Knowledge, Attitude, Practice, Risk Perception and Challenges Towards COVID-19 in East Gojjam Zone, North West Ethiopia, Cross Sectional Study


 Background: Understanding how people perceive the risk of the coronavirus disease outbreak and its impact on undertaking protective behavior can guide the public health policymakers in taking the required measures to limit the magnitude of this outbreak.Objective: This study aimed to assess the knowledge, risk perceptions, and uptake of preventive measures towards COVID-19 in East Gojjam zone.Methods: A mixed method study in order to obtain in-depth behavioral insights related to COVID-19 pandemic prevention measures was conducted in the four randomly selected Woredas of East Gojjam Zone. A flexible data collection tool adapted from World Health Organization (WHO) for quantitative component, and in-depth interview for qualitative component was used. Binary logistic regression analysis was conducted to analyze quantitative data, and while content analysis was used for qualitative component.Results: In this study, a total of 661 study participants were included. Nearly two-third (65.5%) of respondents is residing in the rural area. Only 59.6% of respondents had better understanding of COVID-19 pandemic. Similarly, less-than one-fifth (14.5%) of individuals had favorable attitude towards COVID-19. This study showed that only one-fifth (20.9%) of study participants had good preventive practices. Respondent’s residing in urban area (AOR: 0.1, 95%CI: 0.08, 0.2), who had age between 35 and 45 (AOR: 0.4, 95%CI: 0.2, 0.8), and having secondary and above education level (AOR: 0.2, 95%CI: 0.1, 0.5) had better awareness towards COVID-19 as compared to its counterparts. Similarly, study participants who had better knowledge ((AOR: 3.0, 95%CI: 1.7, 5.5), and residing in urban area had favorable attitude towards COVID-19. Furthermore, respondents with confirmed comorbidity had good preventive practice towards COVID-19.Conclusion and recommendation: In this study, the level of knowledge, attitude and preventive practice towards COVID-19 is low. Residing in rural area, not having formal education, being housewife were factors significantly associated with the poor level of knowledge, attitude, and preventive practice towards COVID-19. Address peoples living in rural area through health professional to create public awareness towards COVID-19 is recommended.

The novel corona virus is genetically similar to other coronaviruses that caused Severe Acute Respiratory Syndrome (SARS) and the Middle East Respiratory Syndrome (MERS). SARS-CoV-2 appears to have greater transmissibility and lower pathogenicity than the aforementioned viruses. Preliminary estimates of the basic reproduction number of SARS-CoV-2, as a metric for transmissibility, range from 2.8 to 5.5, in the absence of intense quarantine and social distancing measures (4).
To date, no effective pharmacological interventions or vaccines are available to treat or prevent COVID- 19. For this reason, non-pharmacological public health measures such as isolation, social distancing, and quarantine are the only effective ways to respond to the outbreak. Isolation refers to the separation of symptomatic patients whereas quarantine is the restriction of asymptomatic healthy people who have had contact with con rmed or suspected cases. Quarantine can be implemented on a voluntary basis or can be legally enforced by authorities and may be applied at an individual, group, or community level (5).
At this time, WHO and the US Center for Disease Control and Prevention (CDC) recommend 14 days of quarantine for individuals who were in close contact with a con rmed case, based on the estimated incubation period of SARS-CoV-2 (6,7). According to early estimates by China's National Health Commission, about 80% of those who died were over the age of 60 and 75% of them had pre-existing health conditions such as cardiovascular diseases and diabetes (8). While there is still much to learn about COVID-19, people can take action to prevent the disease through simple, day-to-day measures. These include the following precautions: Regularly and thoroughly washing hands with soap and water and use alcohol-based hand sanitizer. Maintain a physical distance of at least one meter, particularly if a person is coughing. Persons with persistent cough or sneezing should stay home or keep a social distance, and not mix in crowds. Make sure you are coughing into a tissue or a bent elbow, and make sure to safely dispose of the used tissue afterwards. Stay home if you feel unwell with symptoms like fever, cough and di culty in breathing. Understanding how people perceive the risk of the coronavirus disease outbreak and its impact on undertaking protective behavior can guide the public health policymakers in taking the required measures to limit the magnitude of this outbreak. To date, there is no evidence that shows the level community awareness and uptake of preventive measures in Ethiopia.

Objective
The general objective of this study was to assess the Knowledge, Attitude, practice, risk perceptions and challenges towards COVID-19 in East Gojjam Zone, North West Ethiopia, 2020.

