Towards the Easing of Restrictions During an Infectious Outbreak: A Cross-Sectional Online Survey to Assess the Knowledge, Misperceptions, Attitudes and Behaviour of Ghanaians on the COVID-19 Pandemic


 Background: Ghana’s COVID-19 caseloads stretched to 32,437 with 161 deaths. After the first COVID-19 case recorded in March, the Government of Ghana imposed several restrictions on the life of citizenry to prevent the spread of the infection. However, it is imperative to assess and track the knowledge, misperceptions, attitudes and behaviour of Ghanaian on this public health emergency that is moving fast and not well understood before lives are restored to normalcy. This study investigated the knowledge, misperceptions, attitudes and behaviour of Ghanaians on the COVID-19 pandemic through a rapid online survey system.Methods: The Cochran sample size determination formula was used to estimate a representative sample of adult Ghanaian residents (n = 420) for the cross-sectional survey. An online questionnaire (eQuestionnaire) designed with Google Form was administered to the participants who consented to be part of this study. SMS and popular social media handles were used for the distribution of the eQuestionnaire URL to the participants. The survey commenced on July 5th 2020 through to July 15th,2020. Socio-demographic data of participants were gathered on age, gender, religion and level of education. Data collected were analysed using summary and inferential statistics. Results: A total of 475 adult Ghanaian participants completed the eQuestionnaire. Some Ghanaians believed that the COVID-19 pandemic is a myth (95% CI 25.6%-48.1%) and it does not have any effect on a Ghanaian (African) because of the hot temperate we experience. Majority of the participants (78.2%) thought that older adults were at high risk of death when disease-ridden with COVID-19 pandemic. The majority of the participants (81.5%) were poise that Ghana can successfully manage the COVID-19 pandemic. About 31.5% of the participants indicated they did not wear facial or nose masks when going out of their homes. The participants (81.9%, 389/475) approved that the government should ease the COVID-19 restrictions for life to return normalcy.Conclusion: Although Ghanaians have appreciable knowledge, positive attitude and appropriate behaviour in response to COVID-19 pandemic, a well-coordinated effort is needed to ensure stringent compliance with healthcare protocols toward the easing of COVID-19 restrictions in Ghana.


Methods
Study Participants: A cross-sectional online eQuestionnaire was used to gather data from adult Ghanaians who are keen on taking an interest in the online study. The survey was conducted from July 5th to July 25th, 2020. Data were collected online using an eQuestionnaire [23 -25], designed and administered with Google Forms because it was not reasonable to do a nationwide sampling survey [21] in the wake of recording many cases in the COVID-19 pandemic. Google Forms is an online survey administration tool that allows researchers to collect data from respondents via a personalized survey [26]. The data is then collected and automatically connected to a spreadsheet which is populated with the survey responses [27]. A short URL was generated for eQuestionnaire and shared on social media groups (Religious and Secular) populated with Ghanaians. WhatsApp, Telegram, Twitter, Facebook and LinkedIn group accounts were the main source of dissemination for the eQuestionnaire. The URL was also administered via SMS and emails. The participants who initially received the URL via online groups were entreated to share the URL to their contacts and various networks (unknown to the researchers) to reach a wide population. The participants were restricted to only one response to the eQuestionnaire. The survey considered resident adult Ghanaians who are 18 and older eligible for this study if they were willing to participate [21]. Besides, the participants had to have indicated their uency in English [19] and responded to the consent question by answering an agree-disagree question at the commencement of the survey before responding to the rst question [20].
Sample size estimation: To ascertain a representative sample size for the study, the Cochran sample size determination formula was used based on the information from a previous study [28]. According to Cochran's formula, given that Z (at 95% con dence interval) is 1.96, p (proportion with good knowledge) is 0.5, q (1-p) is 0.5 and e (margin of error) is 0.05, 385 participants were required. Besides, we considered a 10% non-response rate during the collection of data. In total, 424 responses from the participants were needed for the data analysis. However, 475 participants responded to the eQuestionnaire.
