Inadequate level of knowledge, mixed outlook and poor adherence to COVID-19 prevention guideline among Ethiopians

COVID-19 has a potential to cause chaos in Ethiopia due to the country’s already daunting economic and social challenges. Living and working conditions are highly conducive for transmission, as people live in crowded inter-generational households that often lack running water and other basic sanitary facilities. Thus, the aim of this study was to investigate the knowledge, attitudes and practices (KAP) of Ethiopians toward COVID-19 following the introduction of state of emergency by the Ethiopian government to curb the spread of the disease. A cross-sectional study design was conducted in nine reginal states and two chartered cities. Data for demographic, Knowledge, attitude and practice toward COVID-19 were collected through telephone interview from 1570 participants. Descriptive and bivariate analyses using chi-square test, t-test or analysis of variance were performed as appropriate. Binary and multiple logistic regression analysis were used to measure the relationship between the categorical dependent variables and one or more socio-demographic independent variables with two-tailed at α=0.05 significance level and 95% of confidence interval. The level of good knowledge, favourable attitude and good practice among the respondents were 42%, 53.8% and 24.3% respectively. Being rural resident, older than 50 years, having at least primary education, being resident of Amhara and Oromia regions were independent predictors of knowledge level. While being rural resident, married, employed, having at least basic education, being residents of Afar, Amhara, Gambela, Oromia and Somali regions were found to be the best predictors of the attitude, being rural resident, government employee, having at least basic education, and living outside of the capital were the independent predictors of practice level of the respondents. The finding revealed that Ethiopians have inadequate level of knowledge and are generally have a mixed outlook on overcoming the pandemic with poor adherence to COVID-19 prevention practice. reinforcing preventive measures and intensifying sensitization campaigns to fill the knowledge gap and persuading people to follow the preventive measures set by the government with concurrent evaluation of the impacts of these measures on knowledge and practice is highly recommended to mitigate the disease.


Introduction
Organization declared the outbreak of COVID-19 as a pandemic on the 11 th of March 2020, 37 after it has spread to 113 countries worldwide (2). 38 According to current evidence, the COVID-19 virus is primarily transmitted rapidly between 39 people through respiratory droplets and contact routes (3). Airborne transmission has been 40 suggested by some studies (4,5). Recent experimental studies have examined the stability of 41 SARS-CoV-2, showing that the virus remains infectious in aerosols for hours (5) and on 42 surfaces up to days (5, 6). The mean incubation period of COVID-19 is about 3-9 days with a 43 range between 0-24 days (3, 7). However, the mean time between successive cases in a chain 44 of transmission is about 3-8 days suggesting that one becomes contagious before symptoms 45 present about 2.5 days earlier from the onset of symptoms (8). Studies estimated that about 46 44% of transmission of COVID-19 occur before the onset of symptoms (9).

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The first case of COVID-19 was confirmed in Ethiopia on 13 th of March 2020 (10). The state 48 of emergency was declared by the government on 8 th of April 2020 to control the pandemic. 49 The state of emergency includes closing schools, banning public gatherings and requiring 50 employees to work from home (10). The introduction of the state of emergency has been 51 welcomed by most citizens and institutions but was not without critiques from some political 52 opposition parties. While the federal and regional governments announced measures such as 53 suspending large gatherings and inter-city public transport, authorities have not introduced a 54 comprehensive lockdown to try to contain the virus due to some real challenges. Firstly, most 55 citizens live day-to-day and they may see a complete lockdown as counterproductive and unfair 56 to those on the bottom rungs of society. Secondly, complete lockdown could worsen the life 57 of the vulnerable segments of society such as street children, internally displaced persons and 58 refugees (11). 59 COVID-19 has the potential to cause chaos in Ethiopia due to the country's already daunting 60 economic and social challenges. On one hand, the public health risks presented by COVID-19 61 are vast. Living and working conditions are highly conducive for transmission, as people live 62 in crowded inter-generational households that often lack running water and other basic sanitary 63 facilities. Allowing economic activity to continue unchecked could lead to huge infections 64 within months, with serious cases quickly overwhelming the already weak health system (12). 65 Public health intervention measures are rapidly changing around the world to cope up with the 66 rapid transmission of the disease and to minimize the risk for infection and speared of the 67 disease. However, miscommunication regarding the threat of COVID-19 may lead to public 68 confusion and inaction (13). Being older and having underlining health conditions, reduced 69 ability to access and understand health information, inability to make well-informed decisions 70 and failure to take optimal health-promoting are among the greatest risk factors for sever 71 infection and death due to 14). This situation is especially true when the health 72 information itself is not timely, trusted, consistent, or actionable particularly in sub-Saharan 73 African countries where health inequalities are worsened by lack of political commitment and 74 good governance (15). As a result, a wide range of health disparities may exist by age,  On the other hand, the success of national preventive strategy of a pandemic is largely depends 81 on the adherence of the public to the preventive measures established by the government. The 82 public adherence is likely to be influenced by trust in government (18)  The study population included all peoples living in the nine regional states and two chartered 99 cities who are 18 years old and above during the study period. This study was conducted after the government declared a state of emergency in the country to 102 help curb the spread of COVID-19 following 55 cases and 2 fatalities on April 8, 2020. As face 103 to face data collection was impossible, we opted to use telephone interview for enrolling 104 potential participants. We ruled out the online enrolling methods for two reasons: Firstly, only 105 about 17% of the population has access to the internet penetration but more than 45% of the 106 population has access to either mobile network or fixed landline telephones in 2020 (21).

