Running title: Health and Non-health workers’ COVID-19 related KAP

Abstract

Due to the current COVID-19 pandemic and associated high mortality in Sub-Saharan Africa (SSA), there is panic amongst healthcare workers (HCWs) because of the higher risk of being infected. This study compared knowledge, attitude and perception (KAP) towards COVID-19 between HCWs and non- healthcare care workers (NHCWs) and examined common associated factors. A web-based cross-sectional study on 1871 participants (HCWs=430, NHCWs=1441) was conducted over a period when lockdown measures were in place in the four SSA regions. Data were obtained using a validated self-administered questionnaire disseminated through an online survey platform. KAP mean scores were calculated and summarized using t-test for NHCWs and HCWs. Multivariate linear regression analyses was conducted to assess the unadjusted (B) and adjusted coefficients (β) at 95% confidence interval (CI). The mean KAP scores were slightly higher among HCWs than non-HCWs, but not statistically significant. Worried about COVID-19 was the only common factor associated with KAP between the two groups. Knowledge of COVID-19 was associated with attitude and perception between the two groups. Other significant factors associated with KAP were: the SSA region, age 29-38 years (β= 0.32, 95%CI: 0.04, 0.60 for knowledge in NHCWs), education, (β = -0.43, 95%CI -0.81, -0.04 and β= -0.95, 95%CI -1.69, -0.22, for knowledge in NHCWs and HCWs, respectively), practice of self-isolation (β=0.71, 95%CI 0.41, 1.02 for attitude in NHCWs and HCWs (β= 0.97, 95%CI 0.45, 1.49), and home quarantine due to COVID-19, in both groups. Policymakers and health care providers should consider these factors when targeting interventions during COVID-19 and other future pandemics.

Keywords: frontline workers, COVID-19, pandemic, lockdown, knowledge, risk perception.

Introduction

The global population is threatened by the raging pandemic caused by novel coronavirus disease (COVID-19), which started in Hubei Province of the People’s Republic of China in 2019.^1-4 The disease spreads among humans through respiratory droplets of symptomatic and asymptomatic patients,⁵ with the classic respiratory symptoms of fever, cough and fatigue.^6-11 As at 4^th August 2020, the Africa Centre of Disease Control (CDC), confirmed over 17.9m cases of COVID-19 and over 687,011 deaths across the African regions, with Southern Africa reporting the highest burden of the infection and Central Africa reporting the least.¹² Like most developed countries, many countries in SSA are now in the second and third epidemic phases,¹² suggesting the need to strengthen the public health control measures put in place by SSA government to contain the spread of the outbreak.

To mitigate the impact of the disease, the respective SSA governments implemented various recommended public health strategies such as bans on public gatherings, travel bans, social distancing, use of facemasks and others.^{2, 13-15} However, compliance with these measures were variable, largely dictated by economic and other factors.¹⁶ With no antiviral treatment or vaccine recommended explicitly for COVID-19 at the time,^{17, 18} management of severe hospitalized cases consisted of ensuring appropriate infection control and supportive care.¹⁴ A confused comprehension of an emerging disease combined with inadequate expert knowledge can lead to fear and chaos, further aggravating the pandemic.¹⁹ Past experience with outbreaks such as SARS and Ebola showed that misconceptions and excessive panic in the public led to the resistance to comply with suggested preventive measures and contributed to the rapid spread of the diseases.^{20, 21} These experiences underscore the vital role of engaging with both healthcare and non-healthcare professionals and the importance of monitoring their knowledge and compliance with the pandemic control measures.

In sub-Saharan Africa, the people’s perception of their health is rated among the lowest in the world. This may be connected with the low prioritization of health and health care by the respective governments in the four regions.²² According to WHO (2012), improving health care services delivery and disease control in Africa goes beyond increased financing and policy but also encompasses community perceptions and perspectives. As active players in the pandemic response, the healthcare worker is extremely strained.^{1, 23-26} Since COVID-19 is caused by a novel coronavirus, there is a dearth of accurate information available to healthcare workers and non-healthcare alike. Level of knowledge has a direct effect on an individual’s perception of susceptibility to disease and compliance with preventive protocols that could result in delayed treatment and a rapid spread of infection.^27-29 Hence, it is crucial to understand people’s attitude, their perceived risk of contracting the disease and compliance towards to mitigation practices to effectively communicate and frame key messages in response to the emerging disease.³⁰

Country-specific studies on knowledge, attitude and perception (KAP) of COVID-19 control measures among the general population^31-35 and among HCWs^{17, 36-39} have been reported within and outside Africa. However, no study has compared the KAP of COVID-19 among HCWs and NHCWs in SSA. Understanding related factors affecting and influencing people’s decision to undertake precautionary behaviour may help decision-makers respond appropriately to promote individual or community health in a pandemic situation. Comparing knowledge, attitude and risk perception between HCWs and NHCWs will also help to tailor health education messages to each specific group rather than a generic message that does not consider the difference between the two groups of people. Therefore, the aim of this study was to assess the differences in KAP scores as well as compliance with COVID-19 public health control measures, between HCWs and NHCWs in SSA, and to determine the common associated factors.