Data Collection: The study adapted survey questionnaires from preceding studies on similar subjects [19][20][21] on the COVID-19 pandemic. The survey questionnaires measured relevant areas including the cause, status quo, and future development of the COVID-19 epidemic; the risk of a fatal infection course; knowledge of signs and recommended healthcare-seeking behaviour; preventive measures; and the awareness of the risk posed by individuals in Ghana but originating from countries with high COVID-19 caseloads [22].
The eQuestionnaire comprised 3 sections. Section 1 solicited data on socio-demographic characteristics of participants (Gender, Age, Ethnicity, Level of education, Profession, Region of residence, and Total household income). Section 2 of the eQuestionnaire consisted of items from existing questionnaires [20,21]. The section had 12 items which assessed the participants on clinical presentations (KQ1-KQ4), transmission routes (KQ5-KQ7), and prevention and control (KQ8-KQ12) of the COVID-19 pandemic. One point was assigned to each correct knowledge-based item, with a total score ranging from 1 to 12 points. A low score indicated less appreciable knowledge and higher scores indicated appreciable knowledge about COVID-19. In section 3, the participants were questioned whether they believed some falsehoods to determine the extent to which dis-and misinformation about COVID-19 has biased their general beliefs [19][20][21]. Participants were asked if joining a public transport, buying from a Chinese shop or deliveries from China poses infection menace, and whether the use of hand dryers, taking antibiotics, residing in hot and humid climates, taking a hot bath, and immunising against pneumonia are effective conducts to prevent a COVID-19 infection as indicated on the myth busters website of the WHO [29]. Besides, variables such as drinking hard liquor ("Akpeteshi"), smoking cannabis ("Wee"), drinking herbal concoctions (Neem Tree leaves), and being highly religious were introduced to the study to determine the public's misperceptions about COVID-19. The additional variables were not part of the listings on the WHO's myth buster website. Additional questions were asked to measure participants' attitudes (A1-A2) and speci c behaviour (B1-B3) towards the COVID-19 pandemic. The attitude items inquired about the ability of the Ghana Health Service (GHS) to manage the COVID-19 infection and the reliance of Ghana successfully eradicating the infection.
The behaviour items looked at whether the participants have engaged in any activity violating the Executive Instrument (E.I 164) issued by the Government of Ghana: visiting a public gathering with more than 100 people, and the wearing of facial or nose mask when leaving home. Finally, the participants answered a question to indicate their satisfaction on the Government of Ghana easing the COVID-19 restrictions with options ("Yes" and "No"). The eQuestionnaire was developed with Google Forms [25].
Text input Fields which expected numerical responses were validated to reject non-numeric entries (e.g. entries such as 1a, a, or 12 year were not acceptable in numeric text elds).
Data analysis: Data for the study were analysed using parametric and non-parametric test methods. Data entries were downloaded from Google forms as comma-separated values (CSV) and imported into Jamovi statistical package version 1.22.2 for analysis. Measures of central tendencies and dispersion (Mean and standard deviations), frequency, proportion and percentages were used to represent binary and categorical responses obtained from the participants. The Agresti-Coull method was used to estimate the binomial con dence interval for the binary variables. Besides, the analysis involved a comparison between demographic characteristics of respondents and their knowledge score (correct knowledge answers), attitudes, and behaviour response, and nally their perception about the easing of the restrictions. One-way analysis of variance (ANOVA), Independent-samples T-test, and multiple regression test was used for the analysis where necessary. The con dence interval for all statistical tests was 95% (CIs) and the statistical signi cance level was less than 5% (p < 0.05, two-sided) in this study.
