key: cord-0985305-4w2sbqw6
authors: Tesfaw, Lijalem Melie; Kassie, Aragaw Bizualem; Tazebew, Belaynesh
title: Evaluating the Perceptions and Practices towards Coronavirus and associated factors in Metropolitan cities of Amhara region, Ethiopia
date: 2021-11-02
journal: Sci Afr
DOI: 10.1016/j.sciaf.2021.e01027
sha: a519dbc87fc26cf75dc30e3f97e06013a5aca316
doc_id: 985305
cord_uid: 4w2sbqw6

Confirmed cases of coronavirus in Africa, particularly in Ethiopia, are increasing rapidly following improved testing. This study is aimed at assessing the perceptions and practices towards coronavirus among the metropolitan city population of Amhara region, Ethiopia, and examining the associated factors affecting public perceptions and practices regarding coronavirus among the population of metropolitan cities. A total of 1288 randomly selected participants completed a questionnaire designed to assess perceptions and practices towards coronavirus and associated factors. The statistical analysis involved fitting a binary logistic regression model and a chi-square test. Of 1288 study participants, 788 (61.2%) and 500 (38.8%) were male and female, respectively. Their average age and monthly income were 29.2 years and 2484 birr, respectively. Preventive measures followed by the participants involved washing hands with soap and water rubbing for at least 20 seconds (55.4%) and visiting a doctor when corona symptoms show up (49.5%). Permanent rural residents had lower odds of good perception and practices regarding coronavirus (aOR=0.505; 95% CI=0.15, 0.82) as compared to permanent urban resident participants. Due to misguided perceptions and practices, the prevalence of coronavirus in metropolitan city communities of Amhara region is high. The city of residence, marital status, educational level, permanent residence, and information sources were significantly associated with people's perceptions and practices towards the prevention of coronavirus. Perceptions and practices towards coronavirus had a significant positive correlation in terms of preventive measures against coronavirus. Therefore, the authors would like to recommend if substantive effort from the government and different stakeholders regarding to raising the perception and practices of communities in the cities towards the pandemic and reduce the collateral damage especially the lower income communities who cannot afford basic needs.

Corona is a highly contagious viral respiratory disease caused by severe acute respiratory syndrome coronavirus-2 (Wong et al., 2020) . The virus has spread quickly, and confirmed cases have been reported in all countries across the world. As of 20 November 2020, more than 55.94 million confirmed cases are reported, resulting in more than 1.34 deaths worldwide (Wong et al., 2020) . While Africa looks ahead to coronavirus trajectories for taking possible precautions, its special vulnerability is preventing its response (United Nations Economic Commission for Africa, 2020). Confirmed cases of coronavirus in Africa and in particular Ethiopia are increasing rapidly following improved testing. Thus far, Ethiopia ranks the eighth African country next to Morocco for having the highest coronavirus confirmed cases. In Africa, South Africa, Egypt, Ghana, Algeria, Kenya, and Cameroon respectively rank first to sixth. According to reports of the Ethiopian Ministry of Health and Public Health Institute, 111,860 cases of coronavirus are recorded to date in Ethiopia of which 1800 are reported to have died of the virus. As there were no vaccines or cures for the coronavirus, preventive and infection control procedures are of great importance to minimize the spread of the virus (COVID-19, 2020). As a result, the Ethiopian government implemented social distancing, banned group gatherings, and instructed the closure of public facilities. Governmental and non-governmental institutions such as schools are closed; the number of workers is reduced to reduce the spread of the disease. The government engaged in raising public perception and practices of prevention through advertisement and social media (Wong et al., 2020) . In fact, closing schools and others governmental and non-governmental institutions where condensed peoples are located were immediate solution while aggravating the pandemic. However, this couldn't be a sustainable solution as the damage due to prevention practice may be higher (Tesfaw et al., 2021) .

Communities in metropolitan cities of Amhara region are under low income economic status.

As a result, instead of closing schools and others institutions it is better to continue the regular activities by keeping the prevention methods suggested by Ministry of Health of Ethiopia as well as WHO such as social distance, washing hand, wearing face mask, etc.

Thus far, the Ethiopian government, ministry of health and other governmental and non-governmental stakeholders highly striving to protect the communities from coronavirus by developing awareness and prevention practices towards coronavirus (Tesfaw et al., 2021) .

