Determinants of Knowledge, Attitudes, and Practices of Frontline Health Care Givers During the First Wave of Covid-19 in Africa: a Multi-centers Online Cross-sectional

Background: During its rst wave in sub-Saharan Africa, there was insucient understanding of the new pandemic of coronavirus disease 2019 (COVID-19) among frontline health care professionals that has led to a misidentication, and mistreatment of affected patients, with a potential risks of contacting and spreading the disease. This study was carried out to determine the knowledge, attitude, and practices (KAP) of frontline health care givers (HCGs) towards COVID-19 in Africa and their related factors. Methods: This was a multi-centers online cross-sectional study conducted over a 3-months study-period using a google survey link among front lines African HCGs in the COVID-19 response units within 28 African countries. Bivariate and Multivariate logistic regression were used to assess the associations between co-variates. Statistical signicance was set at p ≤ 0.05 and 95% condence interval. Results: There a total of 518 out of 588 approached HCGs participated in the study from 28 African countries. Overall, 496 (96%) had bad practice score, and 405 (78%) had positive attitude regarding COVID-19. The related factors of KAP towards COVID-19 identied were the lack of self- esteem and self-condence in the management of COVID-19 (aOR: - 0.17, 95% CI=-0.766 to -4.33, p >0.05), Ignorance (aOR: 1.55, 95% CI=1.003 to 2.402, p <0.048), lack of knowledge updates on COVID-19 (aOR: 1.81, 95% CI=1.105 to 2.951, p <0.018). Conclusions: Majority of the frontline HCG has an overall good knowledge and attitude towards the disease across the African continents regardless of their level of study. However, the KAP is inuenced negatively by the lack of self-esteem, self- condence, ignorance, and insuciency of frequent update of COVID-19 information. Promoting psychological support in addition to regular trainings could help to enhance the KAP of frontline HCG in African region.


Introduction
The emergence of Corona virus disease 2019  in China and its exponential transmission to more than 219 countries around the world, including fty-two countries in Africa, present a delicate situation for low-resource countries. This current pandemic has immeasurable health, economic, and social consequences that are shaking the entire planet (1-6).
During its rst wave, while millions of people worldwide stay at home to minimize the transmission of the COVID-19, the majority of health care givers (HCGs) remained at the forefront of the response to this pandemic. They go to clinics and hospitals, exposing themselves to a high risk of COVID-19. In addition to exposure to the pathogen, high hours of work, psychological distress, tiredness, overwork, stigma, social and physical abuse are additional burdens that affecting HCGs (7). A recent study published by Hakan E. et al., found that 300,000 HCGs from thirty-seven countries had been infected with COVID-19. In addition to the high number of infections, over 2,500 of HCGs have already lost their lives around the world as of August 15th. Of the thirty-seven countries surveyed, the United States had the highest number of coronavirus infections among HCGs with 114,500 infections (PLEASE reference and ADD a DATE of deaths across the region has been reported by 11% in the last 40 days. Despite the overall decrease of cases in the region, Uganda reported an intensive community transmission in capital Kampala and an increase of over 300% of cases; and similarly, an overall increase in the number of cases has been reported in Namibia and Nigeria in term of 55% and 19% respectively (9,10). Despite the infrastructure and equipment limitations of the African health care system, COVID-19 seems to be contained and under control. Several hypotheses have been reported; this could be explained by more than 60% of the population in Africa are under the age of 25. Authorities revealed some contributing factors to African coping better such as low travel and outdoor living, expertise in epidemic control from tackling other outbreaks, and cross-immunity from other coronaviruses (10,11).
