key: cord-0912030-p8epjlce authors: Ssebuufu, R.; Sikakulya, F.; Binezero, S. M.; Wasingya, L.; Nganza, S. K.; Ibrahim, B.; Kyamanywa, P. title: Awareness, knowledge, attitude and practice towards measures for prevention of the spread of COVID-19 in the Ugandans: A nationwide online cross-sectional Survey date: 2020-05-09 journal: nan DOI: 10.1101/2020.05.05.20092247 sha: 77895d7409a654a9910ac720e79de6f7888f610e doc_id: 912030 cord_uid: p8epjlce Background The world is facing the Coronavirus pandemic which is highly infectious. A number of measures have been put in place to prevent its spread among the population. However, for these preventive measures to be effective, the population requires an appropriate and sufficient knowledge. Thus, a survey was conducted with the aim of assessing the awareness, knowledge, attitude and practices towards measures for prevention of the spread of Covid-19 amongst Ugandans. Methods This was a cross-sectional study conducted during the lockdown in Uganda. An online questionnaire and a snowballing approach was used for participant recruitment of 18 years above literate Ugandans. Data collection was done from 6th to 15th April 2020 during which 1763 people participated. We analyzed all data using STATA 14.2, applying appropriate statistical tests. Results Out of 1763 participants, 97.6% were aware of the current pandemic. 83.9% of participants had a good knowledge score (21.8/27), 72.4% had a good attitude and 85.3% were practicing measures to prevent the spread of the Coronavirus disease. The ordered logistic regression showed that being a Health worker was significantly associated with a high knowledge (aOR:6 (3.32-10.93); a good attitude (aOR:2.5(1.68-3.8)]) and good practice (aOR:2.9 (1.95-4.2). On contrary, being a driver, business entrepreneur and a security personnel were found to have less rate in awareness, knowledge, attitude and practice. Conclusions Ugandans had a good overall awareness, knowledge, attitude and practice. However, there is still a gap of knowledge, attitude and practice among drivers, business entrepreneur and security personnel. There is a need to mobilize the population in the country to have the same degree of awareness and knowledge which will have an impact on attitude and practice to prevent spread of COVID-19. On 31st December 2019, a respiratory syndrome identified to be caused by a beta-coronavirus was reported in Wuhan, China [1] . This was later officially named as an outbreak of a new coronavirus disease-2019 (COVID- 19) by World Health Organization(WHO) [2] , and as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by Coronavirus Study Group (CSG) of the Inter-national Committee on Taxonomy of Viruses, on 11 February 2020 [3] , [4] . Due to the rapid global spread of this disease , the COVID-19 was declared as a pandemic on 11th March 2020 [5] . SARS-CoV-2 presents clinically with fever, dry cough, fatigue, myalgia, and dyspnea [5] ; [6] . The COVID-19 virus is transmitted between people through droplets, fomites and close contact, with possible spread through the eyes, nose and mouth but it is not an airborne disease according to the current studies [7] . The disease is highly contagious with enormous potential for health, economic and societal impacts [6] . As of 28 th April 2020, a total of 2, 954,222 cases of COVID-19 had been confirmed worldwide (22,376 confirmed in Africa) with 202, 597deaths (899 deaths registered in Africa) giving a crude fatality ratio of 6.9% worldwide (4 % in Africa) [7] , [8] . This was a nationwide cross-sectional online survey conducted on the Ugandans using the snowball sampling technique. All literate Ugandans aged 18 years and above constituted the population of this survey. The population of Uganda stands at 44,269,594 which is 78.4% of the literate Ugandans [12] . In Uganda, around 20 million people have a mobile subscription, representing 44% of the general Ugandans among whom nearly half of all mobile subscribers also access mobile internet services [13] . By June 2018, there were nearly 10 million mobile internet connections in Uganda a penetration rate of 23% [13] . All literate Ugandans with a minimal computer literacy level assumed to be able to operate at least an email, WhatsApp, Tweeter or Facebook and also consented to participate were included in the survey. Those who had filled in the form but for some reason were unable to submit the questionnaire were automatically not reflected and therefore excluded in the data base for the survey. For a period of ten days from 6 th to 15 th April 2020, an online snowball sampling technique was used with a semi-structured questionnaire which was developed using Google forms (https://docs.google.com/forms/d/18Ded-NFe65B6HnTFCwe4XzxBA-o3VfcJYogRjgcMsAA/edit ), with a consent form appended to it. The link of the questionnaire was sent through emails, WhatsApp and other social media to the contacts of research assistants. The participants were encouraged to roll out the survey to as many people as possible. Thus, the link was forwarded to other people apart from the first point of contact. On receiving and clicking to the link the participants were auto directed to the information District of health if having signs or symptoms of covid-19" was interpreted as Agree (Yes) and Disagree ( No/Going to hospital). Practice towards the measures put in place to mitigate spread of covid-19 which involved "measures observed for Self-Prevention" was scored as bad practice for 0-4points; fair practice for 4-6 points and good practice for the total of 7 points. The raw data was cleaned and entered into Microsoft excel and exported into STATA 14.2 for processing. Statistical analysis was done using STATA 14.2, where by categorical variables were summarized using frequency tables