Materials and methods

From 18^th April to 16^th May 2020 corresponding to the lockdown period in the four SSA regions, this web-based cross-sectional survey was conducted among respondents from Cameroon (Central Africa), Ghana, Nigeria (Western Africa), Kenya, Tanzania (East Africa) and South Africa (Southern Africa). All of these countries have reported cases of COVID-19 in the recent pandemic, according to the World Health Organization (WHO). The survey was only available in English language and an e-link of the questionnaire was posted on social media platforms (Facebook and WhatsApp) which were commonly used by the locals in the participating countries, and was sent via emails by the researchers to broaden the scope of the survey. Participants in the survey received no incentives.

Sample size determination

The survey assumed a proportion of 50% because there was no previous studies on from SSA that has examined factors associated with 2019-nCoV in HCW and NHCWs, with 95% confidence and 2.5% margin of error. Using an online calculator, we assumed a sample size of approximately 1921, including 20% non-response rate. However, 1871 (97.4%) participants responded to the desired questions.

Consent and ethical consideration

The participants responded with a ‘yes’ or ‘no’ to a question designed to obtain voluntary online consent to express their willingness to attend the study via survey monkey. Human Research Ethics Committee of the Cross-River State Ministry of Health in Nigeria (Human ethics approval number: CRSMOH/HRP/HREC/2020/117) approved this study. The study adhered to the tenets of the Declaration of Helsinki. To participate in this study, respondents had to be 18 years and above. Participation was voluntary and anonymous.

Questionnaire

The survey tool for the COVID-19 knowledge questionnaire was developed based on the guidelines from the World Health Organization (WHO) for clinical and community management of COVID-19⁴⁰. The questionnaire was adapted with some modifications to suit this study’s objective namely to explore the knowledge of healthcare and non-healthcare workers about the nature and origin of COVID-19 and their attitude and perception towards the mitigation strategies to control the spread of the novel coronavirus.

Prior to the launching of the survey, a pilot study was conducted to ensure clarity and understanding and to determine the duration for completing the questionnaire. Participants (n=10) who took part in the pilot were not part of the research team and did not participate in the final survey as well. This was a self-administered 58-item questionnaire divided into four sections (A) demographic characteristics (B) knowledge (C) attitude and (D) risk perception. Demographic variables included age, gender, marital status, education, employment, occupation, the number living in the household, and religion.

Dependent variables

The three dependent variables were knowledge, attitude towards COVID-19 and risk perception for contracting the disease, which were taken as continuous variables. Twelve items on the questionnaire assessed the respondent’s knowledge of COVID- 19, most of which required a ‘yes’ or ‘no’ response. Each question used a binary scale. The score for each ranged from ‘yes’ (score ‘1’) to ‘no’ (score ‘0’). The knowledge score ranged from 0–12 points and these items have been shown to have an acceptable internal consistency⁴¹. The survey tool for the COVID-19 knowledge questionnaire was developed based on the guidelines from the World Health Organization⁴² for clinical and community management of COVID-19. There were 15 items in the survey (each used a Likert scale with five levels) that assessed perception of risk for contracting COVID-19. The scores for each item ranged from 0 (lowest) to 4 (highest). The risk perception score ranged from 0–60 points and the Cronbach’s alpha coefficients of the items were 0.74 indicating satisfactory internal consistency. The COVID-19 attitude items included “whether they have gone to any crowded place such as religious events?” “if they wore a mask when leaving home?”, and “if in recent days, they have been washing their hands with soap for at least 20 seconds each time”. Each question used a Likert scale with five levels with scores for each item ranging from 0 (lowest) to 4 (highest). The total scores ranged from 0-24 points, and the Cronbach’s alpha coefficient of attitude items was an average of 0.73, indicating acceptable internal consistency.

