key: cord-0265394-tnxtmc4o authors: Hedima, E. W.; Michael, S. A.; David, E. A. title: Knowledge and Risk Perception of the Novel Coronavirus Disease among Adult Population in Nigeria: A cross-sectional study date: 2020-08-25 journal: nan DOI: 10.1101/2020.08.23.20180141 sha: d87cbb2b70ee6ac4e0a07f7900f60bac9e92f735 doc_id: 265394 cord_uid: tnxtmc4o COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious disease declared a pandemic by the World Health Organization. The risks of getting infected with the novel coronavirus in Nigeria is high as evident by the increase in the daily number of confirmed cases. Objective: The objectives of this study were to assess the knowledge and risk perception of adult Nigerian population regarding the novel coronavirus pandemic. Methods: We conducted an online cross-sectional survey in which five hundred and ten (510) adult participants consented and filled the questionnaire. The questionnaire is divided in to four sections: the first part was directed at the socio-demographic characteristics of the participants, the second was dedicated to the assessment of knowledge, the third part assessed risk perception and the fourth section assessed preventive measures. Results: Almost all of the participants (95.9%) claimed to be aware of COVID-19 with majority through the traditional media (55.3%), and social media (41%) while only a small percentage (3.7%) gained the awareness through health officials. Knowledge of COVID-19 was significantly poor among participants with lower level of formal education, (p=0.0001). participants with higher income were found to have a good knowledge of the disease (p<0.00001). being a health worker was not associated with good knowledge of COVID-19 (p=0.00001). Risk perception was significantly high among the females (p=0.044), young adult participants (p=0.039) and healthcare workers (p=0.001). Preventive measures like avoiding eating out (p=0.001) and traveling to high risk areas (p=0.017), wearing face mask (p=0.01) and eating balanced diet (p=0.014) were statistically significant across gender. Conclusion: In general, participants were aware of COVID-19 with a low proportion having a good knowledge about the disease and preventive measures. The findings from this online survey could guide information campaigns by public health authorities, clinicians, and the media. Keywords: Knowledge; Risk perception; Public health; Pandemic; COVID-19; Nigeria. The latest threat to global health is the ongoing outbreak of the respiratory disease that was recently given the name Coronavirus Disease 2019 (Covid-19). Covid-19 was recognized in December 2019. 1 The highly contagious severe acute respiratory syndrome coronavirus (SARS-CoV-2), which emanated from China and has since become a global public health emergency. 2 In severe cases, the virus causes fatal pneumonia similar to that caused by (SARS-CoV-2), and Middle East respiratory syndrome coronavirus (MERS-CoV), which have emerged in the past years sporadically in countries. 3 The course of the Covid-19 epidemic will likely be strongly impacted by how the population behaves, which in turn is influenced by what people know and believe about this disease. 4 A particular concern in this regard is the spread of misinformation about COVID-19 on social media sites. This has led the WHO to host a page with "myth busters" on their website and engage in discussions with social media. 5, 26 The concern by the world health organization that COVID-19 could take time to be eliminated and the rate at which the infection is spreading across the world calls for rapid assessments of the population's knowledge and perceptions of this infection. 6, 7 This work is aimed at assessing knowledge and risk perception about COVID-19 among a convenience sample of the Nigerian adult population. This was a web-based cross-sectional survey among adult Nigerian population. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint The survey questionnaire was adopted from other studies (see appendix). 9 ,10 It covered the sociodemographic characteristics, knowledge regarding COVID-19 and its preventive measures and perceived risk about the disease. A pilot study was conducted to assess the reliability of the questionnaire before its use. The questionnaire was pretested on 20 participants who were excluded later from the main study. Participants completed the perceived risk scale (Cronbach's α = 0.82) which had 8 survey-items (5-point likert scale, from strongly disagree to strongly agree). An online survey portal, Google Form was created, and adult participants were invited to complete and submit the form via WhatsApp, Facebook and Twitter social media sites. The process of calling participants to share in the survey was conducted through convenient sampling. Participants continued to spread and were expected to cover the entire six regions of the country. The study was conducted from May to July, 2020 among Nigerian adults. The sample size was determined using the Epi Info 7.0 software (Centers for Disease Control and Prevention, Atlanta, USA). As there were few similar studies related to coronavirus disease in Nigeria, the calculations were based on the assumption that the probability of having good knowledge on preventive measures against coronavirus disease was 50.0%. Using the precision . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint of 5%, a design effect of 1.0, and the confidence interval set at 95%; . 8 The calculated sample size was 384 participants. The survey portal was closed, and interviews stopped at the end of the day when the number of participants exceeded the sample size, i.e. at the end of the fifth week. Participant's responses were analyzed using the statistical package for social sciences (SPSS) version 25.0. Descriptive statistics were used to summarize data on socio-demographic characteristics, infection prevention and control measures against the novel coronavirus by participants and responses to questions concerning knowledge and risk perceptions towards the new coronavirus. Data were summarized as frequencies (n) and percentages (%) for categorical variables. Knowledge concerning COVID-19 was assessed by answering 14 questions followed by the calculation of a total cumulative knowledge score for each participant. Questions were given one mark for correct response and zero mark for incorrect answers. The knowledge score was categorized into: Good, Fair, Poor and Very poor. Chi-square test was performed to determine association between sociodemographic characteristics and knowledge as well as infection prevention and control measures by participants. A post hoc test was carried out after a significant Chi square test to identify where the difference in knowledge of the disease really lies. Kruskal Wallis test with post-hoc was used to assess difference in the risk perception across sociodemographic characteristics. P-value < 0.05 was considered statistically significant at 95% confidence interval (CI). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint This study was approved by the Ethics Committee of Gombe State University. Participants' anonymity and confidentiality were ensured. A Participant information sheet was served and an informed consent was obtained before the participant answered the questionnaire. Five hundred and ten persons from 6 regions of Nigeria completed the survey. Table 1 shows the socio-demographic characteristics of the studied participants. More than two thirds (66.9%) were males. More than half the participants (53.5%) aged 26 to <35 years, less than a quarter aged 18 to less than 25 (16.3%), aged 36 to less than 45 (14%) and aged 46 to ≤55, whereas only 3.7% aged 55 and above. Most of the participant reside in the north east (37.6). More than half were university graduates (56.5%), 23.7% had Masters degrees, 3.7% had Doctorate degrees. 0.4% had less than senior school certificate and 2.7% had senior school certificate respectively. The monthly income of a large proportion of the participants 38.6% was more than N 110,000. More than half of the participants (59.4%) were not healthcare workers, 19.2% were pharmacists, 2.2% were physicians, whereas only 2.5% were nurses. Almost all of the participants (95.9%) claimed they were aware of the novel coronavirus. 55.3% of the participants were aware of COVID-19 mostly through the media (TV/Radio/Bill boards/Newspapers). Only a small percent (3.7%) were aware through health officials. Only 48% of the participants had a good knowledge of the disease while 34.9% had a fair knowledge, 13.9% had a poor knowledge and 3.1% had a very poor knowledge of the disease respectively. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 25, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint The relationship between socio-demographic characteristics and knowledge about COVID-19 is demonstrated in Table 2 . The cumulative knowledge scores were significantly related to the level of education (p<0.001) as well as to the monthly income (p<0.01). Being a Healthcare worker also influence the knowledge about COVID-19 (p<0.01). When asked "If you have a fever or cough and recently came in contact with someone who is confirmed to be positive for , what action will you take? 61% of the participants responded with the recommended care-seeking option of staying home and contacting their health system. 33.3% of the participants stated they would delay care-seeking by self-isolation while a small percent (0.6%) of the participants would rather attend the hospital emergency department and 2% of the participants would rather rest more than usual and if symptom persists, they take a public transport to their primary care provider. However, a post-hoc test was carried out to identify the association between knowledge of the novel coronavirus and sociodemographic characteristics in those that were significant upon chisquare test in which lower level of formal education (p=0.0001) and the status "Other health worker" (p=0.00001) were significantly associated with a very poor knowledge about the novel coronavirus but earning a higher monthly income was found to be significantly associated with a good knowledge of the disease. *Statistically significant at p < 0.05, 95% CI . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . In Table 3 strongly agree that they will not go to the hospital, even if they fall ill because of the risk of getting . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint infected with the virus. Another quarter 28.6%, 95 CI (3.58-3.33) of the participants agree that the infection may continue to spread widely in country and in their immediate communities. 25.1% of the participants with 95% CI (3.55-3.32) strongly agree that they can protect themselves against being infected. Less than a quarter 22.2%, 95 CI (2.73-2.52) of the participants strongly disagree to the statement that they are more likely to get infected with the virus than others people however only 25.7%, 95% CI (2.81-2.58) of the participants disagree that receiving a letter or package from abroad can put them at risk of getting infected with the new coronavirus. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint A Kruskal Wallis test in Table 4 , showed that at there was a significant difference of the mean perceived risk score across gender (p=0.044) however post-hoc test was not carried out because there were less than three fields. The mean perceived risk score was also statistically different CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint across the age groups (p=0.039). A post-hoc test showed a statistically significant difference in the mean perceived risk score between 55+ and 18-25 age groups (p=0.009), 46-55 and 18-25 (p=0.018) however there was no statistically significant difference in the mean perceived risk score . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint A Chi square test as shown in Table 5 revealed that statements like "Avoided travel to novel coronavirus high risk areas" (p=0.017), "Avoided eating outside of the home" (p=0.001), "Wore a face mask" (p=0.01) and "Ate a balanced diet" were statistically significant across gender not withstanding there were no relationship between gender and statements like, "washed hands with soap and water", "Avoided touching the eyes, nose, and mouth with unwashed hands", "Covered your cough or sneeze with a tissue, then throw the tissue in the trash", "Avoided close contact with sick people", "Took a supplement" and "Disinfected surfaces". CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint The latest threat to global health is the ongoing pandemic that was recently given the name Coronavirus Disease 2019 (Covid-19) . Covid-19 was recognized in December 2019. 1 In general, a large proportion of the participants were aware of the novel coronavirus but only a low proportion and had a good general knowledge about the disease, its methods of spread, and prevention. This is in agreement with the findings in studies by. 14, 15, 28 nonetheless a multinational study in Nigeria and Egypt revealed that large proportion of the participants had a satisfactory knowledge about the disease. 29 similarly, in another study conducted among the Iranian population, a large proportion of the study population (56.5%) had sufficient knowledge of COVID-19 transmission and symptoms. 28 when compared with this study. Traditional media platforms; namely: newspapers, television and radio, represented the most important sources of information contrary to the study by. 14 in which social media platforms, and the internet represented the most important sources of information, at the expense of more traditional media platforms. Indeed, research shows that public engagement with spurious information is greater than with legitimate news from mainstream sources, making social media a powerful channel for propaganda. 16 Fake news on social media about potential drugs, including chloroquine has led to the shortage of this medicine because of the high demand making patients who actually need them to be out of the medicine and that has made health officials to issue a warning on the use of this medicine following the death of three persons from chloroquine poisoning. 11 From our study, level of education influences the knowledge of COVID-19 in such a way those with higher degrees tend to have a better knowledge of the disease when compared to those with lower qualifications likewise those with higher monthly income have a better knowledge of the disease when compared those with lower monthly income. This is consistent with. 14, 17, 22, 29 This . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . may be as result of lack of access to credible and timely information about the virus. Being a healthcare worker was significantly associated with a poor knowledge of the disease. This is not consistent with a cross-sectional, web-based study conducted among Health care workers, where it was reported that healthcare workers had good knowledge of 20, 18 in another study. 