Despite governmental efforts to mobilize HCGs to support the health systems, most of those health professionals were not su ciently educated about the adequate precautionary measures of this novel disease, and were at a high risk of contracting the disease, and also of spreading the virus to uninfected patients who seek an assessment (6, 7, 12). There is a paucity of literature on Knowledge, Attitude, and Practice (KAP) of African HCGs towards the COVID-19 pandemic. However, a study among HCGs in Henan, China revealed that over 80% of HCGs had su cient knowledge of COVID-19 and correct practices regarding COVID-19. (13). In Uganda, a study done at Mulago and Kirundu Hospitals reported 69% of HCWs had good knowledge, 21% had a positive attitude, and 74% had good practices towards COVID-19 (14). Several studies reported that, age, news media, holding a diploma or were signi cantly associated with good Practice and Knowledge towards COVID-19 (8, 14,15). There is a paucity of evidence of the current KAP towards COVID-19 in sub-Saharan Africa, despite several WHO materials, up-to-date, and governments' guidelines. Understanding frontline HCGs' KAP and possible risk factors help to improve the safety of both the HCGs and the general population. This study aimed to assess the KAP of the frontline HCGs towards COVID-19 during the rst wave of the pandemic, and also to identify their related factors to the sub-Saharan African countries.

Methods
Study design, setting, and participants: It was a cross-sectional descriptive study using an online structured questionnaires (both French or English version), and sent to the frontline HCGs in several African countries where there was an increasing number of COVID-19 cases and reported deaths between April 2020 and July 2020; In most of those countries, there was a lockdown measure during the same period to control the spread of infections (9,(16)(17)(18). The approached frontline HCGs were either nurses, midwives, or doctors in any level of years of practice in any of those African hospitals where COVID-19 patients are screened or managed.
Study instrument, variables and data collection: The online Google Form link was sent via emails, or social media platforms (Whatsapp, Twitter, and Facebook).
Standardized and pre-tested screening tools and adjusted pre-validated questionnaire were used to obtain information on the study variables. Twenty-eight variables from the Question and Answer about COVID-19 in the webpage of WHO and other previous studies (14,(19)(20)(21)(22) were assessed and adapted during our interview. A pilot study was carried out by 11 HCWs from Benin, Ghana, Malawi and Niger, and adjustment were made based on their opinions relating to the feasibility of the questionnaire, and the nal questionnaire was determined by the authors accordingly. The nal questionnaire had ve sections.
The rst section comprised demographic characteristics of the participants. The second section included 14 questions regarding the knowledge of COVID-19; knowledge was assessed through two points scale, and each incorrect response weighed 0 point and 1 for correct responses (the lower the points, the less knowledgeable is the HCG).
The third section evaluated the attitude, including 5 questions in a Likert scale of agreement as used for assessing the participants' answers from Olum and Goni et al. (14,21). The responses were: strongly disagree, disagree, neutral, agree and strongly agree; each weighing 1-5 respectively. The forth section included 5 questions regarding the practices of COVID-19. The responses were; always, occasional, never, and neutral each weighing 3, 2, and 1 point respectively for a good practice.
The last section estimated the determinants regarding COVID-19, and included 4 questions in which the participants' answers were assessed through 3 points Likert scale of agreement. The responses were: disagreement, occasional, neutral, agreement and each weighing 3, 2, and 1 point respectively for a good answer. Some questions were reversed to eliminate biases of giving a single similar response in all the items (14,22,23).
As part of the data collection process, the most active email of each participant was collected to identify duplicate responses. To optimize the participants' responses to our survey, continuous reminders were given to them through the same way they were contacted (email or social media platforms).
