Perceived Ecacy of COVID-19 Prevention Measures and Intention to Use Among Chronic Disease Patients in Northeast Ethiopia, 2020

Background: The novel corona virus disease outbreak which was rst detected in China is caused by sever acute respiratory syndrome corona virus 2. In Ethiopia, poor perception about COVID-19 prevention methods might be one of determinant factor to the low utilization of adopted prevention measures and increasing of cases. However, it was unknown to what extent individuals were perceived the ecacy of those measures. Hence, this study was aimed to assess perceived ecacy of COVID-19 preventive measures and intention to carry out those methods among chronic disease patients. Methods: Institutional based cross sectional study was conducted among 413 chronic disease patients from 21 July - 5 August, 2020. A pre-tested interviewer administered structured questionnaire was used for data collection. Both binary and multivariable logistic regression analyses were used and in multivariable analysis, variables were declared statistically signicant at p-value of < 0.05. Results: In overall, 42.1% of participants had low perception to the ecacy of COVID-19 prevention measures and 28.3% had low intention to carry out those prevention measures. In this study, young adults (AOR=2.48; 95% CI: 1.42-4.31), male gender (AOR=2.75; 95% CI: 1.73-4.37), uneducated (AOR=3.42; 95% CI: 1.47-7.94) and face mask non-users (AOR=1.64; 95% CI: 1.03-2.61) were signicantly associated with low perceived ecacy of COVID-19 prevention methods. However, male gender (AOR=2.06; 95% CI: 1.28-3.31), rural residents (AOR=1.89; 95% CI: 1.16-3.07) and patients with longer duration of chronic disease (AOR= 2.19; 95% CI: 1.19-4.01) were signicantly associated with low intention to carry out COVID-19 prevention methods. Conclusion: In this study, signicant proportion of patients (42%) had low perception about the ecacy of COVID-19 prevention measures and nearly one-third of participants (28.3%) had low intention to carry

Developing countries faced a great challenge in providing critical care and support to COVID-19 cases (39). Thus, primary prevention strategies are feasible and the best options in resource limited countries (40). A person can be infected after contact history with a known corona virus infected person or from any other unknown source of infection (41). Thus, maintaining physical distance, washing hands with soap and water, staying home, wear face mask and seeking medical advice were the main WHO recommended behaviors to prevent the virus and Ethiopia also adopted those strategies (42). Studies revealed that timely and effectively implemented physical and social distance alone can reduce COVID-19 distribution by 60-95% (13). Few community based studies conducted in Ethiopia in different segment of the population revealed that majority of the urban population had good knowledge about COVID-19 and its prevention methods (43)(44)(45)(46). However, maintaining of COVID-19 prevention methods and behaviors in the community was not satisfactory even if the disease is fatal and wide spreading all over the country (47). Special attention should be provided for chronic disease patients due to their high risk of death. In Ethiopia, the number of peoples infected with novel corona virus have been increasing dramatically from day to day despite of government prevention activities (8). Low perception of peoples about their susceptibility to COVID-19 and its severity were the major predictor to the low utilization and engagement of COVID-19 preventive behaviors (48,49). Poor perception of COVID-19 prevention methods and behaviors might be also one of the main determinant factors to the low utilization of adopted mitigation measures and increasing of cases in Ethiopia. Hence, this study was aimed to assess perceived e cacy of COVID-19 preventive measures and intention to use them among chronic disease patients.

Methods And Materials
Study design, period and setting Institutional based cross sectional study was conducted among chronic disease patients in Hospitals of Dessie town, northeast Ethiopia from 21 July -5 August, 2020. Dessie town is located 400 kilometer far from Addis Ababa (capital city of Ethiopia) and 488 km from Bahirdar (capital city of Amhara regional government). It is located at an altitude of 2470 meter above sea level and based on the 2007 national census, the town has a total population of 151,094, of which 78,203 are females (50). In the town, two governmental and three private hospitals are available that have been serving populations of Dessie town and surrounding zones. In addition, both COVID-19 quarantine and treatment centers are available in the town.

