key: cord-1035689-6pbf37w5 authors: Azene, Abebaw Gedef; Workie, Mekuanint Simeneh; Aragaw, Abiba Mihret title: Knowledge, attitude, and prevention practice towards Covid-19 in Ethiopia: systematic review and Meta-analysis date: 2021-05-06 journal: Curr Ther Res Clin Exp DOI: 10.1016/j.curtheres.2021.100633 sha: 482c3da92efa559655e9fc6db480caedb5e40576 doc_id: 1035689 cord_uid: 6pbf37w5 BACKGROUND: Coronavirus disease is a major global public health problem. The contagious disease caused by a newly discovered coronavirus, coronavirus disease 2019 (COVID-19), was declared a pandemic following the outbreak of cases of respiratory illness in 2019. While studies assessed COVID-19 knowledge, attitude, and practice in Ethiopia the findings were highly variable and inconsistent.1, 2, 3, 4 Therefore, this study assessed the pooled status of knowledge, attitude, and prevention practices regarding COVID -19 in Ethiopia. METHODS: International and national electronic databases, including PubMed/MEDLINE, EMBASE, CINAHL, Google Scholar, Science Direct, and Google, were systematically searched. All observational studies on COVID-19 knowledge, attitude, and prevention practices in Ethiopia were included. We assessed heterogeneity among the included studies using the Cochrane Q test statistics and I(2) test. Lastly, a random-effects meta-analysis model was fitted to estimate the pooled proportion of knowledge, attitude, and prevention practices toward COVID-19 in Ethiopia. RESULTS: Our search identified 206 studies, 13 of which were included in the final analysis. Adequate knowledge, good attitude, and good prevention practice towards COVID-19 in Ethiopia were observed in 70.25% (95% confidence interval [CI], 61.82, 78.02), 69.08% (95% CI: 55.42, 81.24), and 41.62% (95% CI: 27.77, 56.17) of total participants across studies, respectively. CONCLUSION: The results of this study revealed low proportions of adequate knowledge, attitudes, and preventive practices toward COVID-19 in Ethiopia. The lowest pooled proportion was observed in the Amhara region. These findings indicate the need to revise plans and policies to improve the knowledge, attitudes, and prevention practices of people towards COVID-19 in Ethiopia, especially in the Amhara region. Coronavirus disease 2019 (COVID-2019), a contagious disease caused by a newly discovered coronavirus, was declared a pandemic following the outbreak of cases of respiratory illness cases in Wuhan, China, in December 2019. Since that time, it has rapidly spread to other parts of China and worldwide to become a major global health concern [5, 6] . Most people with COVID-19 experience mild to moderate respiratory illness from which they recover without requiring special treatment; however, others may develop severe complications characterized by acute respiratory distress syndrome, septic shock, and other metabolic and hemostasis disorders [7] . Older people and those with underlying medical problems such as diabetes, chronic respiratory disorder, and cancer are more likely to develop serious illness [8] . According to the World Health Organization, as of December 13, 2020, there were 69,808,588 confirmed cases of COVID-19 and 1,588,858 deaths worldwide. The African continent reported 2,363,693 cases and 56,018 deaths; of these 115,000 people in Ethiopia were confirmed to have been infected with COVID-19. The disease affects all ages but its severity is higher among the elderly and people with underlying chronic diseases. Healthcare providers are on the frontline of the fight against the COVID-19 pandemic while most civil servants are staying at home. The general guidance has included regular handwashing, maintaining a secure distance from anyone who is coughing or sneezing, wearing a mask when physical distancing is not possible, avoiding touching the eyes, nose, or mouth, covering the nose and mouth along with an elbow or a tissue to cough or sneeze; and seeking medical attention for fever, cough, or difficulty breathing. However, thousands of health care providers worldwide have been contracted COVID-19 while delivering clinical services to patients with COVID-19; moreover, the risk is higher in developing countries with poor health care systems [9] . Several studies have assessed the knowledge, attitude, and practice regarding COVID-19 in Ethiopia [1] [2] [3] [4] . However, the findings of these studies are highly variable and inconsistent [2, 3] . To our knowledge, this systematic review and meta-analysis is the first to assess the knowledge, attitudes, and prevention practices regarding COVID-19 at a national level. This study aimed to assess the pooled status of these factors regarding COVID-19 in Ethiopia to provide evidence for policymakers and health professionals to improve knowledge, attitudes, prevention practices, and control strategies regarding COVID-19 and improve the study designs and participants in future studies. The articles reviewed in this meta-analysis were identified through electronic web-based database searches and reference-list reviews as described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) checklist guidelines [10] . However, this study was not registered. Two authors (AG and MS) performed a comprehensive search of electronic databases, including PubMed/MEDLINE, EMBASE, Google Scholar, and Science Direct. In addition, national databases such as the Ethiopian Medical Journal, Addis Ababa University Digital Library, and Haramya University Digital Library, were also searched. The authors