Magnitude and associated factors for attitude and practice of Southern Ethiopian residents toward COVID-19 and its preventions: A community based cross sectional study

Background: COVID-19 rst broke out in china, Hubei province on December 29, 2019. Since then it took more than hundred thousand lives worldwide. Although all countries are taking varying degree of measures to curb the dissemination, the virus is still spreading rapidly in all part of the world. Adherence of peoples for COVID-19 precautions measures is one of the most important factors which determine the effectiveness of curbing the spread. However without having good attitude adherence of people toward precaution measures could be challenging. Therefore the aim of this study is to assess the attitude, practice and associated factors of southern Ethiopian residents toward COVID-19 and its prevention. Methods: A community based cross sectional study was conducted among 585 Southern Ethiopian residents. Bivariate and multivariate binary logistic regression was used to determine association between dependent and independent variables. Adjusted odds ratio with their 95% CI was used show the strength of association. P-value < 0.05 was used to decide statistically signicant association. Result: Most of the study participants (90.3%) have good attitude toward COVID-19 and its prevention. Being younger age group, having chronic medical illness, using television as a source of information and having good knowledge were signicantly associated with good attitude toward COVID-19.On other hand; only 20% of the study participants have good practice toward COVID-19 prevention. Educational status, occupation and having chronic medical illness, uses of religious teaching as information sources are associated factors for good practice against COVID-19 infection. Conclusion: We conclude that despite the presence good attitude in majority of respondents much work needed to improve rare practice of COVID-19 preventive measures.

To date, June 7, 2020, about 7 million con rmed cases and 400, 000 deaths have been reported worldwide [3]. Yet the number of positive cases and deaths continues to rise rapidly. Di culty of isolating suspected cases due to long incubation period and its rapid contagiousness makes the diseases challenging to control. The virus can also present in some peoples with few or no symptoms, which makes the spreading quicker and silent [1]. Consequently even developed nations like USA, Italy, Spain, France and China are severely affected by the outbreak [3].
There is a debate on the reason for lower number of cases and deaths. Some of speculations are relatively lower testing rates, poor reporting habits and lower number of passengers coming to continents [5][6][7][8]. However nothing can spare Africa from casualty but preparation and on time response. In addition there is a concern from world health organization (WHO) that the disease could spread rapidly and causes devastating causalities in most African countries where it is di cult to exercise COVID-19 precaution measures [8].
Since the start of the outbreak, Ethiopian government has been taking different measures to tackle the spread based on WHO recommendations, starting from surveillance of people coming from aboard at the airport or border line[9] to varying levels of contact tracing and isolation and quarantine of suspected cases; Awareness creations are also being given by different means such as television, radio, telecommunication and social media in order to encourage peoples for hand washing, respiratory hygiene, social distancing and avoid hand shaking and public gathering [10].
Resources are also being mobilized from the citizens and foreign donors besides preparation of health systems for possible upcoming overwhelms of hospitals by severely ill patients who require isolation, oxygen, and mechanical ventilation [11].
In addition to government effort, people's adherence for preventive measures is vital to accomplish a success against the ongoing ght of COVID-19 pandemics. However, in the absence of good attitude in a community toward COVID-19, adherence for prevention measures could be challenging. Therefore the aim of this study is to assess the attitude, practice and associated factors of southern Ethiopian residents toward COVID-19 and its prevention.

Methods
A community based cross sectional study was conducted on between March 27 to 31, 2020 to assess attitude, practice and associated factors of southern Ethiopia residents towards COVID-19 and its preventions. Face to face interview was conducted among 585 Southern Ethiopian adult's residents.
Sample size was calculated based on the fact that no similar study had conducted during the study period, so p and q were considered as 0.5 and margin of error 0.4 with 95% con dence interval. By using single proportion formula sample size were determined to be 600. There were about 9 (nine) attitude questions. All nine questions use likert scale measurement. Each questions scored out of 5, making the total maximum score 45 and the minimum 9. Those participants who scored below 25 points on all nine questions were considered as they have poor attitude and those who scored 25 and above were considered as they have good attitude.
Practice assessed by 8 questions in likert scale and each scored up to 2 (0 = disagree, 1 = neutral, 2 = agree) and the overall maximum score being 16 and the minimum score 0. Overall Score below 8 was considered as poor practice and, 8 and above as good practice.
Questions were prepared in English and translated to local languages 'Amharic' and 'gedeu'ffa'.
Questionnaires were lled by trained data collectors. Socio-demographic factors such as age, gender, marital status, education, occupation, religion, residence, sources of information, household size …etc were collected as independent variables.
Data were coded and entered in to Epi-data 3.1 and were exported into SPSS version 25 for cleaning and analysis. Frequency tables, and descriptive summaries were used to describe the study variables.
Bivariate binary logistic regression analysis was used to see the crude association between dependent and independent variables. All explanatory variables which had association in bivariate analysis at pvalue less than or equal to 0.25 were entered into multivariable binary logistic regression model. Multicollinearity was checked by variance in ation factor and tolerance level. Adjusted odds ratio with their 95% CI was used to show the strength association. P-value < 0.05 was used to declare statistical signi cance of independent predictors.