and graphs while continuous variables were summarized using means and standard deviation (SD). We did bi-variate analysis between the knowledge score, attitude, practice and Awareness/Affective groups and social demographic characteristics using the Chi-square. For bi-variate analysis between the knowledge score and social demographic characteristics using the T-TTEST and ANOVA for variables with two and more than two groups respectively. Finally, multiple analysis was also done using ordered logistic and logistic regressions for ordered score groups and bivariate variables respectively reporting adjusted odds ratios. Ethical clearance for the survey was obtained from the Institutional Research Ethical Committee of Kampala International University in Uganda (UG-REC-023/201914). As participant logged in online, a statement regarding the consent to participate in the survey was on the top of the questionnaire. and it was assumed that all participants could only proceed after reading the consent and accepting to participate in the survey. The participation in this survey was voluntary. Participants were free to withdraw from the survey at any time by not submitting their form online and there was no any repercussion. The All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint participants' identity was concealed as the form does not require any identification. No name or mail was required from the participant. Therefore, the information obtained was a onymous and was stored anonymously and treated confidentially. Only the 5 members research team was allowed to access data and only the principal investigator accessed the entire dataset. There was no human risk associated with this survey, as we were not meeting participants in person and no names, contact information or biological samples were obtained from the participants. It our hope that the findings of this survey will be of benefit to Ugandans in exploring and understanding their awareness, knowledge and attitudes on prevention of COVID-19 and this enhanced risk communication to inform efforts on how to mitigate the spread of the disease. All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Figure 1 shows that most Ugandans (97.6%) had heard about the ongoing coronavirus pandemic. Although, 73.3% of participants considered the covid-19 to be curable, 26.7% of them thought otherwise. 97.0% of participants thought that covid-19 can lead to death and 10.9% of participants were worried about the ongoing pandemic. (Fig 1) All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint were associated with poor practice measures of prevention of the spread of covid-19 (Table 5 ). All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . As per now the world is facing the coronavirus pandemic which is highly infectious, measures have been put in place to prevent its spread among the population across the world. The population requires an appropriate and sufficient knowledge about these measures, their importance and how to apply them appropriately [8] ; [9] . When a human population is facing an outbreak, changes in behavior in response to the disease can alter the progression of the infectious agent. In particular, people aware of a disease in their proximity can take measures to reduce their susceptibility [15] . However, beyond a critical infection rate, spreading awareness can slow down the spread of the disease and lower the final incidence, but it cannot completely stop it from reaching epidemic proportions and taking over large parts of the population [6] . Only if the disease is easily recognized and information spreads rapidly, while at the same time there is a strong tendency toward protective behavior, awareness of a disease outbreak can bring the infection rate of a disease down significantly. If all of these factors work together, rapid drops in the transmissibility of a disease, as have been observed in the 2003 outbreak of SARS in Hong Kong [16] . All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint Our survey reported that most of Ugandans were aware of the ongoing coronavirus pandemic (97.6%). Despite that awareness, 73.3% of participants considered that the covid-19 is curable, though 26.7% of them rejected that notion (Figure 1) . 10 .9% of participants were worried about the ongoing pandemic with a high thought that covid-19 to lead to death (97.0%). These findings are different from a survey done in USA. The survey looked at covid-19 among adults with chronic conditions, in which all participants reported having heard about the coronavirus, although 24.6% of the participants of that survey were worried about the current pandemic [17] . Action is needed to increase awareness of Ugandans to reduce the observed gap in awareness and to ensure that all population are adequately made aware of the gravity of the COVID-19 pandemic. In India, it was found that despite the high level of awareness among adult population about coronavirus pandemic, there was an increase in worries and apprehensions among the public regarding acquiring of the COVID-19 infection which indicated a need of intensifying the awareness program among Indian population and address the mental health issues of people during this COVID-19 pandemic [18] . As of 28 th April 2020, a cumulative total of 22, 376 confirmed COVID-19 cases with 899 deaths (case fatality ratio: 4%) have been reported across the 45 affected countries in Africa continent including Uganda [8] . Ten days after the first case of Covid-19 being confirmed in Uganda, we conducted an nationwide online survey on awareness, knowledge , attitudes and practice towards measures for prevention of the spread of covid-19 among Ugandan population, we found that the overall participant had 80.7% on knowledge towards measures for