Knowledge, attitude, and practice towards COVID-19 among antenatal care clients of Adama hospital medical college, Adama, Ethiopia: A cross sectional study

Objective An already overwhelmed health system with many sporadic outbreaks is now threatened by the COVID-19 epidemics. Person-to-person transmission is currently ongoing in the country, making it necessary to control the disease. To guarantee successful disease control, the knowledge, attitudes and, practices people hold towards the disease play an integral role. Therefore, the aim of this study was to determine the knowledge, attitude, and practice towards COVID-19 among antenatal care clients of Adama Hospital Medical College, Adama, Ethiopia. Results A cross-sectional study was conducted from May 6, 2021, to May 31, 2021. Among the 292 study participants, 222 (75.3%) had good knowledge and 70 (24%) moderate knowledge status. Signicant number of respondents 131 (44.9%) had neutral attitude while 159 (54.5%) had positive attitude. The prevalence of poor practice was 61 (20.9%). Majority of the respondents, 136 (46.6%) had moderate practice level. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the U. S. Asemahagn MA. Factors determining the knowledge and prevention practice of healthcare workers towards COVID-19 in Amhara region, a cross-sectional survey. 2020; 48(72).


Introduction
At the end of 2019, Wuhan City, the capital city of Hubei province in China, experienced a new coronavirus outbreak (1). The new virus is a member of the beta group of coronaviruses and was named the 2019 novel coronavirus (2019-nCov). Thereafter, the International Committee on Taxonomy of Viruses named the virus SARS-CoV-2 on February 11, 2020, and the disease as COVID-19 (2,3,4). COVID-19, a large family of viruses, is the third zoonotic coronavirus after SARS-CoV and MERS-CoV (5). COVID-19 is the only one that appears to be with pandemic potential (6). The pandemic gave rise to a major public health crisis worldwide and challenged the healthcare system across six continents (7). As the infection has spread to over 216 countries the world health organization (WHO) declared the COVID-19 eruption a Public Health Emergency of International Concern on 30th January 2020 (5,6,7,8).
The WHO declared the COVID-19 outbreak a global pandemic on March 11, 2020 (9). The pandemic presented extra pressure and overstretched the health care system that is already reached the breaking point throughout the world (10).
The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presents an unprecedented challenge to public health, food systems and the world of work (11). People with certain health conditions have a higher risk of severe complications if they acquire the infection. Pregnant women are among this group (12).
The knowledge, attitudes and, practices (KAP) that people hold towards the disease play an integral role in determining a society's readiness to accept behavioral change measures from health authorities (13).
The KAP of people towards COVID-19 is critical to understand the epidemiological dynamics of the disease (14). Pregnancy is an exciting and sometimes stressful experience. Being pregnant during a disease outbreak may add extra anxiety and concern for pregnant women and for those who provide care for them in addition to the high risk to have the severe form of the disease if they acquire the infection.
Therefore, this study aimed to determine KAP towards the COVID-19 among antenatal care (ANC) clients of Adama hospital medical college (AHMC).
The study will contribute by adding knowledge regarding KAP towards COVID-19 and show the direction how to improve for health care providers, health care service managers, researchers and stakeholders who are working in this area.
The source population was all clients visiting ANC at AHMC during the study period and the study population was those clients selected by using a systematic random sampling technique. A single population proportion formula was applied to determine the sample size. Assuming 95% con dence interval, marginal error (d) of 5% and proportion 50%, a correction formula was used and 5% nonresponse rate was added to give a sample size of 302.
Knowledge, attitude and practice were assigned as good or positive if the score was between 80 and 100%, moderate or neutral if the score was between 60 and 79%, and poor or negative if the score was less than 60%.
The data was collected using a pre-tested, structured interviewer-administered questionnaire.
The data was checked for completeness and consistencies, and then cleaned and entered using Epi info version 7.2 .4.0 and exported to SPSS version 26 for analysis. Then, the data was analyzed using appropriate descriptive statistics, and summarized by frequency, percentage, and mean.

Results
From the total sample size calculated (302), 292 pregnant women were included in the study, making the response rate 96.6%.

Knowledge assessment
A total of 37 questions were used to assess the knowledge status of respondents. The questions had ve sections. The sections focused on mode of transmission of COVID-19, major sign and symptoms of the disease, risk groups to develop severe form of the disease, prevention mechanisms and nature of the disease. The minimum knowledge score was 21 and the maximum 35 with a mean score of 31 and standard deviation 2.73.
Among the 292 study participants, 222 (75.3%) had good knowledge and 70 (24%) moderate knowledge status. Only 2 (0.7%) of the respondents had poor knowledge status regarding COVID-19. Of the respondents, 68 (23.3%) didn't know pregnant women has higher risk of developing severe form of the disease if they are one infected. Responses to each knowledge questions are presented in table 2.

Attitude towards COVID-19
A total of thirteen questions were used to assess the attitude of the participants towards understanding severity of the problem and preventive measures against the COVID-19 pandemic. The mean score of attitudes was 52 with standard deviation of 4.65. The maximum score was 63 and the minimum 35.
Of the respondents, 159 (54.5%) had positive attitude while only 2 (0.7%) had negative attitude. Signi cant number of respondents 131 (44.9%) had neutral attitude. Nearly half of the respondents were not willing to take the vaccine and more than one-third didn't agree that they were at risk of acquiring the infection. Responses for speci c questions are presented in table 3.