Study area
The study was conducted in east Gojjam Zone. This zone is bordered on the south by the Oromia Region, on the west by West Gojjam, on the north by south Gondar, and on the east by Debub Wollo and the bend of the Abay river de nes the Zone's northern, eastern and southern boundaries. Based on the 2007 census conducted by the central statistical agency of Ethiopia, this Zone has a total population of 2,153,937. In the administrative Zone there are 423 and 102 health posts and health centers respectively. In addition, in this Zone there are nine primary hospitals and only one referral hospital (26).

Study design and population
A mixed method study in order to obtain an in-depth behavioral insight related to COVID-19 pandemic prevention measures was conducted in the four randomly selected Woredas of East Gojjam Zone. All residents in East Gojjam Zone are the source population, while the selected residents in the selected woredas and town at the time of data collection period were the study population of this study.

Study participants and sampling procedure
This study was undertaken in four randomly selected Woredas of east Gojjam zone namely: Awabel, Enemay, Debre Elias and Motta. The sample size is determined using sample size determination formula for single population proportion formula. Accordingly, the minimum adequate sample size is calculated with the assumption of 26.9% of individuals perceived their risk of getting COVID-19 infection (taken from the previous study), signi cant level at α = 0.05, margin of error = 5%, 10% non-response rate and multiplying by two (for design effect). Thus, a minimum sample size of 1330 will be needed after considering design effect. Next, the calculated sample size will proportionally allocate for each woredas.

Operational de nition
Knowledge: In the context of this study knowledge towards COVID-19 will de ned as understanding symptoms , actual knowledge about effective preventive measures to avoid infection, and other related information related to novel coronavirus. A respondent is considered having good knowledge if he/she answered two-third and above knowledge related questions, while poor knowledge is considered if the respondent answered below two-third of knowledge related questions.
Attitude: Understanding and interpreting the susceptibility and severity of COVID-19 disease. Favorable attitude: if the respondent answered above the mean of attitude related questions. Unfavorable attitude: if the respondent answered below the mean of attitude related questions practicing of preventive measures: The utilization of recommended preventive measures to avoid an infection with the novel corona virus.
An individual is considered practicing preventive measures to COVID-19, if he /she utilize all recommended preventive measures (Frequent hand washing or use of sanitizer, maintaining physical distance).

Variables and measurements
Page 6/27 The following variables were measured in this study: Demographics (Age, Gender, marital status, education, religious, and occupation…..), Knowledge about the novel coronavirus, Attitude regarding the COVID-19, Uptake of preventive measures to avoid infection with COVID-19 and Individual feeling of preparedness to avoid an infection with the coronavirus Data collection tool and analysis A exible data collection tool adapted from WHO was used. The data collection tool was pilot-tested in one non-study woredas. To assure the data quality, high emphasis was given in designing data collection instrument. Regular meetings were held between the data collectors, supervisors and the principal investigators together in which problematic issues was discussed and addressed. The collected data was reviewed and checked for completeness before leaving the data collection sites. Binary logistic regression analysis was conducted analyze quantitative data. For qualitative component content analysis was applied.

