Knowledge, attitude, and preventive practices towards COVID-19 and associated factors among adult hospital visitors in South Gondar Zone Hospitals, Northwest Ethiopia

Background Coronavirus disease 2019 (COVID-19) is currently the critical health problem of the globe, including Ethiopia. Visitors of healthcare facilities are the high-risk groups due to the presence of suspected and confirmed cases of COVID-19 in the healthcare setting. Increasing the knowledge, attitude, and practices towards COVID-19 prevention among hospital visitors are very important to prevent transmissions of the pandemic despite the lack of evidence remains a challenge in Ethiopia. Therefore, this study was designed to investigate the status of knowledge, attitude, and preventive practice towards COVID-19 and associated factors among hospital visitors in South Gondar Zone Hospitals, Northwest Ethiopia. Methods A facility-based cross-sectional study design was employed during August 1 to 30, 2020 from randomly selected 404 adult hospital visitors in South Gondar Zone Hospitals, Northwest Ethiopia. The data was collected using interviewer-administered questionnaire. The outcome of this study was good or poor knowledge, positive or negative attitude and good or poor preventive practice towards COVID-19. Three different binary logistic regression models with 95% CI (Confidence interval) was used for data analysis. For each mode, bivariable analysis (crude odds ratio [COR]) and multivariable analysis (adjusted odds ratio [AOR]) was used during data analysis. From the bivariable analysis, variables with a p-value <0.25 were retained into the multivariable logistic regression analysis. From the multivariable logistic regression analysis, variables with a significance level of p-value <0.05 were taken as factors independently associated with knowledge, attitude and preventive practices towards COVID-19. Main findings About 69.3% of the respondents had good knowledge, 62.6% had a positive attitude, and 49.3% had good preventive practice towards the prevention of COVID-19. We found that factors significantly associated with good knowledge about COVID-19 were educational status who can read and write (AOR = 2.78; 95%CI: 1.18–6.56) and college and above (AOR = 6.15; 95%CI: 2.18–17.40), and use of social media (AOR = 2.96; 95%CI: 1.46–6.01). Furthermore, factors significantly associated with a positive attitude towards COVID-19 includes the presence of chronic illnesses (AOR = 5.00; 95%CI; 1.71–14.67), training on COVID-19 (AOR = 3.91; 95%CI: 1.96–7.70), and peer/family as a source of information (AOR = 2.45; 95%CI: 1.06–5.63). Being a student (AOR = 7.70; 95%CI: 1.15–15.86) and participants who had a good knowledge on COVID-19 (AOR = 4.49; 95%CI: 2.41–8.39) were factors significantly associated with good practice towards COVID-19. Conclusion We found that knowledge, attitude, and preventive practices towards prevention of COVID-19 among adult hospital visitors were low. Therefore, we recommended that different intervention strategies for knowledge, attitude and preventive practices are urgently needed to control the transmission of COVID-19 among adult hospital visitors. Health education of those who could not read and write about COVID-19 knowledge issues and advocating use of social media that transmit messages about COVID-19 are highly encouraged to increase the good knowledge status of adult hospital visitors. Furthermore, providing training about COVID-19 prevention methods and using various sources of information about COVID-19 will help for improving positive attitude towards COVID-19 prevention, whereas for increasing the status of good preventive practices towards COVID-19, improving the good knowledge about COVID-19 of adult hospital visitors are essential.

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Ethical clearance was obtained from the ethical review committee of Debre Tabor University, research, and community service coordinator office. Afterward, consent was obtained from the respective hospital managers of the study site. Informed consent was obtained from each participant after explaining the objective of the study.   World Health Organization (WHO) announces the disease as a public health emergency of 67 international concern and then declared it as a global pandemic on March 11 (4-6). Two days 68 later, the government of Ethiopia reported the first confirmed case of 8).

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COVID-19 transmits mainly through droplets, airborne transmission, and contact between 70 humans (6,9-11). The major sign and symptoms of COVID-19 cases are fever, dry cough, 71 fatigue, myalgia, shortness of breath, and dyspnoea (4-6). The Severe cases of COVID-19 can 72 lead to cardiac injury, respiratory failure, acute respiratory distress syndrome, and death. Elders 73 and patients with chronic medical illnesses like hypertension, cardiac disease, lung disease, 74 cancer, or diabetes have been identified as potential risk factors for disease severity and 75 mortality. Even though the disease has no effective cure, but early recognition of symptoms and 76 timely seeking of supportive care enhance recovery from the illness. The case fatality rate of the 77 disease is approximately 3.4% (6,11).

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According to the Worldometer report, as of October 6, 2020, 9:54 am, COVID-19 spreads to 79 more than 214 countries across the world. A total of 35,707,844 confirmed cases were reported.

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The state of emergency towards COVID-19 prevention was terminated at the end of September were conducted on different aspects of the COVID-19 pandemic in Ethiopia, but scientific evidence on prevention practice of COVID-19 is rare among visitors of healthcare settings.