Population
All chronic disease patients who were admitted or attended chronic disease follow up units in hospitals of Dessie town were the source population.
Whereas, all patients who were admitted or attended in selected hospitals of Dessie town during data collection period were the study population.

Sample size determination
A single population proportion formula [n = (Z a/2) 2 P(1-P)/d 2 ] was used to estimate the sample size.
Since, no previous study was conducted in Ethiopia; we have used maximum sample size assumptions. Proportion of 50%, 95% con dence level (Z=1.96) and 5% margin of error. With this, the required sample size was 384. By adding 10% non response rate, a total of 422 chronic disease patients were planned to be involved in the study.

Sampling technique and procedures
From ve hospitals in the town, one government hospital (Dessie referral hospital) and two private hospitals (Ethio general hospitals and Selam general hospitals) were selected using lottery method. Then, the daily average chronic disease patients attended those hospitals at both out-patient clinics and inpatient units were estimated. Finally, based on their patients load, sample was allocated proportionally in the three hospitals: DRH=295, EGH=67, SGH=60. Finally, data was collected from eligible patients by using systematic random sampling technique.

Data collection tool and procedures
The data collection tool which includes socio-demographic characteristics, clinical pro le and health seeking behaviors of patients was adopted by reviewing different literatures (51)(52)(53). However, patients' perceived e cacy of COVID-19 prevention measures and their intention to carry out those measures was adopted from a standard tool on effective communication in outbreak management for Europe (54). A pre-tested interviewer administered questionnaire was used to collect the data. However, patients' chart was also reviewed to identify the type of chronic disease and presence of other co-morbidities that they had. Moreover, patients were observed whether or not they have used face mask and hand sanitizers at the time of data collection.
Perception of patients to the e cacy of COVID-19 prevention methods and their intention to carry out those prevention methods was assessed by six questions (for both e cacy and intention to carry out measures) in which, each question had a ve scale responses;( 1=certainly not, 2=probably not, 3=perhaps not-perhaps yes, 4=probably yes and 5=most certainly).
For the purpose of analysis; those who responded "certainly not", "probably not" and "perhaps notperhaps yes" was coded by "0" and those who responded "probably yes" and "most certainly" was coded by "1" for each question. Finally, their score out of six was determined and those who scored "0-3" were considered as having low perception and those who scored "4-6" were considered as having high perception about the e cacy of COVID-19 prevention methods. Furthermore, those who scored "0-3" were considered as having low intention to carry out COVID-19 prevention methods and those who scored "4-6" were considered as having high intention to carry out those prevention measures. Finally, the main hindering factors to carry out COVID-19 preventive measure were also assessed for those who responded "certainly not" and "probably not". Data quality control Data quality was insured by undertaking the following measures. The questionnaire was translated from English to Amharic (local language of the study area) by considering the culture and norms of the society and then back to English to check its consistency. Data collectors and supervisors were trained for two days regarding objective of the study, ethical issues and how to collect the data by protecting themselves from COVID-19. They were also trained how to apply personal protective equipments and glove, face mask and sanitizer were provided for both data collectors and supervisors. In addition, the tool was pretested in Bati general hospital by taking 10% of the total sample size so as to check for clarity of language and appropriateness of the tools.

Data processing and Analysis
Data was coded and entered using Epi-Data version 3.1 statistical software and then exported to SPSS (statistical package software for social science) version 20.0 for further statistical analysis. Appropriate descriptive statistics was used to analyze the data and mean, standard deviation (SD), frequency, percentage and tables were utilized to summarize the data. Binary and multivariable logistic regression analyses were tested to identify factors associated to low perceived e cacy of COVID-19 prevention measures and low intention to carry out those prevention activities. In bivariable analysis, variables which had a p-value of less than 0.2 were entered into multivariable analysis model. In multivariable analysis, variables were declared statistically signi cant at p-value of < 0.05.
Moreover, strength of association between factors and the dependent variables were determined using Adjusted Odds Ratio (AOR) with 95% con dence level.