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Secondly, adult literacy is only 52% and social media penetration in Ethiopia is 5.5% by 108 January 2020 (22). As a result, telephone interview was found to be the best alternative among 109 the existing methods of data collection where face-to-face data collection is not possible.  111 We adapted the survey tools from previous KAP studies towards 13,19

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A correct response was assigned 1 point, while an incorrect or I do not know response to the 122 question was assigned 0 points. Each respondent achieves between 0 and 10 score points.

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Twenty data collectors were recruited and trained online. The data collectors were recruited 140 from each region. All data collectors had previous experience of KAP data collection by phone.

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In most cases, phone numbers were randomly selected from local phone book. Following the 142 verbal consent, each respondent was assured that the voice is not recorded, and any personal 143 data is not required to participate in the study.   Good level of knowledge: Respondents who scored above the mean score of the total 150 respondents were considered as having good level of COVID-19 knowledge and those who 151 scored below the mean as having poor level of COVID-19 Knowledge.

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Favourable attitude: A response of agree or strongly agree to attitude questions were 153 considered as favourable attitude for logistic regression analysis. However, for two questions: 154 "I believe that traditional herbs and faith such as holy water can cure COVID-19; and I do not 155 think I will get sick from COVID-19" a response of strongly disagree or disagree were 156 considered as favourable attitude.

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The association between the socio-demographic variables and COVID-19 attitude was assessed 230 by chi-square test ( Table 5). The overall favourable attitude response rate was 43.8%.

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Interestingly rural residents had more favourable attitude ( (Table 7).  and Dire Dawa compared to respondents from other regions (Table 9). regions were significantly lower than the odds of Addis Ababa (Finfinnee) respondents (Table   292 10). CoV-2) and its being pandemic poses a significant threat to public health (9). Given that the 298 disease is pandemic threat with no vaccine or proven treatment drug, preventive measures are 299 the most essential methods available to reduce the infection rates and control the spread of the 300 disease. This implies that public adherence to preventive and control measures are essential to 301 curb the disease. The extent of public adherence to preventive and control measures is affected 302 by their knowledge, attitude and practice (KAP). Therefore, this study was envisioned to assess 303 the KAP of the Ethiopian population for the control of COVID-19.

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The finding has shown that the participants level of COVID-19 knowledge is unsatisfactory.

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Only 42% of the respondents achieved a satisfactory knowledge score and the result is lower 306 than most previous reports from various countries (2,13,19,(23)(24)(25) particularly on social media (32). Hence, they largely depend on the information from the local 361 and national governors. Rural residents are also less likely than the urban residents to translate 362 service dissatisfaction into discontent with their government and hence have more trust in 363 government and evaluate information from local and national officials more positively than 364 urban peers (33).

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Only one in 5 of the respondents adhered to COVID-19 prevention measures either usually or 366 always. While a third of respondents never wash their hands with soap, more than 80% of the 367 respondents had never applied a 2-meter social distancing rule at least once. Ethiopia is among 368 one of the poorest sub-Sharan countries where a significant proportion of the population (70-80%) have no access to adequate water supply, sanitation and hygiene facilities (34) which 370 challenges the handwashing practice to limit the spreading of COVID-19. Maintaining social 371 distance is unattainable practice in Ethiopia since majority of the citizens live in slums. About 372 80% of Addis Ababa, the capital of the country, is considered slum areas, characterized by 373 widespread sanitation challenges where families live in crowded rooms and are exposed to 374 health and safety risks (35).

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The ability of the government to persuade people to internalize the externality they would

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In summary, the present study was able to provide a comprehensive investigation of the of the population with the progression of the pandemic in Ethiopia. Finally, we believe that the 397 study will inspire the healthcare authorities, and media to spread more COVID-19 related 398 accurate knowledge which ultimately results in better preventive practices toward  Since no proven medicine or vaccine is developed yet, the best way to curb the spreading of 400 the disease is maximizing knowledge and preventive practices toward COVID-19 at all levels.