Knowledge, Attitudes, and Practices Regarding COVID-19 in Africa: A four country comparison
By Sabere A. Traore, MD, MPH
Dr. Sabere is a physician and a public health professional from Burkina Faso, currently a Fulbright Fellow pursuing another degree in Health Policy and Management at Emory University in Atlanta, GA, USA.
The spread of the recent global COVID-19 pandemic has inspired the implementation of an avalanche of public health measures. Among those, facemask wearing, physical distancing, regular handwashing, travel restrictions, lockdowns and curfews, quarantines, closures of markets, schools, and worship places have played critical roles both globally and in Africa.
After a few months of strict implementation of public health measures to “flatten the curve,” many countries, particularly in Africa, have started to relax restrictive policies. Economic and social pressure have incentivized this policy rollback [1]. However, easing these public health restrictions is not synonymous with the end of the pandemic in Africa. The virus is still circulating following the stages of transmission patterns (sporadic cases, clusters of cases, and community transmission) identified by public health experts and discussed in my earlier blog. Consequently, African populations must continue to adopt and maintain preventive behaviors to protect against the catastrophic health consequences of the disease.
Figure 1. Cumulative confirmed COVID-19 cases in Nigeria, Ethiopia, Sudan, and Tanzania. Data available from OurWorldinData.org [2].
For decision makers and key health stakeholders to make a significant positive impact on the pandemic while balancing the social and economic needs of their populations, they must assess the current state of knowledge, attitudes, and practices (KAP) towards COVID-19 among African populations. Indeed, research shows that adherence to control measures is influenced by KAP [3]. This blog examines KAP in four countries across Africa: Nigeria, Ethiopia, Tanzania, and Sudan [4-7]. According to the Africa CDC, as of August 21, 2020, Nigeria ranked third among African countries with the highest number of cumulative COVID-19 cases, after South Africa and Egypt country in Africa with the highest number of cumulative cases (50964 confirmed cases). On the same date, Ethiopia, Sudan, and Tanzania reported 35836, 12582, and 509 confirmed cases, respectively.
Knowledge
Researchers in all four countries used questionnaires consisting of multiple-choice or “true/false” questions to assess knowledge in adult men and women. Most knowledge-oriented questions revolved around symptoms and transmission of COVID-19 [4-7]. In Nigeria, the percent of correct responses per question regarding COVID-19 symptoms and transmission ranged from 76.2% to 99.5% (total n=589) [4]. In Ethiopia, the percent of correct responses ranged from 37.7% to 95.1% (n=247) [6], while the percent correct ranged from 22% to 99.5% in Tanzania (total n=400) [7]. In Sudan, the percent of correct responses per question ranged from 16% to 97% (total n=812) [5]. Despite these wide ranges, the majority of questions in all countries were answered correctly at least 70% of the time. Over 80% of all respondents in all countries were able to identify common symptoms of COVID-19 and also knew that hand-washing was an important tool to prevent transmission. Questions most frequently answered incorrectly are shown in the table below.
Table 1. Percent correct answers to frequently missed questions regarding COVID-19 knowledge. Shown is the percent of the total study population that answered each question correctly. Specific wording may have varied, particularly across the different languages used. Percents are rounded to the nearest whole number [4-7].
Attitudes and practices towards COVID-19
Attitudes and practices towards COVID 19 varied significantly between countries, so each will be examined in turn.
Nigeria
Reuben et al. revealed in their Nigerian study that only 79.5% of the participants reported following the guidelines recommended by the Federal Ministry of Health of Nigeria and Nigeria Center for Disease Control despite the fact that 94.7% of participants reported knowing these recommendations [4]. Most of the participants (97.6%) agreed that crowded places should be avoided during the pandemic. However, 31.7% reported visiting crowded locations during the pandemic. Other attitudes and practices displayed by around 75% of the participants included: social distancing, avoid handshakes and face kissing. The most common feelings expressed were boredom (51.6%) and nervousness (40.6%). Increased knowledge of COVID-19 was associated with positive attitudes and better practices towards COVID-19.