However, the incidence of corona virus and the death due to corona virus in Ethiopia are still increasing.

The efficiency of these preventive measures is largely affected by the perception and practices of the public towards corona. "Perception" involves knowledge and attitude of individuals towards coronavirus. "Knowledge" refers to the community's or people's understanding about relevant biomedical concepts. "Attitude" refers to thoughts, feelings and actions about a concept that predispose people to act in a preferential manner. "Practice" refers to the extent to which preventive measures have been implemented among the public (UlHaq, 2012). Though, since the onset of the pandemic, there are researches have been done, little attention was given to evaluate perception and practices towards coronavirus based on a data collected from the communities in Northwest Ethiopia. Thus, this research findings helps to fill this gap and enable to be inputs for policymakers, government, researchers and any other interested stakeholders regarding to evaluate the trends of perception and practice towards coronavirus. This study is therefore aimed at assessing the perceptions and practices towards the coronavirus disease among the metropolitan population in the Amhara region, of Ethiopia, and exploring the associated factors affecting the people's perceptions and practices towards coronavirus.

The study adopted a cross-sectional study design involving participants recruited from the metropolitan cities of the Amhara region. The duration of data collection was six months, August to December 2020. A total of 1288 participants who were randomly selected from six metropolitan cities of the region were included in the sample subjects of study. There were twelve sub cities involved in this study. The sample size was determined using a binary logistic regression with a power of 80% and a significance level of 5% (Wong et al., 2020) . The sample size was allocated using a proportional stratified sampling method. A metropolitan city with a higher number of sub-cities had a high number of participants that were recruited for the study.

Data for the study was collected using a questionnaire distributed for the participants in order to assess their perceptions and practices towards corona and associated factors. Training was given for the data collectors on methods of data collection. The investigators was checked the completeness and consistency. The data collection process was closely monitored by the principal investigator. After data collection, the data was edited and cleaned to ensure accuracy, consistency and completeness of data.

The questionnaire developed in a prior research was adopted and the questionnaire elicited socio-economic, cultural, biological, and demographic determinants that are associated with the perceptions and practices of populations towards coronavirus (Chan et al., 2015; Wong et al., 2020) . The draft of the questionnaire was first prepared in English and translated into Amharic following standard translation procedures to ensure semantic and content equivalence. To reduce risk of the virus's transmission, wearing mask, social distance, confidentiality and using hand sanitizer were strictly needed during administering the questionnaire. Convenience and stratified sampling approaches were combined in recruiting the participants of the study. The data collection method was self-administered for participants who enable to write and read.

While for illiterate respondents the interviewer interviewed the participants and filled the questionnaire.

Participants' having no experience in medical field in the metropolitan city and being 18 years old or older were the eligibility criteria for participation in the survey.

The questionnaire consists of three sections. The first section describes demographic characteristics such as sex, marital status, residence area, etc. of the participants. The second section describes the perceptions of the participants towards corona. This section contains questions that help to assess the knowledge and attitude of the participants towards coronavirus.

Knowledge about coronavirus was assessed using nine multiple choice questions (items) to determine the participants' knowledge of the symptoms and signs, transmission paths, and preventive measures against coronavirus. The values were recoded as "1" for each correct answer and as "0" for each of the incorrect alternatives. Attitudes towards coronavirus were evaluated using eleven items, and which each item was rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The attitude of the participants was computed using the mean score of each subscale. Reliability test was made using Cronbach's alpha for the entire scale which equals to 0.79, indicating that the items used to measure the attitudes of the participants were consistent and reliable. Finally, summing up the knowledge and attitude score on the perception of each participant was computed. Hence, the possible perception score ranged from 0 to 68, with a higher score indicating a better perception of the participants.

The participants' practices of preventive measures against coronavirus were assessed using eight items consisting of personal hygiene, wearing face mask, maintaining social distancing, etc.

Each item was rated on a 3-point Likert scale ranging from 1 (never) to 3 (always). Cronbach's alpha of practices of the preventive measures against coronavirus of the Likert scale items was 0.82. The possible practice score of the participants ranged from 0 to 24. A higher score indicated a higher level of implementation of the preventive measures. This indicates that the overall possible perception and practices score of participants ranged from 0 to 92.

