Assessment on awareness towards preventive measures of COVID-19 in Sheka, Southwestern Ethiopia: Community based cross-sectional Study


 Background: The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and it is the most important of public health problem worldwide. A critical element in tackling the COVID-19 crisis is personal behavioral change; however, there is a paucity of evidence about peoples’ awareness towards COVID-19 pandemic. Hence, the aim of this was to assess the community’s awareness status towards COVID-19 in Sheka, Southwestern Ethiopia.Methods: Community-based cross-sectional study was conducted 10th to 21th April 2020. Four hundred-nineteen individuals participated during the study. Both univariable and multivariable logistic regression analyses were used to identify significant factors of awareness status, and variables with p-value<0.05 indicated it significantly influences the awareness status of the individuals towards COVID-19.Results: According to the study’s results, nearly half (49.4 %) of the participants had awareness about COVID-19 pandemic. Factors such being female equal (AOR: 0.476, 95%CI: 0.293, 0.772),education being secondary and above(AOR:2.178,95%CI:1.323,3.586),and prevention methods being fully used (AOR,8.127,95%CI: 1.273, 51.871)were significantly influencing the awareness status of the community towards COVID-19 pandemic than their counterparts.Conclusion: The study showed that there is a low awareness status among people towards COVID-19.Hence, programs to improve awareness towards COVID-19 pandemic is essential to prevent and control the pandemic.


Introduction
Coronavirus is among the diverse families of viruses and a source of illness of the disease ranging from the common cold to more several diseases such as middle respiratory syndrome (1,2) .COVID-19 case was first reported on 31 month of December 2019 in Wuhan city of China. Since then, it has been rapidly spreading as infectious disease, which has now developed to the global pandemic (3). The pandemic is affecting all major world economies; predicting to cause huge global economic crisis in 2020 (1). Currently, the virus is spreading to the entire world and can infect people of all age groups. Older people and those with pre-existing medical history problems are more vulnerable to becoming severely ill with the virus (4)(5)(6)(7). COVID-19 can be transmitted through droplets and fomites during close unprotected contact between an infected and healthy person. The airborne spread has not been reported for COVID-19, and there is no big driver of transmission based on available evidence (8).
Novel coronavirus case was first happened in Ethiopia on the 13 th ,March 2020 and preventive measures against COVID-19 is continuing in all parts of the country (9).
COVID-19 pandemic impact on declines in tourism, business travel, spillovers of weak demand to other sectors, economies through trade and production linkages. Similarly, supply-side disruptions to production and trade and effects on health such as increased disease and mortality as well as shifts in health care spending are the major impacts of COVID-19 pandemic (10)(11)(12). The COVID-19 is affecting educational systems worldwide, and it is leading to the widespread closures of schools and universities. The virus affected over 1.5 billion students worldwide, accounting for 87% of enrolled learners (13,14).
The related study done in Ethiopia, there is still a big issue in preventing and control the pandemic because most of the community assumed that the disease cease, and the general public has little understanding or awareness about the disease (15). Communities must save themselves and others from COVID-19 by considering the following important habits such as regular hand washing ,use sanitizers, avoid touching their faces ,practice covering their mouths, noises at any time while coughing and sneezing, keep physical distance and isolate themselves if any feeling of illness and the like (16)(17)(18)(19). Ethiopia is now sharing a major proportion of the global burden of infectious diseases, while the patterns of COVID-19 are still at an earlier stage of the epidemiology curve. The Ethiopian government exerted tremendous efforts to curb the disease (20).Globally, COVAX vaccine is producing and it has targeted immunization that covers of at least 20% of the population in each participating country by the end of 2021, and has contracted for 2 billion doses of COVID-19 vaccines; however, it is neither inclusive nor adequately planned. The timely supply of vaccines to COVAX is questionable in low-income countries because high-income countries (HICs) step to the front of the queue for limited supplies of COVID-19 vaccines (21).
Awareness is very important for establishing prevention beliefs and promoting positive behaviors to be effective to prevent the spread of the pandemic (22). Myths and false assurances were the most prevalent perceived inhibitors of the spread of COVID-19 compared to the perception that engagement in precautionary measures protect from exposure to and spread of the virus (23). Currently in almost all of the scientific journals, COVID-19 related scientific investigations ranging from the trial of effective therapeutics and vaccines to short and long term impacts of COVID-19 on the different sectors are the priority issues (24).
Currently, there is (COVAX) vaccine or treatment that is officially giving to individuals for both developing and developed countries to prevent COVID-19. Though messages related to COVID-19 transferred from health professionals and other concerned bodies frequently, still the utilization of preventive measures is low in our observation. A critical element in tackling the COVID-19 crisis is public behavior change. Behavior change requires public understanding, acceptance, and implementation of the recommended prevention methods. There is a paucity of evidence showing the status of individual awareness towards COVID-19 in Ethiopia. Thus, the aim of this study was to assess the awareness status of people towards COVID-19 in Sheka, Southwestern Ethiopia.