Results
Socio-demographic characteristics of study participants A total of 413 adults with chronic disease were participated in the study with response rate of 97.8%. The mean age of participants was 48.2 years (SD ± 15.8 years) and 215(52.1%) were females. Majority of participants, 268(64.9%) were urban dwellers and 287(69.5%) participants were married. Of all participants, 191(46.2%) had no formal education and 159(38.5%) were housewives. The mean family size and house room number of participants was 4.4 (SD ± 1.7) and 3.0 (SD ± 1.4), respectively (Table 1). living with their disease for more than ten years. Majority of participants, 350 (84.7%) had no additional co-morbidities; and 63.2% and 26.6% of participants were utilized face masks and sanitizer, respectively at the time of data collection. Regarding risk assessment to the current pandemic, no one had contact history with a known con rmed COVID-19 cases: However, 41(9.9%) patients had reported respiratory symptoms and 16(3.9%) had travel history to other areas in the last two weeks. Furthermore, 194(47%) participants were members of community based health insurance and 81(19.6%) clients will have no social support if they were isolated or quarantined due to COVID-19 (Table 2). In this study, 155(37.5%) participants were perceived as applying face masks "probably" helps to prevent COVID-19 and 185(44.8%) were perceived as hand washing with soap and water "probably" helps to prevent COVID-19. Whereas, 21.3% and 20.6% of respondents perceived that maintaining of physical distancing and wearing face mask may "not probably" helps to prevent the current pandemic disease, respectively (  (Table 3).
In this study, we have also assessed the main reason why participants had no willingness (for those who responded "certainly not "and "probably not") to carry out the most important recommended COVID-19 prevention measures and behaviors. Thus, takes too much effort was the main reason identi ed by participants for not willing to wear face masks (38.6%), wash their hands with soap and water (43.7%) and not to use alcohol based hand sanitizers (67.8%). In addition, 33.8% of participants described that they will not maintain physical distancing because they had doubt whether it helps to prevent the disease or not. Moreover, about 24.8% of participants responded that they will not stay home so as to prevent COVID-19 because of other peoples in their environment would not carry out this measure (Table 4).  with low intention to carry out COVID-19 prevention methods and behaviors (Table 6).