Ethiopia
Relative to Nigerians, Ethiopians reported engaging in fewer preventative practices. Practices most frequently used were frequent handwashing with soap and water (77.3%) and avoidance of handshaking while greeting (53.8%) [6]. Approximately one third or less of all participants endorsed maintaining social distance of at least one meter (33.6%); avoiding crowded places (33.2%); wearing a mask outside the home (14.2%), or avoiding touching one’s face (11.3%). Notably, though Nigeria still has more confirmed cumulative COVID-19 positive cases, Ethiopia has reported more new daily cases every day since July 26th, 2020 to date (August 21st) [2].
Figure 2. Daily confirmed COVID-19 cases in Nigeria, Ethiopia, Sudan, and Tanzania. Data available from OurWorldinData.org [2].
Tanzania
The Tanzanian study from Rugarabamu et al did not report assessing as many specific attitudes and practices as the other studies. However, the majority of respondents affirmed wearing masks when going out (80.0%) and not visiting crowded places recently (77%) [7]. Almost all respondents (96%) also presented an optimistic attitude, agreeing that the COVID-19 pandemic can be controlled. Tanzania does currently have the lowest confirmed case rate of all the countries examined here, which may contribute to the positive attitudes.
Sudan
In Sudan, 66.9% (n=544) of the participants concurred with the cancellation of religious gatherings and events for reducing the spread of the disease [5]. However, only 34.1% (n=277) of participants admitted wearing face masks and 57.9% (n=470) avoiding shaking hands recently. This rate of mask-wearing is similar to that reported in the neighboring country, Ethiopia. Cultural may underly some of this similarity in attitudes and practices.
Conclusion
Methodologies varied among the four studies examined. Major differences include the specific study population and the method of obtaining survey answers. In Tanzania, the questionnaire was distributed electronically across the entire country [7]. In Nigeria, the questionnaire was also distributed electronically, but the population was confined to the northern part of the country [4]. In Sudan, the questionnaire was again electronic, and its distribution was confined to Khartoum [5]. In Ethiopia, the study population came from a single hospital, and the questionnaire was performed by in person interviews, maintaining social distance [6]. Thus, comparisons are more easily made among the Sudanese, Nigerian, and Tanzanian studies. The fact that the majority of respondents in all countries indicated adequate knowledge of COVID-19 is promising. The data indicate, however, that more work is needed to encourage better attitudes and preventative practices, particularly in Ethiopia and Sudan.
One limitation of these studies is that respondents were self-selected from among the population of individuals that uses Internet and social media regularly. The studies using electronic distribution reported doing so in part due to the infectious nature of the virus and the potential to worsen spread of the very pandemic under study. However, internet access is a privilege more likely to be experienced by middle to upper class individuals, while those of the lowest socioeconomic class may be excluded. Future studies should work towards greater inclusion of this neglected population.
Dr. Traore has no financial involvement or interest in the Bio Africa Marketplace or products mentioned therein or elsewhere within the BioAfrica Innovation Hub websites. His role in the Scientific Resource Hub does not constitute endorsement or recommendation of specific products or suppliers mentioned within the Bio Africa Innovation Hub websites.
References
Publicly available websites and news articles are linked in the text. Full references for peer-reviewed articles or other sites not publicly accessible are available below.
1. Bonnet, E., et al., The COVID-19 Pandemic in Francophone West Africa: From the First Cases to Responses in Seven Countries (preprint). Health Economics and Outcomes Research, 2020. 14.
2. Roser, M., et al. Coronavirus Pandemic (COVID-19). 2020 August 9, 2020]; Available from: 'https://ourworldindata.org/coronavirus.
3. Zhong, B.L., et al., 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. Int J Biol Sci, 2020. 16(10): p. 1745-1752.
4. Reuben, R.C., et al., Knowledge, Attitudes and Practices Towards COVID-19: An Epidemiological Survey in North-Central Nigeria. J Community Health, 2020.
5. Hezima, A., et al., Knowledge, attitudes, and practices of Sudanese residents towards COVID-19. East Mediterr Health J, 2020. 26(6): p. 646-651.
6. Kebede, Y., et al., Knowledge, perceptions and preventive practices towards COVID-19 early in the outbreak among Jimma university medical center visitors, Southwest Ethiopia. PLoS One, 2020. 15(5): p. e0233744.
7. Rugarabamu, S., A. Byanaku, and M. Ibrahim, Knowledge, attitudes, and practices (KAP) towards COVID-19: A quick online cross-sectional survey among Tanzanian residents. . MedRxiv, 2020. 18.