Socio-demographic characteristics of respondents
In the quantitative component of this study, a total of 661 study participants were included. About 37.5% of study participants were males. Nearly two-third (433(65.5%)) of respondents are residing in the rural area. Of the total study participants, majority (534 (80.8%)) were married. About half (51.4%) of individuals are without formal education, and only 13.3% of respondents had secondary and above education level.  Ref. Factors associated with the level of attitude towards COVID-19 pandemic In the multivariable logistic regression analysis, residence, level of knowledge, occupation, and having con rmed comorbidity were factors associated the level of attitude towards COVID-19 (Table 3). Respondents residing in urban area had favorable attitude (AOR: 0.5, 95%CI: 0.3, 0.8)) towards COVID-19 than study participants living in rural area. The result of this study revealed that study participants who had better awareness are more-likely (AOR: 3.0, 95%CI: 1.7, 5.5) to have favorable awareness.  The result of this study revealed that residence of study participants, occupation, and having con rmed comorbidity were factors associated with the level of preventive practice. Respondents residing in urban area had better preventive practice (AOR: 0.2, 95%CI: 0.1, 0.3) than study participants living in rural area.   After analysis and reviewing articles, in this study both emerged (psychosocial and perceived behavior) and prede ned (perception of susceptibility to a health threat, the perception of its severity, and the perception of the bene ts, costs and barriers) themes were identi ed.
In this nding, the higher portion of the respondents had awareness on the occurrence of the virus. Some understood that it is originated from animals whereas a few of them believed the virus as a result of God punishment to humans and other say it is a man-made virus. Contrarily, some respondents still had doubt about the existence of the virus they are ignorant. The level of ignorance could create a problem as this set of individuals about spreading the disease.
Almost all respondents were highly understood the disease prevention strategies; but nearly all were not practicing all. This is because they believed /denied as the occurrence of the case in the study settings. In the study area, some claimed that if the case is why measures were not taken in market pleases; but the state tried to implement in the religion/faith based organization. This made a question for respondents to believe the occurrence of the disease. A few respondents believed that the only solution to prevent the virus is praying for our Lord/God. Most respondents do their job for the sake of living. Respondents have strong spiritual feelings and sense of right and wrong have made them to perform their duties as usual. The respondents' being trustful/abide for God and will not make anything to them and some perceived as it (COVID-19) is because of sin. All study subjects experienced a signi cant amount of negative emotions in the rst week, especially in the period when o cials providing acquaint to the rst time about the occurrence of the disease. As stated by a few respondents, as the rst case noti ed in the country the concern about everything continued to rise. When normal work hours changed and proclamations declared; warries increased and the community were conserve many things necessary for survival for them as well their family. Some respondents failing to meet physical and psychological needs brought a sense of helplessness. Most of the respondents felt different levels of anxiety. All most all expressed concern about the impact of the outbreak on the health of their families. They also said that their families were worried about it too.
"Firstly, at the occurrence of the disease and at the time of the o cials notifying about the disease; I was very nervous, the overall activity was very troublesome, made frustrations…. Even I was not con dent to be out of home, to perform my routine activities and … All conditions were upsetting me." (Respondent 6, Participants explained how impacts like physical distancing and not being able to socialize with friends, meant they experienced a general loss of meaning in life. Some respondents felt that direction on physical distancing had been generally unclear, and that information about the problem had conveyed 'mixed messages' and a few participants described a lack of trust, who were seen to be politicizing the case. A few participants explained that being physically distant, inability to socialize, and the loss of social support led to them feeling a loss of 'self-worth'. "I tried to know about the situation, seen professionals to advocate and tried to message about distancing in the straight, market please and on media too. They/professionals/ advised the community to …, the government set a strategy to be far from my intimates, but in my opinion noting is said about marketing. This is a paradox for me to accept the message and implement distancing. This feel me something…. Ohhh…." Respondent 7, 28 year's old lady).

Theme 2: Perceived susceptibility
Regarding respondents' individual susceptibility for the disease, a few individuals are susceptible for the disease and a few of them may claim they may have the virus unless they are tested and know their status. A participant perceived the disease is belonging to common cold family. A few respondents experience a mild u like symptoms and they claim this situation as it happens for the virus.

Information Overload, but Lack of Trusted Sources
Respondents' reported being assaulted with information about COVID-19, including from social media, mostly (TV), and as well radio, government announcements, and through face-to-face conversations with neighbors during kettle ceremonies. Despite that, individuals still have many uncertainties regarding the existence of the case: " I still feel like people have so many questions, they want answers in a clear way about the mechanisms of transmission, and the exact time to be stop, the current situation how it continues….? " (Respondent 1, male24 year's old trader) As explained by some respondents, even government information was perceived to be unreliable with the understanding that it was aimed at maintaining government interests. The information and rumors spread in part cause fear and emotion. Media played a very big role in creating awareness and also make panic to many individuals. This led to individuals to perceived as COVID-19 was more dangerous, which create fear and anxiety within the communities. However, the information and rumors also created wrong perceptions to the situation, individuals perceived differences among the black and white race in immunity towards the virus/disease with suggestions given by a respondent that: "… in my perception the virus cannot affect more us; we have /among the blacks and white/ a difference during our development. We/blacks are prone for many cases. We lived in most circumstances … these may help us to resist conditions. Also our/communities in the setting/ feeding habits help us too. Thanks to our herbals, I always use hot drinks by adding garlic, lemon, , , ginger …" (Respondent 1, male24 years old trader) About the spread of COVID-19, respondents' experiences during the early days of the spread of COVID-19 due to its novel dimensions, they/some participants/ were feel helpless and frustrated, and feel sense of loss their love and made ambiguity on the help of their family if it happened on either side and they had to do many unusual activities. One of the respondents described as: "I remember the day when our prime said something about the disease… I was become …... something which made me uncomfortable and less effortful to do something in my way. I was tried to know many about the disease; but nothing I found…. walking here and there… aggressive even for my kids… I was not correct on that occasion." (Respondent 7, 28 years old lady).