Ethical consideration: The study was compliant with the Helsinki Ethical Principles for Medical Research declaration [28,30]. Participants below 18 years were considered as minors and were, consequently, excepted from the study [29]. The researchers followed the CHERRIES (Checklist for Reporting Results of Internet E-Surveys) guidelines to present the ndings of the study [31]. The participants who admitted to looking for an answer online for an item speci c were excepted for that item during the analysis [19].

Socio-demographic characteristics
A sum of 475 participants took an interest in this survey; majority, 135/475 (28.5%) were within 18-24 years and more were female 252/475 (53.2%). We had a representation for major ethnicities in Ghana.
The Majority (268/475, 56.4%) of the participants were residing in the southern sector (region) of Ghana. About two-thirds (382/475, 80.4%) of the participants had at least a university-level education. With regards to occupation, 130/475 (27.4%) of the participants were students. Table1 illustrates the sociodemographic characteristics of the sampled Ghanaian participants in the study. Knowledge scores of participants about COVID-19 pandemic Table 2 exhibits the results of a comparison between the knowledge scores obtained by participants and their demographic characteristics. The mean score (m=10.6, SD=1.14, 88.3%, range 0-12) obtained by the participants on the COVID-19 knowledge items suggests that the participants had all-inclusive knowledge of issues regarding the pandemic. The overall mean score (M=10.6/12, 88.3%) for this study, in the region of 4 months into the pandemic, was between the correct percentage rates reported by Clement [20] and Zhong [21] in their sample of United State and Chinese citizens respectively. The data also showed statistically signi cant differences between the correct knowledge score and the demographics (independent variables) of participants (p<0.05): "Age group", "Education", "Participant's Occupation", and "Region of current residence". However, "Gender", "Marital Status" and "Religion" were not statistically signi cant (p>0.05). The data revealed an interesting result concerning what Ghanaians believed could potentially be the cause (on a 7-point Likert scale) of the COVID-19 pandemic. The majority of the participants (85%, 95% CI 71.2%-91.5%) selected "extremely unlikely" and "moderately unlikely" which implies that they did not believe the infection could be a bioweapon. This result goes contrary to the nding of [19] were 23% (95% CI 22.4%-25.5%) of US and 18% (95% CI 17.1%-19.9%) of UK participants believed the infection was a bioweapon when they were asked the same question. The participants estimated a range of 10,000 to 13,000 infections in Ghana. The estimate by the participants corresponds to a median of 11,000 infections. The participant also thought that the rate of COVID-19 infection in Ghana is likely to extend beyond 20,000 cases by the end of 2020.

COVID-19 Infection and mortality rate among Ghanaians
With regards to the rate of infection and associated risk, 10

Etiquettes for preventing the spread of COVID-19 Infection
The results showed that the participants are well acquainted with the COVID-19 prevention etiquettes.
Majority of the participants (95%, 95% CI, 92%-97%) acknowledged that wearing of facial or nose mask; washing of hands with medicated soap more than 3 times per day; the use of sanitizers to disinfect hands regularly, and avoiding touching of the face with unwashed hands are the in uential etiquette for preventing COVID-19 infection.
Even though the majority of the participants recognized the good practices towards the prevention of COVID   restrictions. Participants' self-reports of approval toward ease of restrictions had a negative association with COVID-19 knowledge. For every unit of increase in COVID-19 knowledge score, the odds of the participants' approval of the government of Ghana's decision to ease the COVID-19 restriction increased by 220% (Table 5). In the context of the age cohort, the odds of reporting approval towards the easing of COVID-19 restrictions increased by 238% and 453% for "25-34 year" cohort and "35-44 year" cohort respectively, compared to "18-24 year" cohort. Moreover, the odds of approval towards the easing of the restrictions increased by 78%, 245% and 571% for participants with associate's degree, bachelor's degree and master's and above respectively, compared to participants with high school and below quali cations.
In the context of religion, the odds of participants reporting approval towards the easing of COVID-19 restrictions 598% and 176% for Christians and Muslims respectively, compared to the other regions.
