of prevention methods, knowledge of re-infection, and perceived self-protection knowhow were signi cantly associated with COVID-19 prevention practice. Respondents who believe that after a person has recovered from the disease, he/she has chance of reinfection had 1.86 [AOR: 1.86; 95%CI (1.03, 3.38)] times better odds of prevention practice as compared to those who believe that a person after recovery will be immune to COVID-19.

Discussion
To the best of our knowledge, this study which aimed to assess the self-reported prevention practice towards COVID-19 among Ethiopians is the rst in the country. In this study, 54% [95% CI (49.6, 58.5 %)] educated Ethiopians had good self-reported prevention practice towards COVID-19 in the early stage of the outbreak. The self-reported prevention practice towards COVID-19 was good in that 88.8% of the participants wash their hands for at least 20 seconds in 20 minutes interval, 80.5% avoid touching their eyes, nose, and mouth with unwashed hands, and 72.9% practice physical distancing. The possible explanation for this high practice could be the study participants were educated and the rst coronavirus case was reported in Ethiopia on 13 March (after 2 months since the rst case of COVID-19 was reported from China) and it may increase the dissemination of information which helped them to practice preventive measures. People should practice possible preventive strategies to protect themselves and others from infection by washing hands or using an alcohol based rub frequently and not touching the face, practicing physical distancing where possible and self-isolate if they start to show symptoms such as fever, tiredness, dry cough, shortness of breath, sore throat, and body aches (22,23).
The adjusted odds of self-reported prevention practice towards COVID-19 was two-fold higher among female respondents when compared with males. The ndings of this study is supported by other study (24). It might be because mostly females participate in childcare, food preparation and other tasks compared with males. Therefore, preventive measures are more likely to be practiced better among females to protect themselves and others from infection.
Respondents aged 33-37 years and 38-72 years had 1.98 and 2.6-fold better practice of COVID-19 preventive measures as compared to those aged below 28 years respectively. Studies on COVID-19 published so far revealed the case fatality rate of COVID-19 close to 15% in patients over the age of 80 in contrast to the average overall case fatality rate of 2.3% (25) and evidences from China suggested that paediatrics COVID-19 cases might be less severe than cases in adults and that children might experience different symptoms than do adults (26)(27)(28). Because of the above scenario, older participants may have better practice of COVID-19 preventive measures than the younger individuals.
When compared respondents who have poor knowledge of COVID-19 symptoms and prevention methods, who have good knowledge of COVID-19 symptoms and prevention methods were 2.82 times and 4.55 times more likely to report better prevention practice respectively. Knowledge of respondents on people at risk group were elderly above 60 years 465 (88.1%), people with pneumonia 412 (78.0%), people with diabetes mellitus 396 (75.0%), people with asthma 396 (75.0%), and people with chronic heart disease 375 (72.0%) from highest to lowest respectively. Knowledge on symptoms of COVID 19 shortness of breath 498 (94.3%), sore throat 447 (84.7%), headache 415 (78.6%), and fatigue 406(76.9%). Knowledge about coronavirus disease (COVID-19) sign and symptoms, transmission, treatment, and how to prevent infection will increase prevention practice of an individuals and they might be implement the key messages of the guideline include causes, how to choose and wear face masks, proper hand washing habits, preventive measures at different locations (e.g., at home, on public transportation, and in public space), disinfection methods, and medical observation at home (24,29). Study participants who reported to have su cient knowhow to protect themselves from COVID-19 had 1.83 times higher better self-reported prevention practice as compared to their counterparts. Knowing the mode of transmission, the prevention mechanism of COVID 19, and the ways of protecting themselves by practicing physical distancing and self-isolation where possible can improve prevention practice.
Respondents who believe that after a person has recovered from the disease, he/she has chance of reinfection had 1.86 times higher better prevention practice as compared to their counterparts. Experts unsure if 'cured' COVID-19 patients are re-infected or relapsed and U.S. experts in a World Health Organization delegation that visited China in February. He said Chinese experts told the visitors that there were no examples of people who became "re-infected" (30). However, there are contradictory reports regarding re-infection which supported the presence of re-infection (31).

Limitations Of The Study
This study was undertaken among educated Ethiopians within a very short period. As this is a crosssectional study it does not show cause effect relationship. The lack of su cient literature made the comparison of results di cult.

Conclusion
The COVID-19 preventive practice among educated Ethiopians is not su ciently satisfactory. Females, those with advanced age, those who believes presence of re-infection by COVID-19, those with good knowledge of symptoms, prevention methods, and self-protective knowhow had better preventive practice. Extensive public awareness raising focusing on young population and males is essential to ght further spread of the virus. Further study on the knowledge, attitude and practice of COVID-19 prevention among uneducated Ethiopians is essential.