used the following key terms in the database searches: "Knowledge," "attitude," "practice," "Covid-19," and "Novel coronavirus." These search terms were pre-defined to allow a comprehensive search strategy that included all fields within records and Medical Subject Headings (MeSH terms). This study also used the Boolean operator (within each axis, we combined keywords with the "OR" operator; we then linked the search strategies for the two axes with the "AND" operator) to search for publications on COVID-19 knowledge, attitude, and practice in Ethiopia. The searches were conducted on September 20 and November 20, 2020. After identifying potentially relevant studies using this search strategy, the studies were retrieved and managed using Endnote X8 software. The inclusion criteria were freely accessible full-text articles, written in English, and conducted in Ethiopia in 2020. Among studies published in peer-reviewed journals or found in the gray literature, all observational study designs (i.e., cross-sectional, casecontrol, and cohort), studies involving human beings, and studies reporting the knowledge, attitude, and practice of COVID-19 in the full article, were eligible for inclusion in this systematic review and meta-analysis. Studies without accessible full texts after using all the PRISMA-P search strategies and studies that did not quantitatively report specific proportions of good knowledge, attitude, and practice regarding COVID-19 were excluded. The primary outcome of this review was an estimate of the knowledge, attitudes, and practices of COVID-19 in Ethiopia, which was expressed as the proportions of participants with good knowledge, a good attitude, and good practices regarding COVID-19 [11] . Good knowledge: Knowledge of COVID-19 signs, symptoms, prevention, and control, with the sum of the score for each participant greater than the mean/median of the questionnaire. Good Attitude: Individual agreement or willingness to participate in combatting the COVID-19 epidemic and trust in the government and partners in winning the battle against COVID-19, with the sum of the score of each participant greater than the mean/median of the questionnaire. Good practice: Practices were assessed against those recommended for COVID-19 safety, infection prevention, and control guidelines, such as physical distancing, hand washing, and no handshaking, with the sum of the score of each participant greater than the mean or median of the questionnaire. The two authors (AG and MS) used two stages of screening. First, we screened the titles and abstracts based on the criteria set in the protocol. Second, we identified potentially relevant articles using titles and abstracts for further screening of the full articles. The relevance of each article was evaluated based on the topic, objectives, and methodology, as listed in the abstract. The abstracts were also assessed to ensure agreement with the inclusion criteria. When it was unclear whether an abstract was relevant, it was included for retrieval. At this stage, articles deemed irrelevant or outside of the scope of the study were excluded, and the full texts were downloaded for a detailed review. Data were extracted following the JBI data extraction format [12] , which included the first author; publication year; study design; the proportions of participants with good knowledge, attitudes, and practices regarding COVID-19; and sample size. Any disagreements between the two reviewers during data extraction were resolved by discussion and with the third author (AM). The risk of bias of the included studies was assessed using the 10-item rating scale developed by Hoy et al. for observational studies [13] . The sampling, data collection, reliability, validity of the study tools, case definitions, and study periods were assessed. We categorized each study as having low ("yes" answers to the domain questions) or high ("no" answers to the domain questions) risks of bias. Each study was assigned a score of 1 (Yes) or 0 (No) for each domain; these domain scores were then summed to provide an overall study quality score. Scores of 8-10 were considered to have a low risk of bias, those with a score of 6-7 a moderate risk, and those with scores of 0-5 a high risk of bias (Appendix 1). Two independent reviewers (AG and MS) critically appraised each paper. Disagreements between the reviewers were resolved through discussion. For the final risk of bias classification, discrepancies between the reviewers were resolved via discussion and consensus involving the third author. Information on the study characteristics (time frame, study location, study design, sample size, proportion of good knowledge, proportion of good attitude, and proportion of good practice) was extracted from each study using a Microsoft Excel spreadsheet template. These data were then transferred to R version 4 software to describe the pooled proportions of good knowledge, attitude, and prevention practices regarding COVID-19. Heterogeneity across studies was assessed using the inverse variance (I 2 ) and Cochran Q statistics, with 25%, 50%, and 75% indicating low, moderate, and severe heterogeneity, respectively [14] . I 2 values >75 indicated severe heterogeneity [15, 16] . Dersimonian and Liard's random-effects model was used for analysis owing to heterogeneity [17, 18] . Subgroup and sensitivity analyses were conducted using the study location, study design, and risk of bias [19] . A forest plot was used to visualize the findings. We applied