Discussion
In Ethiopia, peoples infected with SARS-CoV-2 have been increasing signi cantly from day to day despite of government mitigation measures (4). As of 30 August, 2020, a total of 50,000 peoples have been infected with corona virus and 770 deaths were reported in Ethiopia (9). In the era of COVID-19 pandemic, every individual is expected to be susceptible to be infected and it brings signi cant morbidity and mortality. Individuals' perceived susceptibility to the novel corona virus infection and fear were the main predictor to the utilization and engagement of COVID-19 protective methods and behaviors (48,49,55). A lot of factors might be contributed to the widespread distribution of the disease in Ethiopia. In our context, though not studied, one of the main reasons could be related to wrong perception of people towards the disease and the recommended prevention measures. Studies revealed that severity of COVID-19 was found to be high in patients who had chronic disease concomitantly (11,18). Thus, patients who have been living with chronic diseases should perceive as they are the most vulnerable group of peoples to COVID-19 and as much as possible they should carry out all the recommended protective measures. The more peoples perceived as the recommended COVID-19 prevention measures are effective, the more they will carry out those measures. However, in our study, 42.1% (95% CI: 37.3-46.5) of participants had low perception to the e cacy of COVID-19 prevention measures. Speci cally, more than half of participants were perceived that wearing face mask (58.3%) and washing hands with soap and water (61%) helps to prevent COVID-19. This is nearly similar with studies reported in Egypt (56), India (57) and Australia (58) where more than half of respondents were perceived face mask and hand washing as an effective COVID-19 prevention measures. In the present study, staying at home (90.5%) and selfquarantine (if suspected) (94.5%) were the main prevention measures perceived to be effective in preventing COVID-19 pandemic than the other precautionary behaviors. However, it contradicted with a study reported in Korea that hand hygiene and wearing face mask were perceived as more effective measures (59). Our study revealed that uneducated patients were more likely to had low perception about the e cacy of COVID-19 prevention methods compared to more educated patients. This could be due to the fact that more educated peoples have more knowledge about the disease and the recommended prevention strategies. COVID-19 severe clinical disease and death have been reported mainly in peoples with advanced age and patients who had chronic disease concomitantly (11,18). In our study, an independent association was observed between young adults and low perceived e cacy of COVID-19 prevention methods. Furthermore, male gender and face mask non-users were signi cantly associated to low perceived e cacy of recommended prevention methods.
Risk perception to COVID-19 was one of the main determinant factor to the adoption and utilization of COVID-19 prevention measures (60). In this study, 28.3% (95% CI: 24.1-32.7) of participants had low intention to carry out COVID-19 prevention measures. In Ethiopia, at the beginning of the pandemic, many people were observed to implement the adopted prevention (43,61) methods. However, after three to four months of the outbreak, people's engagement in COVID-19 prevention measures and health seeking behaviors have been decreased extensively; as a result the number of people infected with the virus and related death have been increased dramatically (9). In our study, 63.2% of participants had used face mask so as to prevent themselves from corona virus infection which is similar to a study reported in South Korea (59) but lower than a study reported in Pakistan (62). However, about 81.9% of participants had an intention of wearing face mask in the present study which is higher than a study reported from Egypt(35%) (56). In Ethiopia, numerous factors could contribute to the reduction of COVID-19 prevention measures and behaviors used in the population. Those factors may be related with lack of awareness, negligence, perception, resource limitation or a combination of those factors (61). In this study, we have also assessed the main reason why participants had no willingness to carry out the most important COVID-19 prevention measures and behaviors. As a result, "takes too much effort" was the main reason identi ed by participants for not willing to wear face masks and not to maintain their hand hygiene. It is mainly associated with lack of resources and study from Kenya also supported our nding; expensive hand sanitizers and lack of personal water source were the main barriers (63). In addition, 33.8% of participants described that they will not maintain physical distancing because they had doubt whether it helps to prevent the disease or not and 24.8% of participants will not stay home so as to prevent COVID-19 because of other peoples in their environment will not carry out this measure. In this study, male patients had low intention to carry out COVID-19 prevention methods and behaviors compared to females. It is supported by study ndings in Chicago (64) and Hong Kong (51) that female patients were maintaining social distancing more than males. Despite of disease severity in advanced age and in chronic disease patients (11,18), multivariable analysis of this study revealed an independent association between longer duration of living with chronic disease and low intention to carry out COVID-19 prevention methods.
In the present study, patients from rural area were less likely to carry out adopted COVID-19 prevention measures than urban residing patients which is in line with a study reported from China (65). This could be related to lack of information accessibility and awareness about the disease in rural resident. The possible limitation of this study could be related to the nature of cross sectional study design used and method of data collection which may predispose respondents for social desirability and recall bias.
Additionally, this study was done on selected hospitals of Dessie town, thus our nding may not be generalized to the overall population of the town. Furthermore, factors related to health care setting and economical status of patients was not assessed which could have impact on adoption and utilization of COVID-19 prevention methods and behaviors.

Conclusions
In this study, signi cant proportion of chronic disease patients (42%) had low perception about the e cacy of COVID-19 prevention measures and behaviors and nearly one-third of participants (28.3%) had low intention to carry out the adopted prevention measures. our study revealed that young adults, male gender, uneducated and face mask non-users were signi cantly associated with low perceived e cacy of COVID-19 prevention methods. However, male gender, rural residents and patients with longer duration of chronic disease were signi cantly associated with low intention to carry out those prevention methods and behaviors. Thus, an intensi ed awareness creation program has to be provided about COVID-19 prevention measures and their risk of infection if they did not carry out those measures. Furthermore, interventions aimed to enhance patients' attitude and behavioral changes on COVID-19 prevention measures have to be provided.