Statistical analysis: Fully completed questionnaires were extracted from Google Forms and exported to a Microsoft Excel 2016 for cleaning and coding. The cleaned data was exported to STATA version 16 and GraphPad 8.3 for analyses (14,21  Association of knowledge score and socio-demographics, attitude and practice: Country/Place of work, quali cation, education level, attitude, gender, and marital status were signi cantly associated with knowledge of frontline HCGs toward COVID-19 with p <0.05 (Table 4). The Ghana's frontline HCGs scored the highest mean of knowledge 16.1±4.0. The men's mean knowledge score was 13.9± 2.8. Doctors' mean knowledge was 14.4±2.5. Holding a master or PhD had a knowledge mean score of 14.9±2.6. The mean of knowledge score of married participants was 13.9±3.0. The mean of knowledge score of having a positive attitude was 14.2±2.4. At multivariate analysis, the factors positively associated with knowledge were practicing in "Uganda" (aOR: 1.1, 95% CI=0.39 to 1.87, p <0.003), Ghana (aOR: 3, 95% CI=2.03 to 3.94, p <0.000) and holding a Masters, and a PhD degrees (aOR: 1.1, 95%CI= 0.27 to 1.91, p <0.010), and having a positive attitude (aOR: 2, 95% CI=0.27 to 1.91, p =0.000). The factors negatively associated with knowledge include practicing in "Algeria" (aOR: 0.9, 95% CI=1.74 to 0.02, p <0.045), being a "Nurse" (aOR: 0.6, 95% CI=1.18 to 0.09, p=0.023), and lacking of the "good practice" (aOR: 1.9, 95% CI=3.04 to 0.7, p=0.002) ( Table 4). Ignorance of COVID-19 as a politicized disease was found to be determinant factor of knowledge of COVID-19 in multivariate linear regression (  (Table 6). Again, ignorance towards COVID-19 as a politicized disease, and lack of updated information of COVID-19 trends have been found to be signi cant factors for the attitude of HCGs towards COVID-19 management during its rst wave ( Table 7).

Discussion
Among 518 frontline African HCGs leaving in 28 countries who agreed and returned the questionnaire between April and July 2020, we noted that 78% of participants had positive attitude towards COVID-19. This nding is in agreement with a study conducted in Pakistan which reported a high positive attitude among HCGs about COVID-19 (15). This result is higher than the ndings reported in Uganda and Ethiopia in term of 21% and 65.7% respectively (8, 14,25). This nding could be explained by a positive attitude regarding COVID-19 among frontline HCGs might result to a good knowledge. This statement is con rmed by a multivariate positive logistic regression found between attitude and knowledge in this study. The above nding of positive attitude among African frontline HCGs is corroborated with the ndings of Bhagavathula et al. who revealed that 78% of HCGs, had positive attitude about COVID-19 (26). Interestingly, the factors positively associated with Attitude of frontline HCGs towards COVID-19 in Africa were marital status, religious denomination, good knowledge about COVID-19(p<0.05). In contrast, attitude did not differ signi cantly (P>0.05) with country, age, gender, quali cation, education level, and practice. These results are similar with other surveys (15,22).
In contrast, the survey found that 96% of participants had bad practices regarding COVID-19. This nding has revealed a practice gap among African HCGs and could explain the major barriers to infection control in African region. A possible explanation of this nding is that a poor practice is negatively associate with knowledge and vice-versa. This is shown by a negative logistic regression found between knowledge and practice in this survey.
Multivariate logistic regression showed that the factors positively associated with knowledge were practicing in Uganda, Ghana, holding a Masters, graduation and PhD degrees, and having a positive attitude regarding COVID-19. Among frontline African HCGs, the factors negatively associated with knowledge include practicing in Algeria, being a Nurse, and having a bad practice. The factors positively associated with attitude of frontline HCGs towards COVID-19 in Africa: being Married, and Christian, having knowledge toward COVID-19. The factors positively associated with Practices of frontline HCGs toward COVID-19 in Africa: practicing in Ghana, being aged from 41years and above and having knowledge toward COVID-19.
Our results could inform policy makers on the practice of African frontline HCGs towards SARS-CoV-2 infections. Our ndings by providing a more precise assessment of the magnitude of bad practice among frontline HCGs, offer an additional knowledge which could explain the insu cient understanding of the disease among frontline HCGs, and can lead to misidenti cation and mistreatment of affected patients. This would cause rapid spread of the disease, nosocomial contamination and exposing the lives of several patients (1). In addition, this misunderstanding would contribute to the spread of the virus to uninfected patients who seek an assessment. (6, 7, 12). Frontline HCGs are directly exposed to SARS-CoV-2 infections. The risk of acquiring COVID-19 is higher among HCGs compared to the general population (27).