prevention of the spread of Covid-19 in the Ugandans. This result is approximately similar to the knowledge rate (90%) found among Chinese residents during a quick online survey on covid-19 [6] and during the All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint 0 Ebola outbreaks in Sierra Leone in 2014 [19] and DRC in 2018 [11] . This result could be explained by the fact that the covid-19 found Ugandans already familiar with observing similar measures to prevent the spread of some other highly infectious diseases within the country such as Ebola and Marburg disease. The ordered logistic regression from our survey showed us that the level of knowledge was significantly associated with a certain degree of education level as per Health worker [aOR:6 ( 3 . was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint 1 outside but with an optimistic attitudes towards COVID-19 which could be attributed to the very strict prevention and control measures implemented by local governments such as banning public gatherings [ 6 ] . In Nigeria, a study on Ebola outbreak evaluating the KAP of Ebola virus infection among secondary school children, found an association between inadequate knowledge and carried a negative attitude towards the outbreak [20] . were found to be associated with poor practice All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint measures of prevention of the spread of covid-19. This result can be explained by the fact that participants within these professions had poor knowledge in ordered logistic regression analysis (Table 3) compare to the one expected having a certain level of education and being in Northern Uganda was associated with poor attitude (Table 4) . Our results were similar to the study done in China; having a good practice was related to being a health worker or student and from their findings the authors suggested that the health education intervention would be more effective in sensitizing the other categories of population about measures to observe prevention of the current coronavirus pandemic [6] . Overall participants about KAP, the profession of security gent, driver and business were having less rate of KAP as indicated above (Tables 3-5 ). This category of population needs an urgent sensitization across the country to avoid the spread of covid-19. Unfortunately, the government of Uganda has allowed the movement of these people (driver, business entrepreneur and security agents) within the country and across borders during the ongoing lockdown. If measures are not taken under consideration, Uganda could increase its number of confirmed cases by these categories of Ugandans. The survey was limited to participants who had smartphones, computers, tablets and with internet connectivity and had an understanding of English. Therefore, those with no smartphones and internet connectivity were unable to access the online form and participate in the survey. The survey captured the literate population of the country, so it could not be generalized to the whole population. The awareness, knowledge and attitudes in uneducated people might be different from the findings of this survey. Therefore, awareness, knowledge and attitudes towards COVID-19 of vulnerable populations deserve special research attention. In addition to the limited sample representativeness, the other limitation of this survey was the inadequate assessment of attitudes towards COVID-19, which should be developed via focus group discussion and in-depth interview and constructed All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint as multi-dimensional measures. But this was not possible due to the lockdown in the country during the survey period and as one of strategies observed by all population in the country was social distancing to avoid the spread of the COVID-19. In summary, we found that most of Ugandans are aware, knowledgeable and have good attitude and observing good practice towards measures to prevent the spread of COVID-19 within the country. Despite these findings, we found that there is a lack of knowledge, attitudes and practice among a certain group of population (driver and security agents). This group should be targeted for sensitization or else they become the source of the spread of the coronavirus disease within the country. There is a dire need of taking action of mobilizing all population around the country to have the same degree of awareness and knowledge which will have an impact on attitude and practice. The government of Uganda could use the health workers, teachers and students to help in mobilization of all population within the country about measures towards prevention of the spread of the coronavirus pandemic in the country. All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. All rights reserved. No reuse allowed without permission. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20092247 doi: medRxiv preprint Cluster of pneumonia cases caused by a novel Coronavirus Disease ( Covid-19 ) Outbreak : Rights , Roles and Responsibilities of Health Workers , Including Key Considerations for Occupational Safety Stockholm: ECDC; 2020. 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The COVID-19 resource centre is hosted on Elsevier Connect , the company ' s public news and information National survey of Ebola-related knowledge, attitudes and practices before the outbreak peak in Sierra Leone Authors thank Ugandans who participated in the survey and research assistants who cared of this survey during data collection. RS and FKS conceived and designed the survey, supervised the online data collection and critically reviewed the manuscript.SBM participated in conception of Google data form;LW and SKN participated in online data collection PK critically reviewed the manuscript.