The outcome variable of the study, "perception and practices status", was computed from the perception and practices score. The perception and practices status was categorized into two as " good " and "not good" for the perception and practices scores that are greater or equal to 46 and less than 46, respectively. Forty-six is the half of the perception and practices score. In addition, eleven independent variables that showed the participants' characteristics were considered (see Table 1 ).

To assess the effect of independent variables on the outcome variable, i.e., "perception and practices status" towards coronavirus, the logistic regression model was employed. The logistic regression is used to detect the association of the categorical outcome variable and a set of factors (Hosmer, 2013) . When the categorical values of the outcome variable were dichotomous (i.e, success or failure), the binary logistic regression is used. Thus, as perception and practices status measured using dichotomous values of: "not good" (score of < 46), and "good" (score of ≤ 46), the analysis was carried out using the binary logistic regression model. For any binary outcome variable Y (Good=1, and Not good=0) and X = {x1,x2,...,xp} factors. The probability that the perception and practices of the "i th " individual belongs to "Good=1" of the outcome variable given all possible factors X is given by P(Yi = 1|X). Thus, the binary logistic regression model is given by (Hosmer, 2013) :

where α is the intercept, X is the matrix of all possible factors and β its corresponding effect.

Data entry and organization were done using SPSS. The data was then exported into SAS and all statistical analysis such as fitting the binary logistic regression and estimating the adjusted odds ratio (aOR) with 95% confidence intervals (95% CI) was computed using SAS version 9.4 and interpreted accordingly.

Ethical approval was obtained from the Research and Community Services Committee of the 

The independent and outcome variables with the frequency of the participants within the corresponding categories are presented in Table 1 . Of the 1288 participants involved in the study, 788 (61.2%) of them were males. The average age was 29.2 years, while the average monthly income of the participants was 2484 birr. 77.5% of the participants were followers of Orthodox Christianity and 12.2% permanently lived in rural areas. The highest number of the participants were from Bahir Dar city (18.6%) and Gondar city Table   1 ).

The correct response rates of the participants' perception (knowledge and attitude) and

practices towards coronavirus were depicted in Table SM1 and Table SM2 , respectively. The participants' perception of coronavirus was the combination of participant's knowledge and attitude towards coronavirus (see Table SM1 ). There was a significant positive correlation (0.64) between the participants' perception and practices towards coronavirus, which indicated that higher perception score of the participants corresponds with higher practices of preventive measures against coronavirus and vice versa (see Table 2 ). The bivariate analysis depicts the association between independent variables with perception and practices status ( Table 3 ). The city of residence, marital status, education level, permanent residence, and sources of information were significantly associated (p-value < 0.05) with perception and practices status. The male participants (37.9%) had better perceptions and practices towards corona as compared to female participants (62.1%). Compared to those participants whose sources of information are friends/family/neighbors and hospital/health experts, those participants whose information sources about corona were the media (TV, Radio, etc.) had better perception and practice about corona. Participants who were single marital status (51.1%) compared to their corresponding counterparts. Participants with education level are college and above (45.2%), and whose permanent residents are urban (91.8%) have better perception and practices towards corona. Table 4 indicates that compared to communities in Woldya metropolitan city, communities in Bahir Dar, Gondar, Dessie, Debre Markos and Debre Tabor metropolitan cities were more likely to have good perception and practices towards coronavirus. Compared to the unemployed participants, the employed participants had higher odds of having good perception and practice (aOR=1.699; 95% CI=1.250-3.34). The employed participants were less likely to have good perception and practices towards coronavirus owning to their giving more attention to their work rather than to the spread of corona. In this study education level of the respondents haven't significant effect on perception and practice of the communities towards coronavirus.