Finally, participants residing in the southern sector and middle sector of Ghana reported increased odds of approval towards the easing of COVID-19 restrictions.

Declarations
The WHO ultimately declared COVID-19 as a global pandemic [29,32,33]. Ghana recorded and con rmed the rst-two imported COVID-19 caseloads on the 12th of March 2020. The caseloads have steadily worsened, claiming over 161 lives and creating agitations among Ghanaians [28]. The Greater Accra leads the 16 regions in the country, as the region receives a huge in ow of people from international communities through air and land ports, making its inhabitants more vulnerable to the COVID-19 infection [13,19]. This study, to the best of my knowledge, is the initial study examining the knowledge, misperceptions, attitudes and behaviour of the Ghanaian populace towards the COVID-19 pandemic during the government's effort to ease the COVID-19 restrictions. Also, this study con rms the feasibility of conducting a Survey in a short time frame to assess participants' perception and knowledge of COVID-19 [20] using eQuestionnaire disseminated via social media channels.
Majority of the study participants were female, aged between 25-34 years. The studies by [19][20][21] reported similar results with a higher number of female respondents. Hypothetically, the implications from the literature suggest that the female gender tends to respond to online surveys more than the male gender.
All the participants were literacy with the least having SHS education. Moreover, related results showed that the majority of the participants knew about the COVID-19 outbreak. Barely 5 months after Ghana con rmed the rst COVID-19 case, this study recorded a mean knowledge score of 10.6 (88.3%, SD = 1.14) out of 12 points for the participants selected for the study. The ndings showed that Ghanaians are well informed about the COVID-19 pandemic. The high correct rate of COVID-19 knowledge score in Ghana was expected since a lot of campaigns had been initiated by the Ghana Health Service (GHS) via myriad media platforms (Social Media, TV and radio). A study by [19 -21, 33] to assess the knowledge and perceptions of COVID-19 among people in the China, United States, Mexico, Paraguay and United United Arab Emirates found an association with high average knowledge (ranged between 70% to 90%) among the study population though the ndings were recorded at earlier stages of the pandemic.
The Ghanaian public had several misconceptions about COVID-19 pandemic. With regards to the rate of infection and associated risk, the participants believed that children and older adults infected with the COVID-19 are likely to experience a lethal disease and possibly die. However, the current literature [34,[36][37][38] debunk these misconceptions. The participants also held the belief that the most effective way to protect yourself from the COVID-19 pandemic is when individuals wear a face shield or a non-medical mask (fabric mask). According to WHO [39], surgical or medical masks can protect people wearing it from getting COVID-19 infection; however, [19] reported should debunk this mis-and disinformation that circulates on social media [40][41][42] and emphasize the use of medical masks rather fabric masks, and also encourage the populace to observe the COVID-19 protocols which include regular hand washing of hand with soap under running water, and observing physical and social distancing with individuals. Although the majority of the participants seem knowledgeable about COVID-19 symptoms, one of the crucial campaign messages is the healthcareseeking action to take when experiencing COVID-19 symptoms [19].
The participants held a positive attitude towards successful case management and reliance on eradicating COVID-19 pandemic in Ghana. The majority of participants (81.5%) held the credence that the COVID-19 pandemic in Ghana will nally be managed successfully. Though 22.9% of the participants were pessimistic about the chances of Ghana winning the ght against the COVID-19 pandemic, the majority of the participants (77.1%) believed otherwise. The self-report of the pessimistic participants may be attributable to the accentuating numbers (700+) in the COVID-19 caseloads recorded daily in Ghana [13,29]. Notwithstanding, among the participants, 95.3% avoided public gathering and 79.1% wore facial or nose masks when exiting the home in the light of COVID-19 case counts increasing in Ghana. We did not discover unusual purchasing behaviour among the participants. The current buy behaviour may imply that the citizenry is learning to live with the COVID-19 infection though the caseloads in Ghana are accentuating. The nding also indicated signi cant associations between the demographic characteristics of the participants and their knowledge, attitude and behaviour. These ndings are concerning recent literature [19][20][21]. Also, the ndings are relevant for Ghana Health Service and frontline workers towards the identi cation of potential COVID-19 hotspots and also the designing of speci c health education and prevention policies [21].