funnel plot asymmetry and Egger's test to check for publication bias [20] . The database search and desk review yielded a total of 206 articles from the above-mentioned electronic sources. After reviewing the titles and abstracts, 46 articles were excluded due to duplication. One hundred forty-six articles were excluded for lack of relevance. Additionally, one article that did not report the outcome of interest (proportion of adequate knowledge, good attitude, and good prevention practice) was also excluded [21] . Finally, the final meta-analysis included 13 studies [1] [2] [3] [4] [22] [23] [24] [25] [26] [27] [28] [29] [30] (Figure 1 ). All 13 studies included in this review were published in 2020. Among these, only four were used community-based cross-sectional studies [3, 22, 26, 27 (Table 1 ) [2, 3] . We assessed the quality of each study included in this review based on the JBI Critical Appraisal Tool. Of the included studies, 10 (76.9%) had a low risk of bias, two (15.4%) had a medium risk of bias, and one (7.7%) had a high risk of bias. This meta-analysis included 12 studies in the estimation of the pooled proportion of participants with adequate knowledge of COVID-19 in Ethiopia. We observed significant heterogeneity in the fixed model (I 2 = 98.21%, p<0.001). Due to this heterogeneity, we applied the random- was significantly related to heterogeneity (Q=13.46, p =0.009); however, the heterogeneity was low (I 2 = 0.00%) ( Table 2 ). Egger's regression test of publication bias confirmed that no publication bias was related to the effect size (p=0.2785). The analysis of the attitudes of people toward COVID-19 included seven studies [ 78.54), respectively. In the subgroup analysis, only the region was significantly related to this heterogeneity. Even though this heterogeneity was significant, I 2 was less than 25%, indicating minor attitude variations toward COVID-19 between regions (Table 3) . The publication bias test (Egger's regression test) confirmed that no publication bias was related to the effect size (p =0.4793). We conducted a sensitivity analysis using the leave-one-out method to identify the possible source of heterogeneity in the estimation of the pooled proportions of attitudes toward COVID-19 in Ethiopia. We found that the pooled proportion did not depend on the outcome of a single study, and it was robust. After the stepwise removal of a single study, the pooled prevalence ranged from 64.98% (95% CI: 51.27, 77.53) to 74.13% (95% CI: 64.26. 82.89) ( Table 4) . We assessed the proportion of participants engaged in COVID-19 preventive practices based on six studies [1, 22, 23, [27] [28] [29] . The pooled proportion of good prevention practices was 41.62% (95% CI: 27.77, 56.17) (Figure 4) . The subgroup analysis revealed good prevention practices in 44.40% (95% CI: 25.29, 64.41) and 36.13% (95% CI: 16.55, 58.48) of participants in institutionbased and community based cross-sectional studies, respectively. The variation was not statistically significant because the between-group heterogeneity was not statistically significant (p = 0.585) ( Table 5) . Furthermore, the assessment of publication bias by Egger's regression test showed no publication bias (p = 0.8167). We conducted a sensitivity analysis using the leave-one-out method to identify the possible source of heterogeneity in the estimation of the pooled proportion of COVID-19 prevention practices in Ethiopia. The results showed that the pooled proportion did not depend on the outcome of a single study and that it was robust. After stepwise removal of single studies, the pooled proportions ranged from 36.59% (95% CI: 24.68, 49.40) to 45.03% (95% CI: 30.05, 60.48) ( Table 6 ). Coronavirus is a contagious pandemic disease and a major public health concern worldwide, including Ethiopia. Controlling the distribution of viruses is a current issue worldwide. Estimating the pooled proportion of adequate knowledge, attitudes, and practices towards COVID-19 in Ethiopia may contribute to informing policymakers to implement interventions. The main objective of this study was to estimate the pooled proportion of adequate knowledge, attitude, and prevention practices for covid-19 in Ethiopia. The findings of this study revealed that the pooled proportion of adequate knowledge of covid-19 was 70.25% (95% CI, 61.82. 78.02). This proportion is consistent with that reported by Bekele et al., in which 40-99.5% of participants had good knowledge of COVD-19 [31] and higher than the 56.6% (95%CI: 45%) reported by Bhagavathula et al. [32] . The knowledge of people regarding COVID-19 in the present study was low at the country level. The subgroup analysis indicated a higher knowledge in institution-based studies (73.91%) compared to community-based studies (62.60%). Moreover, knowledge of COVID-19 was highest in the Oromia region (83.07%) and lowest in the Amhara region (61.50%). In this study, the pooled proportion of participants with a good attitude regarding COVID-19 was 69.08% (95% CI: 55.42, 81.24), which was low for controlling viral transmission. This result is consistent with the findings reported by Bekele et al., in which 70-97.1% had a good attitude [31] , and higher than the 46% (95% CI: 15, 77) reported by Bhagavathula et al. [32] . The pooled proportion of positive attitudes regarding COVID-19 was low compared to that for knowledge in this study. The highest and lowest proportions of positive attitudes were observed in Addis Ababa (89.80%) and the Amhara (61.50%) region, respectively, in