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Therefore, the study was designed to assess COVID-19 prevention practice and associated 108 factors among visitors in hospitals ofSouth Gondar Zone, Northwest Ethiopia.  Visitors who were less than 18 years old and those who were unable to respond due to illness 123 during data collection were excluded from the study.

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The sample size was determined using the single population proportion formula by taking the 126 following assumptions.
Zα/2 is the standard normal variable value at (1-α)% confidence level (α is 0.05 with 95% CI, Zα/2 129 = 1.96), an estimate of the proportion of knowledge attitude and practice, was considered as 50% 130 as there was no similar studies conducted and margin of error, 5%. The sample size became 384 131 and adding 10% non-response rates so that the final sample size becomes 422.

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Initially, two hospitals were selected using a simple random sampling technique by lottery 133 method. The patient flow data were estimated by reviewing the patients' logbook in the last three 134 months and the average number of the patient for a month was calculated to determine the 135 interval. Then, we used a systematic random sampling technique to select study participants of 136 the study. Then, the proportional allocation was carried out to determine the number of 137 participants from each hospital.

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Outcome and explanatory variables 139 The outcome variable was the preventive practice of COVID-19 (good/poor), knowledge 140 (good/poor), and attitude (good/poor), while explanatory variables comprised of socio-141 demographic variables, behavioral variables, pre-existing medical condition, and sources of 142 information towards COVID-19.

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Knowledge was measured by using 15 questions consisting of signs and symptoms, risk groups 145 and prognosis, method of transmission, and /preventive methods. Each question was responded 146 as either yes, no, and I do not know. Respondents who answered correctly were given 1 point while others were given 0 points. The total knowledge score ranges from 0-15 and a cut-off level 148 of ≥12 (80% and above) was considered as good knowledge while <12 (80%) was considered as 149 poor knowledge (24). The attitude section was measured by using 11 items and the response 150 was categorized based on 3 scale measurements with agree (3 points), neutral (2 points), and 151 disagree (1 point). The score of attitude varies from 11 to 33, with an overall score of ≥26.4 152 (80%) was considered as a positive attitude (27). The prevention practice was measured using 153 10 items and those who respond as yes were given 1 point while no was marked as 0. The total 154 prevention practice score ranges from 0-10 and a score with a cut-off ≥ 8 (80%) was considered 155 as good practice while <8 was taken as a poor practice (25,26).

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Data collection, management, and quality assurance 157 The data were collected using a structured questionnaire which was adapted from articles variable analysis (AOR) was determined using binary logistic regression analysis with 95% CI.

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In the bivariate analysis, variables with p <0.25 were a candidate for multi-variable analysis.  (Table 1).

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The finding of the study showed that 388 (96.0%) of the participants heard about COVID-19 203 from different sources of information. But a lower number of respondents 322 (79.7%) knew as 204 COVID-19 is a viral disease while 339 (83.9%) of the respondents knew the major sign and 205 symptoms of COVID-19 cases. Furthermore, 320 (79.2%) participants knew that elders, those 206 who had a chronic medical illness, and obese are more likely to have severe cases of  Similarly, 283 (70%) of the respondents knew that COVID-19 can be transmitted from one 208 person to another even in the absence of COVID-19 (Table 1).  The multi-variable analysis indicated that educational status and use of social media as a source 241 of information were statistically significant with the knowledge of COVID-19. The finding 242 revealed that those who can read and write were 2.78 times more likely to have good knowledge 243 than those who can't read and write. Similarly, those who have college and above educational 244 level were 6.15 (2.18-17.40) times more likely to have good knowledge than those who can't 245 read and write. Additionally, respondents who used social media as a source of information was 246 2.96 (1.46-6.01) times more likely to have good knowledge than the corresponding group of 247 those who did not use social media (Table 5). 248 The multi-variable analysis revealed that those who had primary education were 6.49 (1.52-249 27.78) times more likely to have a positive attitude than those who can't read and write while 250 college above was 6.91 (2.58-14.5) times more likely to have a positive attitude than the 251 corresponding reference group. Medical visitors who had chronic medical illnesses were 5.00

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(1.71-14.67) more likely to have a positive attitude than those who don't have a chronic illness.

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Respondents who took training on COVID-19 were 3.9 (1.96-7.70) more likely to have a 254 positive attitude than those who didn't take the training.

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Additionally, participants who used peer and family as a source of information were 2.45 (1.06-256 5.63) times more likely to have a positive attitude than those who didn't exchange information 257 from their peers and families (Table 6). 258 The finding also indicates that being a student was 7.  (Table 7).

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The pandemic of COVID-19 is still the critical concern of the globe including our country 265 Ethiopia. But up to date, there is no confirmed treatment for the pandemic. Therefore prevention 266 is the single most important method of alleviating the spread of the pandemic.