Several reports [13,29] show that the COVID-19 pandemic is not abating anytime soon, and people must learn to live with it by observing the necessary protocols. The government of Ghana also believes that the life of the Ghanaian populace must return to normalcy. The ndings of this study indicate that majority of participants are in support of the easing of the COVID-19 restrictions. There was a signi cant association between the demographic characteristics and participants' approval towards the easing of COVID-19 restrictions. The highest odds of approval were recorded among the participants of the Christian faith (OR: 6.98, 2.90-9.45). However, the self-reports of older adults (45+ cohort) was negatively associated with the approval towards the easing of COVID-19 restrictions. The disapproval towards the COVID-19 restrictions by the older adults may be attributable to reports that indicate their vulnerability to the COVID-19 pandemic [19]. Finally, these ndings on the approval and disapproval towards the easing of COVID-19 restriction could inform the government of Ghana to draw an effective COVID-19 restriction easing strategy going forward.
The statistical power of this study lies in the short period used to collect the data from a large number of respondents at peak of the COVID-19 pandemic, and the sample representation of women considering the population statistics of Ghana [42]. However, the study experienced some challenges: Firstly, there was an over-representation of participants with higher education and high employment status which may have accounted for some variation of characteristics between the participants and the entire Ghanaian population [19]. These variations in characteristics may have in uenced the decision of some participants not to partake in the e-Survey, and besides, correlate participants' perceptions and knowledge of the COVID-19 pandemic with their characteristics [19][20][21]. Secondly, using social media platforms as the main channel for the dissemination of the eQuestionnaire may have prevented people who have not subscribed to any of these platforms or are digital immigrants from participation. Moreover, the authentication process did not allow the researchers to paint a re ective picture of Ghanaians concerning their knowledge and perception of the COVID-19 infection as participants with Gmail accounts could respond to the eQuestionnaire. Limitations in access to the eQuestionnaire, online information resources and internet prevented the researchers from collecting data from older adults and people residing in rural communities who are more likely to have low knowledge, pessimistic attitudes, and inappropriate preventive behaviour towards the COVID-19 pandemic [12]. Currently, in Ghana, older adults and people residing in rural communities are seen as more vulnerable to the COVID-19 infection; hence, extensive research is required to ascertain their knowledge, attitude and behaviour of the COVID-19 pandemic.

Conclusion
Ghana joined the global community in the battle against COVID-19 pandemic since her rst case was recorded in March, however, the caseloads of the infection keep rising daily. A quick online cross-sectional survey was needed to evaluate and track the knowledge, misperception, attitudes and behaviour of Ghanaians during the COVID-19 infectious outbreak concerning the government's effort towards the easing of COVID-19 restrictions. Such assessment was expedient to ascertain the level of knowledge, reduce the rates of infection, and nally prevent case fatalities among the Ghanaian populace. This study, to the best of knowledge, is the rst attempts to de ne in uences of public knowledge and misperceptions, attitudes and behavioural response to the COVID-19 pandemic in Ghana during the government's resolution to ease the COVID-19 restrictions. The ndings suggest that Ghanaians have had appreciable knowledge, positive attitudes, and maintain cautious behaviour towards COVID-19 pandemic despite the rapid upsurge of the infectious outbreak. Hence it is a step in the right direction for the government of Ghana to ease the COVID-19 restrictions for the populace activities to return to normalcy. However, precaution must be taken towards the easing of the COVID-19 restrictions as enough research have not been conducted on the uneducated populace in the Ghanaian society. Such studies will shape up the government's decisions to implement an all-inclusive easing policy.