the subgroup analysis. Moreover, the overall proportion of participants engaged in COVID-19 prevention practices was 41.62% (95% CI: 27.77, 56.17). Prevention practice was low at the national level. Therefore, the distribution of the virus was related to personal hygiene and social distancing. The overall rate of COVID-19 prevention practices at the institution was higher (44.40, 95% CI: 25.29, 64.41) than those in community-based studies (36.13, 95% CI: 16.55, 58.48 ). This result indicated that institutional prevention practices were good relative to the communities in Ethiopia. This meta-analysis has several limitations. First, only articles published in English were considered to estimate the pooled proportions in Ethiopia. Moreover, most of the studies included in this analysis used institution-based cross-sectional study designs and most of the participants were health professionals; thus, the results might have been affected by other confounding variables. The results of this study revealed low proportions of adequate knowledge, attitudes, and preventive practices regarding COVID-19 in Ethiopia. The lowest pooled proportion was observed in the Amhara region. We recommend that the Ethiopian Institute of Health and Ministries of Health improve the awareness of health professionals towards COVID-19. Furthermore, these results indicate the need to improve planning and policies to increase adequate knowledge, attitudes, and prevention practices toward COVID-19 in Ethiopia, especially in the Amhara region. Not applicable. Table 5 : Subgroup analysis of studies included to assess the proportion of participants engaged in prevention practices regarding COVID-19 in Ethiopia. Factors determining the knowledge and prevention practice of healthcare workers towards COVID-19 in Amhara region, Ethiopia: a cross-sectional survey Knowledge, Attitudes, and Practices Towards COVID-19 Pandemic Among Quarantined Adults in Tigrai Region, Ethiopia. Infection and Drug Resistance Knowledge level and factors influencing prevention of COVID-19 pandemic among residents of Dessie and Kombolcha City administrations Knowledge and attitude towards COVID-19 and associated factors among health care providers in Northwest Ethiopia Geographical tracking and mapping of coronavirus disease COVID-19/severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic and associated events around the world: how 21st century GIS technologies are supporting the global fight against outbreaks and epidemics WHO Director-General's opening remarks at the media briefing on COVID-19-11 Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19) Coronavirus Disease-2019: Knowledge, Attitude, and Practices of Health Care Workers at Makerere University Teaching Hospitals Reporting quality of systematic reviews and meta-analyses of otorhinolaryngologic articles based on the PRISMA statement Incubation periods of acute respiratory viral infections: a systematic review. The Lancet infectious diseases The Joanna Briggs Institute Critical Appraisal tools for use in JBI systematic reviews. Checklist for Randomized Controlled Trials Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement Meta-analysis Measuring inconsistency in meta-analyses Meta-analyses in mental health research. A practical guide Meta-analysis of brain size in bipolar disorder meta: An R package for meta-analysis. R news Regression methods to detect publication and other bias in metaanalysis. Publication bias in meta-analysis: Prevention, assessment and adjustments Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis JUGAL HOSPITAL, HARARI REGIONAL STATE Knowledge, Attitude, and Practice of High-Risk Age Groups to Coronavirus Disease-19 Prevention and Control in Korem District, Tigray, Ethiopia: Cross-Sectional Study. Infection and Drug Resistance Among Chronic Disease Patients at Addis Zemen Hospital, Northwest Ethiopia Knowledge and Precautionary Behavioral Practice Toward COVID-19 Among Health Professionals Working in Public University Hospitals in Ethiopia: A Web-Based Survey Knowledge, perceptions and preventive practices towards COVID-19 early in the outbreak among Jimma university medical center visitors, Southwest Ethiopia Community's Knowledge of COVID-19 and Its Associated Factors in Mizan-Aman Town, Southwest Ethiopia, 2020 Psychological Impacts of COVID-19 among College Students in Dessie Town COVID-19-Related Knowledge, Attitude and Practice Among Hospital and Community Pharmacists in Addis Ababa KNOWLEDGE, ATTITUDES, AND PRACTICES TOWARDS CORONAVIRUS DISEASE -19 AMONG HEALTH PROFESSIONALS IN ADDIS ABABA Patterns and associated factors of COVID-19 knowledge, attitude, and practice among general population and health care workers: A systematic review Knowledge, Attitude, Perceptions and Practice towards COVID-19: A systematic review and Meta-analysis. medRxiv The authors acknowledged the Elsevier Language Editing Services team for proving manuscript preparation assistance. Next we would like to acknowledge all authors of the studies included in this review. Not applicable. All data are available from the corresponding author upon reasonable request. The authors declare that they have no competing interests. No funding was obtained for this study All authors (AG, MS, and AM) were involved in the design stage and problem specification, selection of articles, and data extraction. All authors participated in the statistical analyses and manuscript writing. All authors read and approved the final draft of the manuscript.