Social barriers
Social barriers were the other challenge to individuals to practice the prevention measures for COVID-19. ? /how will individuals survive using protecting themselves by using clothes…. I am not con dent enough to use it (the mask) … because I am not believing about the purpose." (Respondent 2, male50 years old urban resident)

Individuals' Concerns About Being Judged by Others
As few respondents stated, uncertainty of con dentiality of information, and fear of losing social interaction among individuals, and nally individuals' concerns about being judged by others were among barriers to COVID-19 prevention mechanisms' in the study community. In this regard, one of the respondents stated this as:

Discussion
A community based study to assess knowledge, attitude, practice, risk perceptions and challenges towards COVID-19 was conducted in east Gojjam Zone. The study was encompassed both male (37.5%) and female (62.5%) with great females response. From study participants only (59.6% (95%CI:55.8, 63.6) have shown a good knowledge on COVID-19 prevention with high variation outcome with conducted at Illu Aba Bor and Buno-Bedelle Zones, Southwest Ethiopia (93.3%) (27). Early studies which has been conducted in Bangladesh has identi ed similar outcome with this study. On the another hands, the level of knowledge has been assessed as good for both gender with male AOR 1.4 (0.9, 2.1) (28).
Another important nding of this study is that the attitude of respondents towards COVID-19 and its preventive measures. The results of this study showed that the overall level of attitude towards COVID-19 and its preventive measures among rural communities of East Gojjam zone in the Amhara regional state of North West Ethiopia is very low. In this study only 14.5% (95% CI: 11.6, 17.1) of respondents had favorable attitude towards covid-19 and its preventive measures which indicates a large proportion of respondents have had unfavorable attitude. This nding is almost comparable with a study done in Uganda which has been reported as nearly 21% (n = 29) of health care workers had positive attitude toward COVID-19 (29).
The nding of this study was by far lower than the previous studies done in different parts of Asia and Africa. For instance: in Asia particularly in Bangladeshi (30), China (31) and Saudi Arabia (32) about 52.4%, 73.81% and 86.6% of respondents reportedly had favorable attitude towards COVID-19 and its preventive measures respectively. Similarly in Africa; in study done in Egypt (33) and North-Central Nigeria (34) more than 75.9% and 79.5% of respondents reported as having favorable attitude towards covid-19 respectively.
The possible reason for the discrepancies of this result might be the difference in study population and methods of data collection in that unlike this study; most of previous studies collect data from educated and those populations having internet access through online data collection methods (29)(30)(31)(32)(33), which is prone to selection bias and unrepresentativeness.
The third main outcome of this study was the practice level towards COVID-19 preventive measures and factors affecting it among East Gojjam Zone, North West Ethiopia. The result indicated that, the magnitude of poor practice was very high in this study, despite the government's effort to improve the challenges. This nding is higher than studies conducted in Iran (35), face book based online study in Ethiopia by Bekele D et al (36). The possible reason might be a difference in sources of information especially unde ned rumors, different myths, less information-seeking behavior, lack of modern main stream media and social media exposure towards COVID-19 disease. Moreover, the current study was conducted mainly in rural residents of East Gojjam Zone, which has limited cell phone based internet, the study participants were mainly farmers in their occupation and contributes to limited access to information towards COVID 19 disease. In addition, the study participants may believe that their feeding practice and God/Allah prevent them from COVID-19 and fail to practice appropriately.
Unlike the current study ndings the Sudanese people were practiced many preventive measures such as, staying at home, frequent hand washing, using antiseptics, and wearing masks, avoiding hand shaking and visiting over crowded places (37,38).
Similarly, the current nding is much higher than studies conducted in Saudi Arabia, Malaysia, Philippines, and China (39)(40)(41)(42). This might be due to different parameters used to quantify outcome of interest. i.e. in our case we used 3/4th of the correct response to measure the good and poor practice of the preventive measures where us in Saudi Arabia, the mean score was used as measurement of practice status towards COVID 19 preventive measures. Moreover, the variation might be due to socio demographic and cultural difference across the Ethiopia, China, Philippines, Malaysia and Saudi Arabia.
The studies conducted in Arba Minch town, Southern Ethiopia, Bangladesh and review articles conducted on knowledge, attitude and practice among Ethiopian residents share similar features on the limited practice of preventive measures towards COVID-19 pandemic disease (43)(44)(45). This might be due to the inability to afford and the scarcity of the mask in the country. Generally, these poor practices in this study might be primarily attributed to the lack of strict prevention and control measures implemented by local government, such as banning public gatherings and enforcing peoples to wear a mask. It could also be the result of the patients' poor knowledge regarding the high infectivity of the COVID-19 virus. Besides, the poor practice in this study may be attributed to the less serious situation of the COVID-19 in the Ethiopia and Bangladesh, at large besides study areas.
Those respondents having previous comorbidity were 70% less likely to have unfavorable attitude towards COVID-19 and its preventive measures compared with those who had not comorbidity. Likewise, those respondents who were civil servants occupationally were 80% less likely to have unfavorable attitude towards COVID-19 and its preventive measures compared to housewives while those who had poor knowledge towards COVID-19 were three times more likely to have unfavorable attitude towards COVID-19 and its preventive measures compared to their counterparts.
This result is supported with previous done in Bangladeshi (45): those who were working as government staff (civil servants) were more likely to had positive attitude towards COVID-19 compared to their counter parts. This consistent result might be explained by the fact that those working as civil servants are generally educated and might have access to health information required to establish beliefs and attitudes towards preventive measures of a pandemic. In addition this nding is supported by previous studies done in Ethiopia among health professionals which reveled having good knowledge (AOR = 3.17; 95%CI: 1.97, 5.06) was positively associated with the attitude of health care providers towards COVID-19 (47).
Moreover those who had good attitude had favorable attitude towards COVID-19 and its preventive measures. This nding is in line with the theory which states knowledge is the pre request to have positive attitude and good practice.
The factors associated with poor practice of preventive measures towards COVID-19 in East Gojjam community were study participants with primary Education (AOR: 1.6 (95% CI: 1.0, 2.7)), being farmer in occupation (AOR: 2.9 (95%CI: 1.3, 6.2)), urban residence (AOR: 0.2 (95%CI: 0.1, 0.3)), and participants who didn't know comorbidity (AOR: 3.9, (95%CI: 1.1, 13.8)). The current study and studies in Iran mentioned lower education as factor or poor preventive measures (35,48). This is due to the fact that as educational level decreases from higher to lower; it leads to less understanding of the pathogenesis and infectivity of the disease and non-compliance to preventive measures. However, with similar topic of study the additional factors were age, male gender, being single, and having health-care-related occupations were signi cantly associated with lower practice (35,43,44,49,50).
Study participants with the educational status of primary education were more likely to have poor practice than those with educational status of "secondary and above". Similar to this nding, a study in Iran showed that higher level of education was associated with high practice score. This may be due to the fact that education is an in uential determining factor of healthy behavior. As one gets more educated, there will be multiple ways of acquiring information to know about the prevention of COVID-19 and will practice accordingly. Also, when someone gets more educated he/she will have a better understanding of control measures and preventive strategies related to COVID-19, and the ability to practice recommendations to protect COVID-19 will increase Limitations The study has several limitations worthy of further discussion. It was measured through community selfreport and thereby exposed to the subjectivity. A further limitation is that the gold standard for estimating practice of COVID 19 prevention measures is arguably direct observation. But, due to budget scarcity, direct observation has not been conducted; therefore the accuracy of estimates level of practice was obtained through self-report compared to this gold standard is unknown and the potential for response bias must be considered.