Result
Socio-demographic characteristics of respondents From a total of 600 eligible respondents, 585 were analyzed and the rest of 15 were excluded due to lack of cleanness and incompleteness of the data. The mean age of the respondents was 33.7 with a standard deviation of ± 11. About 41.9% of the study participants were female and 12.5% have no any formal education. Majority (74.4%) of study participants were married and nearly half (54.4%) of the respondents live in rural area. The socio-demographic characteristics of respondent were shown in Table1.

Associated factors for practice toward covid-19 and its preventions
The presences of chronic illness, occupation and uses of religious places as a source of information and educational status have association with practice toward covid-19 prevention. As shown on

Discussion
This study was conducted 2 weeks after the rst con rmed covid-19 case (March 13) in Ethiopia. At the time of data collection there were 16 con rmed covid-19 cases but no death [12]. We investigated the attitude, practice and associated factors of southern Ethiopian residents toward covid-19 and its preventions.
On the present study, most of the study participant (90.3%) have good attitude toward covid-19 and its prevention. This nding is consistent with study done in Iran though it is by far higher compared to the study done in Thailand [13] which showed 61.5% of populations have good attitude toward COVID-19 and its prevention. The difference could be due to the fact that our study conducted later than the study of Thailand. In between period of two studies so many fatality and crises happened around the world which can change the perception and attitude of mankind toward COVID-19 and its prevention.
This study also reveals that being younger age, having chronic medical illness, using television as a source of information and having good knowledge about COVID-19 were associated factors which increase the likelihood to have good attitude. Similarly study done in Thailand [13] showed peoples who have medical illness were more likely to have good attitude. Surprisingly in our study elder population have relatively poor attitude despite being more vulnerable for complications of COVID-19 infection. In contrast A. Erfani et al. [14]demonstrated that older age groups have higher likelihood to have good attitude. The difference could be due to elders in our country see such kind of events either traditionally or spiritually perspectives.
Practicing preventive measures like frequent hand washing using soap, uses of sanitizer, avoidance of hand shaking and public gathering and use of face mask are paramount important for mitigating the spread of COVID-19 infection [15]. However, our result showed that only 20% of the populations are practicing prevention measures favorably. For example only 6.3% of participants had worn face mask when leaving home. Comparing with the reports of Peeradone et al, in Taiwan, [10] and Azlan A.A. et al. in Malaysia [16] in which there was 98% and 51% practice of using face mask ; our respondents have by far lower experience of using face mask. This huge variation can be explained primarily by scarcity of protective equipment at national level. In addition peoples in our country were discouraged to use medical face mask so that it can be saved to be used by health care providers.
In addition to lower rate face mask user, social distancing had practiced by only 10% participants which was much lower than the nding of a study conducted by John M Clements et al, USA, which was 70% peoples avoid mass gathering [17]. The difference might be due two major reasons; rstly, the variation of number of reported cases and fatality in two nations at a time of data collection; secondly, difference of two country's peoples in capacity to cop up economic burden of social distancing. On other hand majority of our participants avoid hand shaking (56%) and frequently practicing hand washing using soap (58.6%). These two practices relatively received better acceptance by the community. This might be due to they are relatively cheaper tasks to exercise. However, in a comparison to other developing nations like Bangladesh [18] in which there is 98.6% hand washing practice our nding revealed a huge gap in the study area.
Educational status (p-value = 0.003), occupation (p-value = 0.015), presence of chronic illness (p-value = 0.035) were associated with practice against covid-19 infection. This is nding partly in line with the study conducted by Peeradone Srichan et al who showed age, gender, educational status, annual income as a factors for good practice. The type of analysis method used, Multivariate Vs. Bivariate, might be a reason for such difference [10].we found that educational level positively affect the practice of our respondents though Azlan AA et al. [16] Showed no effect. This difference could be due to variation in educational status categories.

Conclusion
We conclude that majority of responders have good attitude toward COVID-19 and its preventions. However, preventive measures of COVID-19 were practiced by only fewer respondents. Age, chronic medical illness, use of television as a source of information and level of knowledge are associated factors for level of attitude. Level of practice of preventive measures associated with educational status, occupation, presence of chronic medical illness and use of religious teaching as sources of information.

Declarations
Ethical Approval and Consent to participate