However, employment status have its own significant effect. Unemployed participants were more likely of having good perception and practices. The authors suggest that, this may be because of that the participants become unemployed to prevent coronavirus. Commonly educated participants became unemployed because of coronavirus and to reduce its transmission. Compared to permanent urban resident participants, permanent rural resident participants had lower odds of good perception and practice towards coronavirus (aOR=0.505; 95% CI=0.15, 0.82). For a unit increase of income (in birr), the estimated odds of the participants for having good perception and practices increased by 20% (aOR=1.20; 95% CI=1.01-1.99). This indicates that the participants who have higher income were more likely to have better perception and practices regarding coronavirus. In addition to aOR, the crude odds ratio (COR)

for each covariates was also depicted in Table 4 . Figure 1 depicts the distribution of average score for perception and practices. Compared to participants from other metropolitan cities, those from Bahir Dar city had better average score for perception and practices. Participants from Woldya city had the worst score for perception and practices towards coronavirus. Overall, the participants in Amhara metropolitan cities had inadequate perception and practices which indicates that there still exists a gap in perception and practices, which needs to be significantly improved in order to manage and control the spread of the pandemic. About one out ten participants (10%) do not know how coronavirus is transmitted while more than half of the participants (58.6%) don't realize that coronavirus infects individuals of older age groups rather than any age group. The authors recommended the participants to have concrete awareness by reducing social desirable bias such as cultures. Besides, the way the participants who are living at metropolitan cities of Amhara region celebrating religious and non-religious holidays exposed to easily transmit communicable diseases like coronavirus.

The governments and others non-governmental and private stakeholders needs to work on communities to scale up the awareness and practices towards coronavirus.

In the metropolitan cities of Amhara, the prevalence of communities with inadequate perception and practices towards coronavirus was high. City of residence, marital status, educational level, permanent residence, and source of information were significantly associated with perception and practices of preventive measures against coronavirus. Perceptions and practices towards coronavirus have a significant positive correlation which indicates that more positive perception would help to practice more preventive measures against coronavirus. So many of the people in the studied communities carry on involving in social interactions such as weddings, funeral ceremonies, and religious and nonreligious holidays which could aggravate the spreads of the disease. Therefore, the authors would like to recommend if substantive effort from the government and different stakeholders regarding to raising the perception and practices of the city communities towards the pandemic and reduce the collateral damage especially the lower income communities who cannot afford basic needs.

Data Availability: The data used to support the findings of this study are available from the corresponding author upon request.

Community Service Committee of Bahir Dar University, Ethiopia. To keep personal information of participants in the study confidential, an identification number was assigned instead of their names. All the participants provided informed consent and assured that their participation was voluntary to participate in the study before completing the questionnaire.

Funding: This research was funded by Bahir Dar University.

Attitudes and Practices Towards COVID-19 Amongst Ethnic Minorities

United Nations Economic Commission for Africa, 2020. COVID-19 in Africa: protecting lives and economies

A cross sectional assessment of knowledge, attitude and practice towards Hepatitis B among healthy population of Quetta

Knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease (COVID-19)

Knowledge, attitudes, and practices of Hong Kong population towards human A/H7N9 influenza pandemic preparedness

Applied logistic regression

Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey

Knowledge, Attitude, Practice, and Associated Factors Regarding the Novel Coronavirus Disease 2019 (COVID-19) Pandemic. Infection and drug resistance

Community-based assessment of knowledge, attitude, practices and risk factors regarding COVID-19 among Pakistanis residents during a recent outbreak: a cross-sectional survey

Knowledge, attitude and practice towards COVID-19 among chronic disease patients at Addis Zemen Hospital, Northwest Ethiopia. Infection and drug resistance

Knowledge, attitude, and practice regarding COVID-19 outbreak in Bangladesh: An online-based cross-sectional study

Coronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teaching Hospitals, Uganda. Frontiers in Public Health

Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia

Ethiopian Culture

Knowledge, attitudes, risk perceptions, and practices of adults toward COVID-19: a population and field-based study from Iran

Knowledge, attitude, and practice toward COVID-19 among healthcare professionals, ancillary support staff, family members, and patients in a tertiary care COVID-19 hospital

Knowledge, Attitude, and Practice of the Lebanese Community Toward COVID-19

Sexual violence and other complications of corona virus in Amhara Metropolitan Cities, Ethiopia. Risk management and healthcare policy

We would like to thank our data collectors, the supervisor, the study participants, City Administrative Offices in Amhara region, and Bahir Dar University academic and administrative workers for their cooperation and assistance during the data collection. The manuscript was edited for languages by Berhanu and Ayenew (PhD), department of English Language and Literature, Bahir Dar University.

All authors collected and entered the data in excel. LMT specified the statistical analysis and wrote the manuscript. ABK and BT edited and revised the manuscript.Finally, all authors approved the manuscript.

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

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.