Conclusion
In conclusion, only one third of respondents had better understanding of COVID-19 pandemic. Similarly, less-than one-fth of individuals had favorable attitude towards COVID-19. Speci cally, about one third of individuals believed that COVID-19 comes for sinners. This study has also showed that only one-fth of study participants had good preventive practices. Residing in rural area, not having formal education and being below age of 25 age of were factors signi cantly associated with the poor level of knowledge towards COVID-19. Having poor level of knowledge, residing in rural area and having con rmed comorbidity were factors associated with unfavorable attitude towards COVID-19. Furthermore, respondents with con rmed comorbidity had good preventive practice towards COVID-19. Based on the result obtained in this study the following recommendations are forwarded: Address peoples who are living at rural area through health professionals in order to create public awareness towards COVID-19 is recommended, Lea ets prepared in local languages about COVID-19 to the community should be administered, the health education programs should be continued in uncompromising and intensi ed way in rural community, religious leaders should teach the believers by interacting faith and science on the means of preventing the pandemic.

Abbreviations
Not applicable.

Declarations
Ethics approval and consent to participate The study was reviewed and approved by the Debre Markos University, Ethical Clearance Committee. All participants were informed about the aim of the study and their full right to withdraw or refuse to participate before their written informed consent was obtained. Written informed consent was obtained from each participant.

Consent for publication
Not applicable

Availability of data and materials
All the data supporting the study ndings are within the manuscript.

Competing interests
The authors declared no con ict of interest