Independent variables

The independent variables were as follows: The demographic characteristics included age, country of origin, country of residence, sex, religion, educational, marital and occupational status, number of people living together in the household. Attitude towards COVID-19 included compliance to mitigation practices to minimize the spread of the virus such as, domestic self-isolation and quarantine measures. The risk perception variables included questions on, how they felt about the quarantine, whether participants think they were at risk of becoming infected, at risk of dying from the infection, if they were worried about contracting COVID-19, and participants’ feeling towards self-isolation (Table 1). Questions on knowledge and attitude towards COVID-19 were included when each variable was not the dependent variable in the analysis.

Table 1. Demographic Characteristics and Knowledge, Attitude, and Risk Perception Scores Among HCWs and Non-HCWs in Sub-Saharan Africa

Data analysis

Data analysis was performed using Stata version 14.1 (Stata Corp. College Station United States of America). KAP by independent variables were summarized using t-test for two categorical groups and one-way analysis of variance (ANOVA) for more than two categorical groups.

Univariate linear regression analyses were conducted to assess the unadjusted coefficients (B) with 95% confidence intervals among HCWs and NHCWs. The adjusted coefficients (β) with 95% confidence intervals obtained from the multiple linear regression model were used to measure the factors associated with KAP among HCWs and non-HCWs.

For the multiple linear regression analyses, a four-staged modelling technique was conducted. In the first stage (Model 1) included regions and demographic factors and manual process backward stepwise elimination process was conducted and those with P< 0.05 were retained. The factors associated in Model 1 were added to Model 2, which was attitude towards COVID-19. The variables would influence action to reduce the spread of the infection and this was then followed by similar backward stepwise elimination procedure. The significant factors retained in Model 2 were included in Model 3, which was feeling about isolation during COVID -19 lockdown. This was because they would help in identifying individuals who could develop mental health issue during the lockdown. Manual process backward stepwise elimination process identified the associated factors in Model 3. The fourth and final model included addition of knowledge and attitude scores to Model 3, which were added because knowledge is strongly related to attitude and practice while knowledge and attitude has been reported to be associated with practice⁴³.

Results

Figure 1. Mean scores for knowledge, attitudes, and perceptions of COVID-19 among HCWs and non-HCWs in sub-Saharan Africa. Error bars are standard deviations. P values are results of comparison between both groups. Abbreviations: HCW, healthcare worker; KAP, knowledge, attitudes, and perceptions; non-HCW, non-healthcare worker.

Figure 1 presents the mean scores and their 95% confidence intervals for KAP among respondents who were NHCWs and HCWs. The mean score for knowledge (7.2 out of 12 points) and attitudes (13.7 out of 24 points) of COVID–19 were relatively high with low risk perception (20.7 out of 60 points) for contracting the disease. In figure 1, there was no significant difference between both groups for KAP scores.

Descriptive statistics

Majority of the respondents were NHCWs (77.0%, mostly teachers, managers and administrators; Supplementary Table S1) and 23.0% were HCWs. The breakdown of the responses are shown in Table 1 including the results of comparative analysis for the mean KAP scores. Most of the participants were single, men, aged between 18 and 38 years old, were from West Africa, and had completed University education or its equivalent, at the time of this study. 66.4% of HCWs and 64.0% of NHCWs were employed. About 40% of NHCWs and HCWs stated they voluntarily quarantined themselves during the lockdown period. Regarding their concern on the spread of the 2019-nCoV virus, about 62% of NHCWs and HCWs were worried about contracting the infection.

There were significant differences in mean scores between the age groups for NHCWs and between educational status, worried about contracting the infection, practised self-isolation and self-quarantined during the lockdown in both HCWs and NHCWs (see Table 1 for details).

Unadjusted coefficients of COVID-19 related knowledge, attitude and perception of risk of contracting the infection

The unadjusted coefficient for factors associated with COVID-19 related knowledge, attitude and perception are presented in the Supplementary material (S2). Among HCWs and NHCWs, older age was significantly associated with all three-outcomes. In HCWs and NHCWs, Southern and Central Africans had significantly higher attitude scores, those with secondary/primary education, not worried about contracting the infection reported a lower attitude scores. NHCWs who were unemployed had lower knowledge and attitude scores. In HCWs and NHCWs, knowledge and attitude were significantly associated with risk perception (see S2 for further details).

Factors associated with KAP during COVID-19 among HCWs and NHCWs

Table 2 shows the factors associated with KAP of COVID-19 in HCWs and NHCWs, after adjusting for the potential cofounders. Region of origin (Southern and Central Africa), age group (29-38 years) were significantly associated with high knowledge but lower education (primary/secondary) and not worried about COVID-19 were associated with low knowledge of

COVID-19 among NHCWs. For HCWs, lower education (primary/secondary) and not worried about COVID-19, were associated with low knowledge of COVID-19.