Study area and design
The current study was conducted in Sheka Southwestern Ethiopia, and Tepi city administration. The zonal city is located 951 Km to North West of Awassa, the capital of SNNPR and 676 km to Southwest of Addis Ababa. Sheka is bordered on the south by Benchi-Sheko, on the west by the Gambela Region, on the north by the Oromiya Region, and on the east by Kaffa Zone. Administratively, the Sheka Zone structured into three provinces and two city administrations. A community-based cross-sectional study was conducted in between 10 th to 21 th of April 2020. The study populations were all those who are living in Sheka Zone, Southwestern Ethiopia.

Sampling Procedure
The study population was both female and male adults whose age (>=18 years) who were selected by chance walking along in the study sites. The sample size was calculated in a single population proportion formula. Hence, simple random sampling technique was used, because the population who lived in the study area is homogenous and has equal chance of being selected. In sample size calculation, maximum proportion (50%) was considered. It is because there was no previous study done in the study area about awareness status of the community about COVID-

19.
Henceforth, confidence level, margin of error, and expected maximum proportion were considered for calculating the sample size (25).The required sample size was computed as /2 is at 95% confidence level for normal distribution, which is 1.96, is a margin of error (5%),and 10 % none response rate was considered. Thus, considering = 0.5 50% (a maximum proportion for the awareness of individuals about COVID-19 pandemic because of no previous study was done), the sample size for this study becomes:

Data collection tools and procedure
The data were collected using structured administered questionnaire with interview that was prepared based on the study objectives. The data collection tool was initially prepared in English version were followed by translation to local Amharic language. Hence, the consistency and appropriate meaning between two versions was maintained through back translation of the questionnaire to the original version. The source of questionnaires was literatures that are related to the current study. Research committee and health officers approved the validity of the questionnaire.
Six health extension workers enrolled for twelve days (10 to21 April 2020) for data collection to complete the questionnaire participants. One-day training was given for data collectors by the investigators to control the quality of data.
The researchers supervised the overall activities during data collection period .Hence, the questionnaire was prepared based on the COVID-19 pandemic prevention and control mechanisms that was recommend by both ministry of health of Ethiopia, and Ethiopian government, and also by world health organization recommendation.
Consequently, socio-demographic factors, coronavirus prevention and control related factors were measured.

The study variables
The outcome variable was the awareness status of participants dichotomized as aware and not aware (measured from understanding towards COVID-19 pandemic).
The participants are aware when she or he did know about COVID-19 prevention methods and control mechanism that were recommended by world health organization (WHO), and not aware when the participants have poor understanding in the direction of COVID-19 prevention methods and control mechanism.
The socio-demographic factors such as age, sex, level of education, religion, source of income, prevention method used, knowing symptoms, use of quarantine, treatment, source of information, level of implementing of government and health professionals' declaration perceived by individuals, and pre-existing health condition of participants were measured from structural administered questionnaire.

Data analysis
Data were analyzed using SPSS software package (version 20). Frequency distribution, percentage, and plots were used to provide sound results (26).The chi-square test was applied to examine the association between factors and the dependent variable. The logistic regression model was used to express the dependent variable or the response variable qualitatively expressed (27).
Binary logistic regression is the form of regression, which is used when the dependent variable is dichotomous, and the independent variables are any type. A binary variable has only two possible values, such as presence or absence of a particular event, in our study to identify whether the participants had awareness towards COVID-19 pandemic not.
The odds are simply the ratio of the probabilities for the two possible outcomes [28].If is the probability that an event will occur, and then1 − is the probability that an event will not occur. . The ratio of the odds from the two rows (odd ratio) is given by

Parameters Estimation
The maximum likelihood and Wald test were used for parameter estimation methods in fitting logistic regression model.
The maximum likelihood estimates of the parameters could be obtained by maximizing the log-likelihood function from (ii) is given by = ( 0 + 1 1 + 2 2 + …….. ) ) [27]. Since observe values of say, ' ( = 1, 2 … )are independently distributed as Bernoulli, the maximum likelihood function of Y is given by: Wald χ 2 statistics is used to test the significance of individual coefficients in the model and are calculated as follows:

Assessments of the fitted model
The Wald test is the most computing parameter estimation method for logistic regression method. After the model is fitted, the next important step is checking the model adequacy. Therefore, the Hosmer-Lemeshow test was used [29].