A good knowledge about COVID is correlated with having a higher educational status because of increased opportunity to access to local and international information, mini-round, seminar, lectures, research, conference and knowledge. 335 (65%) of participants revealed that o cial websites and media of the International Health Organization were the main source of information for COVID-19, followed by Newspapers 157 (30%), and Social media 118 (23%). These results are different with other studies which reported that the majority of frontline HCGs use social media to seek information about COVID-19 (14,15,22,26). This study revealed that holding Masters or PhD degree is positively associated with better knowledge. Previous studies supported this nding(20, 26).
Throat irritation, cough, respiratory disorder, and fever are the major symptoms of COVID-19 in terms of 86%, 65%, 59% and 52% respectively. Very old patients (88%), patients with comorbidities (82%) and obese (47%) are recognized as main categories of patients who are at risk of developing severe forms of COVID-19 in African region. 472 (91%) participants are convinced that COVID -19 spreads through the droplets emitted by the respiratory tract of infected people. 434 (84%) of frontline HCGs believed that wearing surgical masks can prevent someone from getting COVID-19 versus 307 (59%) thought that wearing a home-made mask (masks with clothing) prevent against COVID-19. 427 (82%) disagreed that children and older adults do not need to take protective measures against COVID-19. 470 (91%) of participants reported that people should avoid frequenting public places such as parking lots, churches, schools or universities, markets, and avoiding public and public transportation in order to prevent contracting COVID-19 infection. 464 (90%) of frontline HCGs are convinced that isolation and treatment of patients infected with COVID-19 virus are the safe ways to reduce the spread of this virus. 464 (90%) of participants are agreed that persons who have been in contact with patients infected with COVID-19 should immediately be isolated and quarantined in an appropriate place. In general, this observation period is 14 days. These ndings are consistent with previous studies which shown the knowledge of frontline HCGs towards the transmission, the typical and atypical COVID-19 symptoms, signs and preventive measures and management of COVID-19 (28-31).
Only 129 (25%) of frontline African HCGs reported to be able to manage with self-esteem and selfcon dence COVID-19 disease. This nding con rmed the practice's gap among African frontline HCGs. Half of participants declared that they have many other more important patients than those with COVID-19 which could be interpreted as negligence or fear towards COVID-19 cases. The psychological impact of COVID-19 among frontline HCGs is well documented by the previous ndings in terms of anxious regarding their safety and psychological distress (35, 36). 302 (58%) of participants revealed that COVID is not a politicized disease made by researchers. 242 (47%) of frontline HCGs recognize that have insu cient training which could affect their KAP regarding COVID-19 versus 382 (74%) of participants declared have been updated on COVID-19 trends/ new features. These ndings corroborated with previous 20 studies from Australia, Central and North America, Asia and Africa. The frontline HCGs reported a lack of training about COVID-19 itself and about how to use personal protection equipment (37).
As the area of study was bigger and nancial constraint, we didn't nd adequate sample size to include in our study which could help us to assess better knowledge, attitude and practices of African frontline HCGs. Then, the study assessed knowledge and attitude and practice, it may not necessarily re ect the actual attitude, practice and that people comply with. The best way to assess practice could be by daily observation of African frontline HCGs. Despite these limitations, our ndings provide valuable information about African frontline HCGs' KAP regarding COVID-19.

Conclusions
Majority of the frontline HCG has an overall good knowledge and attitude towards the disease across the African continents regardless of their level of study. However, the overall KAP are in uenced negatively by the lack of self-esteem, self-con dence, ignorance, and insu ciency of frequent update of COVID-19 information. Promoting psychological support and additional update of the trends of the disease as well as regular trainings could help to enhance the KAP of frontline HCG in African region.