29 it was reported that being a healthcare worker or having a background medical knowledge was associated with a good knowledge about the disease. The knowledge of healthcare workers cannot be over emphasized in pandemic like COVID-19 knowing fully well that scientists are still studying the novel coronavirus. When we asked our participants about their risk perceptions regarding infection with the virus, most participants believed that their health will not be negatively affected even if they contract the virus but they were concerned that the virus may continue to spread in the country. However, a large proportion of our participants believed that they can protect themselves against the virus. The participants also perceived that the novel coronavirus is more infectious than Ebola virus and nevertheless the fear of getting infected with the virus when seeking medical care in the hospital was low likewise the participants did not perceived that receiving letters or package abroad can pose a risk of infecting them, which is in agreement with findings from a study in the U.S and U.K that receiving a package from overseas did not pose a greater risk of infection with the virus. 10 This study also determined the association between the socio-demographic variables with the mean risk perception rank, in which there was a significant difference across gender with the females having a higher risk perception than the males. However, the male gender was found to have a high-risk perception towards the virus according to. 27 The younger adults have the highest risk . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint perception towards the virus as well. The perceived risk score of working as a healthcare worker also differ significantly, this is similar to the findings of. 21 in which healthcare providers have a higher mean perception rank than the general population because of their close contact with suspected/confirmed COVID-19 cases. Avoiding travel to high risk areas was significantly different across gender in which females were much less likely to travel to areas with high cases likewise avoiding eating out significantly contrasted with gender in which the female gender was less likely to eat out than their male counterpart. Wearing of face mask and eating balanced diet also significantly differ across gender in which males were more likely to wear face masks but females are more likely to eat balanced diet. Studies by. 12, 24 revealed that diet and nutrition invariably influence the immune system competence to fight infections and determine the risk and severity of infections. There are bidirectional relationships among diet, nutrition, infection, and immunity. Improving the diet quality in susceptible individuals for COVID-19 might alleviate their risk of severe infection. Notwithstanding, gender did not contrast with washing of hands with soap and water, avoiding touching of eyes, nose and mouth, respiratory hygiene, avoiding close contact with sick people, taking a supplement and disinfecting surfaces. Nigeria Centre for Disease Control (NCDC), the Nigerian public health institute offers infection prevention and control measures to healthcare workers as well as the general public. Online courses were made available to the general public but targeted at health care workers, to reduce the risk of transmission of COVID-19 and other infectious diseases in Nigeria. 24 Lastly, more than half of the participants selected a health care-seeking option that could lead to reduction in transmission of SARS-CoV-2. This is consistent with a study by. 10 in the U.S and the U.K in which just one-fourth of the participants chose health care seeking responses that could . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted August 25, 2020. . https://doi.org/10.1101/2020.08.23.20180141 doi: medRxiv preprint lead to increase in the transmission of the novel coronavirus. Thus, clear messaging on the recommended care-seeking action by the NCDC has really helped in informing the general public about the common symptoms of COVID-19 and how to seek medical care. The distribution of the survey through the internet allowed only those who can read and have internet access to participate and likewise the distribution of responses by participant's regions may differ from the general population owing to the fact that samples from South-South and the South-East were small. Another limitation could be that our data was skewed to the young adults also lack of inclusion of those with chronic illness in this study is also a limitation as novel coronavirus tends to be more deleterious on those with chronic diseases. In general, our participants had a good knowledge of COVID-19 with a low risk perception among non-healthcare providers but a high-risk perception of getting infected with the novel coronavirus was observed among healthcare providers. This knowledge is mainly acquired through the traditional media platforms. However, knowledge was lower among less educated and lower income groups. Intervention may require more efforts or using different methods to communicate with these groups. Although the government has taken major steps to reduce the spread of the disease, more effort is needed to support the most affected groups from the economic impact of the disease. . World Health Organization. Pneumonia of unknown cause -China: disease outbreak news. Geneva Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients The Health Belief Model: A Decade Later How to fight an infodemic. The Lancet. 2020 2020/02/29 What Is an Endemic Virus? WHO Warns COVID-19 'May Never Go Away An interactive web-based dashboard to track COVID-19 in real time World Health Organization. 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