Results
The response rate of the respondents was 98.8 %( 419/424).The socio-demographic factors of the study participants were illustrated in     A classification table used to distinguish accurately predicted value of awareness of respondents towards COVID-19 ( Table 3). The table is indicating the validity of predicted probabilities ( Table 3). The first two rows in Table 3 stands for the two possible outcomes, and the two columns under the heading predicted are for high and low probabilities.
The observation also held in the sensitivity (71. 5%) as compared to that of specificity (76.4%). Sensitivity  The results from multivariable analysis revealed that sex being female, religion being muslim, catholic, protestant and others, education level being secondary and above, prevention methods being fully used were significant factors for awareness status of the community towards COVID-19 (Table 4).
The odds ratio of education being (secondary and above) ( AOR:2.178 ,95% CI: 1.323, 3.586) (adjusted other variables).The respondents whose education level being secondary and above were 2.178 times more likely to aware of COVID-19 than respondents whose education level is illiterate( Table 4). The odds ratio of religion being of COVID-19 pandemic than those respondents whose religion was orthodox ( Table 4).
The odd ratio of prevention method being fully used (AOR: 8.127; 95%CI: 1.273, 51.871) (other variables are adjusted) was 8.127 times more likely to aware about COVID-19 pandemic than those respondents who partially used (at most three prevention method have used).
The odd ratio of sex being female (AOR: 0.473; 95%CI: 0.293, 0.772) (other variables are adjusted) was 0.473 times less likely to aware about COVID-19 than the respondents who were male.

Discussion
Now days, the COVID-19 pandemic is accelerating worldwide. The Ethiopian government is taking many measurements to tackle the impact of COVID-19 on any business sector and the wellbeing of individuals. It is, therefore, mandatory to explore the effects of COVID-19 in Ethiopia and to set out immediate priorities and longerterm strategies for appropriate interventions. Culturally, in Ethiopia, it is hard to apply all COVID-19 prevention strategies since individuals are highly sociable, culturally indispensable among each other, and the marketing system is traditional.
The COVID-19 is a current language spoken by almost all media all over the world. However, society is still not aware of the risk of COVID-19 pandemic. The study showed that 50. were not still implementing the government declaration.
The awareness of some individuals depends on religious aspects. Some religions may preach that the disease becomes from God and so that it is so hard to stop by government declaration and health professionals. The model may tell us some religions are less aware (religion concern) than other religions even if we cannot recommend which religion is better. As it is known, the Ethiopian religious association agreed to announce declaration for one month to pray to tackle the hidden challenge of the pandemic, which is an unseen enemy causing multitude of socioeconomic crisis all over regardless of all aspects in the world.
The study found that mass media and public health care workers were the most important sources of information in Sheka Zone, Tepi Town administration for individual's awareness towards COVID-19 pandemic. This finding is similar to Myanmar adults study because it used the familiar sources which are social media and mass media (30).
Also the study conducted in Hong Kong in which their common sources were social platform and mass media but different with health care workers study in which their primary sources were not only social media but also official government websites (31,32) and in Pakistan healthcare professionals study reveal the same result with the current study (33).
The multivariable binary logistic regression was used to identify the factors influencing society's awareness of COVID-19. The results showed that sex, educational level, and preventive strategies are significant factors in the understanding of individuals. These findings were similar to the study conducted in Myanmar adults on awareness, perceived risk, and protective behaviors to COVID-19 and in Saudi Arabia (30,34).

Limitation of study
This study is limited because of cross-sectional design, which cannot determine the cause and effect relationship .In addition, the study was done as early as the pandemic expanded in Ethiopia, and for this many literatures were not reviewed in first development of the study,

Generalizability of the results
The study results generalized on the whole population because of the study used principle probability sampling technique, and appropriate statistical procedures. Thus, more than ninety-eight percent of participants actively participated during the survey.

Conclusions
The finding highlights the awareness status of participants towards COVID-19 in Sheka, South Nation Nationalities' Peoples of Region, Tepi town administration, Southwestern Ethiopia, and individuals presently practicing concerning COVID-19 pandemic. The study assessed individuals' awareness and experience in the direction of COVID-19 pandemic. According to our finding, the main factors for being aware are sex being female, education level being secondary and above level, religion being muslim, protestant and others, knowing symptoms of COVID-19 and prevention strategies. The study found that below half of the respondents (49.4%) agreed on the essential role of individuals in the prevention of COVID-19 pandemic. In addition, the finding confirmed that more than half (50.6%) of the individuals had no awareness and poor protecting experience to prevent COVID-19 pandemic. The study found 54.18 percent of the individuals fairly implemented and 0.48 percent of the individuals did not put into effect the government declaration strategies to stop COVID-19 pandemic. The study was also capable of highlighting gaps in the precise element of perception and preventive experience that should center in future attention and instructional campaigns.
Further study should be done and explored by including other factors that are not addressed in this study. The participants were told them about the study objectives and the provided information kept confidentially. They were also told them that they have the right to say no the interview even in the at the time of survey if they are inconvenient