Level of practice towards COVID-19 prevention
The questions assessing practice were 12. Correct answers were assigned 1 point. The total practice score among respondents ranged from 3 to 12. The mean score was 8.4 with standard deviation of 1.99.
More than half of the respondents (54%) reuse masks and (51.4%) didn't practice "physical distancing" by remaining 6 feet/2 meters away from others at all times. Responses for speci c practice questions are presented in table 4.

Discussion
Currently, the alarmingly spread of COVID-19 is a major public issue in the world. So far, no treatment is discovered to it. Therefore, prevention is the best solution. Effective prevention and control of COVID-19 is achieved through increasing the populations' knowledge, attitude, and practice towards COVID-19.
This study revealed that, 222 (75.3%) of the respondents had good knowledge, 70 (24%) moderate knowledge and only 2 (0.7%) poor knowledge status regarding COVID-19. The level of good knowledge status in this study is lower when compared to a survey among Cameroonian residents, which revealed 84.19% (15) and Nigeria (99.5%) (14). This discrepancy could be subjected to variations in the cut-off values. In addition, the discrepancies might be due to differences in community awareness creation through mass media and social media.
The level of good knowledge in this study is comparable to a study done in Amhara region where 279 (70%) had demonstrated good knowledge and relatively higher when compared to studies conducted among residents of Dessie and Kombolcha city administrations where 54.11% had inadequate knowledge (16), Tigray region where 42.9% of respondents were knowledgeable (17), Sidama region where 43.9% of the study participants had good knowledge (18) and Addis Abeba where only 37.2% had good knowledge (19). The level of poor knowledge is much lower than a study conducted in Addis Zemen Hospital where the prevalence of poor knowledge was 33.9% (20). This may be due to timing of the studies. At the time of previous studies, the virus was new and people were learning more about the symptoms every day. Moreover, it may also be due to the differences in a tool used for assessment of knowledge.
This study showed that majority of the respondents 159 (54.5%) had positive attitude while only 2 (0.7%) had negative attitude and signi cant number of respondents 131 (44.9%) had neutral attitude. The level of attitude in this study is low when compared to other studies in Nigeria where 69% of respondents had a high attitude score (15) and in Addis Abeba where 60.7% of the respondents had positive attitude (19). The differences in the level of attitude could be subjected to variations in the cut-off values and different type of tools used by the studies. The different level of knowledge among respondents could also attribute to the discrepancy.
The nding in this study regarding the level of positive attitude was higher when compared to a study conducted in Sidama where 37.5% of respondents had high attitude (18). This difference might be related to variations in the study period.
More than one-third (39.7%) of the respondents didn't agree that they were at risk of acquiring the infection. This is supported by another studies. Of the study participants in Addis Zemen, 20.5% perceived that they had a very low risk of infection (20) and 24.6% of the respondents from U.S. believed that they were not at all likely to get infected with COVID-19 (21). This perception of very low risk of infection might be due to poor understanding of high infectiousness of COVID-19.
According to this study, the prevalence of poor practice was 61 (20.9%), majority of the respondents, 136 (46.6%) had moderate practice level and the remaining 95 (32.5%) had good practice towards COVID-19 prevention. This result was comparable to a study in Sidama region where 24.4% of study participants had good practice (18).
In contrary to this study, most participants (77%) in Palestine complied with preventative measures (10), 60.8% of respondents were taking precautions (good practice) in Cameron (15), majority (62%) of the respondents in Amhara region had good prevention practices (22) and 59.8% of study participants in Addis Abeba had good practice to mitigate the pandemic (19).
Prevalence of poor practice in Addis Zemen was 33.9% (20) which is slightly higher than witnessed in this study.
The possible justi cation of this disparity might be a difference in sources of information, information seeking behavior, frequency of media exposure, knowledge, phase of the outbreak in the study area, and worry related to the outbreak of study participants which lead to the variation in the application of recommended actions and behaviors to prevent COVID-19.
Generally, this level of moderate and 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.
Very interestingly, during early phase of COVID-19 pandemic, there has been an aggressive promotion of covid19 information through ministry of health and main government mass media. This led to better knowledge and preparedness about the pandemic. Though still the promotion is present, adherence seems to become less.

Conclusion
In conclusion, the study revealed that, about three-fourth of respondents had good knowledge, majority of the respondents had positive attitude while signi cant number of respondents had neutral attitude and the prevalence of good practice towards COVID-19 prevention was very low.
About one-fourth of the respondents of this study didn't know that pregnant women have higher risk of developing severe form of the disease if they are once infected. Nearly half of the respondents were not willing to take the vaccine and more than one-third didn't agree that they were at risk of acquiring the infection.
Preventive attitude has to be reinforced by all stakeholders and appropriate prevention and control strategies should be promoted consistently and priority needs to be given to improve prevention practices parallel to awareness creation.
ANC providers should include health information regarding the higher risk of pregnancy for developing severe form of the disease.
Since the study found there were many respondents who were not willing to take the vaccine, further qualitative researches should be done by AHMC to nd out the reason of this resistance.

Limitations
The likelihood of giving socially acceptable answers by the respondents and use of small sample size could be limitations of the study. To conduct the study, ethical clearance and supporting letter was obtained from the Ethical review committee of AHMC. Then, permission was be obtained from ANC department. Participants were recruited to the study after a verbal explanation of the objectives of the research and were provided a written information sheet. All potential participants who agree to participate were provided a written consent to continue with the interviews and informed that their participation in the study was voluntary and they are free to withdraw their participation at any time they want. Con dentiality was maintained for information collected from each study participant by omitting their names and personal identi cation or privacy. Information obtained from them was not disclosed to a third party. All clients were given assurance that there was no physical and emotional harm resulting from participating in the study.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.