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In this finding, about 81.67% of the knowledge questions were correctly replied to by the 268 respondents. This finding was in line with the study conducted in Saudi Arabia (80.5%) (4) and 269 in Nigeria (77.36) (35). The finding of this study was lower than the study conducted in China 270 (90%) (36). This discrepancy may be due to variation in the study population's characteristics, 271 government commitment, and health care system quality on awareness creation. On the contrary, 272 this study result was higher than in the Egyptian population (71.26%) (37). This discrepancy 273 might be due to Spatio-temporal variation.

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The finding of this study revealed that 69.3 % (CI; 65.1-73.8) of the participants had good 275 knowledge of COVID-19 which was consistent with a finding in India (70 %) (38). On the other hand, the finding of this study was lower than a multicenter study conducted among health care 277 workers in Ethiopia with 88.2% (16) and Nigerian residents in an urban setting (99.7%) (39).

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This deviation may be due to the change in the study population (health care professionals vs. 279 general population) and residents of the study population.

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This finding showed that almost all (96%) of the respondents heard about COVID-19 by using 281 different sources of information. About two-thirds (62.4%) of the participants used social media as 282 a source of information of COVID-19 which was slightly higher than the study conducted in 283 Nigeria 55% (39). This deviation may be due to a change in the study period and setting, socio-284 demographic characteristics of the study population. On the contrary, this finding was lower than 285 the study conducted in Ethiopia (73.6%) (16). This deviation may be due to a change in the 286 heterogeneity of the study population (general population vs. health care professionals), and 287 variation of participants resident. Furthermore, this study also indicated that about 80% of 288 participants knew that the elderly, those who had chronic medical illnesses, and obese are more 289 likely to develop severe cases of COVID-19. This finding was slightly higher than the study 290 conducted in Ethiopia (72.5%) (11). This variation may be due to the change in Spatio-temporal 291 variation, socio-demographic characteristics of the study population, and coverage of awareness 292 creation towards COVID-19. Even though children and young adults are vulnerable groups, 293 only 83.4% of the participants knew that these groups need to take preventive measures towards 294 COVID-19. Neglecting such types of the population may wide-spreading the transmission of the 295 pandemic (11).

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Regarding the attitudes, 62.6% (95% CI; 57.2-67.6) of respondents had a positive attitude 297 towards COVID-19 which was lower than the study conducted in Ethiopia (94.7%) (16), Nigeria 298 79.5% (39), and Pakistan (82.16%) (40). This discrepancy may be due to a change in the study 299 population (health professionals vs general population), government commitment towards 300 COVID-19. On the other hand, less than half (44.6%) of the participants believed that the 301 government of Ethiopia can control the spread of COVID-19 within a short time. This finding 302 was lower than the study conducted in china 97.1% (24) and India at 87.2% (41). This deviation 303 may be due to the variation in the quality of the health system, socio-demographic characteristics 304 of the study population, and government preparedness to respond to the control of the pandemic.

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The report of WHO showed that the government's of Ethiopia scored only 52% towards 306 COVID-19 preparedness response (21) which supports the finding of this study. Furthermore, 307 this study also indicated that almost two-thirds of the respondents believed that the pandemic of 308 COVID-19 leads to the development of social stigma which was lower than a study conducted in 309 Ethiopia at 77% (16) and 83.8% (11). This deviation may be due to differences in Spatio-310 temporal variation, socio-demographic characteristics of the study population. On the contrary, 311 this finding was higher than the study conducted in the Peruvian population 59.1% (42). This 312 variation may be due to a change in the socio-demographic characteristics of the study 313 population and time, awareness creation towards COVID-19, and the burden of the pandemic.

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The social stigma may be developed due to fear of its mortality and high communicability. The 315 history of social stigma due to pandemic was not a new phenomenon (43,44).

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Regarding the prevention practice of COVID-19, the overall practice score of the respondents 317 was 73.2% which was higher than the study conducted in Ethiopia (26). The finding of this study 318 showed that only half 49.3% of the participants had a good preventive practice of COVID-19.

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But this finding was lower than other studies conducted in Ethiopia (16,26) and China (45). This 320 variation may be due to the change in the study setting, socio-demographic characteristics of the 321 study population, and occupation of the participant (being a health professional vs. general finding also revealed that more than two-thirds of 70% of the respondents avoid going to 333 crowded places after the emergence of COVID-19 which was higher than the finding in Nigeria  The study was approved by the ethical review committee of Debre Tabor University. Permission 366 to conduct the study was obtained from the respective hospital managers of the study site. Before 367 the data collection, the purpose of the study was explained and verbal consent was obtained from 368 each participant. Individuals who were volunteer to participate in the study were also told as they 369 have the right to withdraw from the study at any stage of the interview. The confidentiality of the 370 study participants was ensured by avoiding possible identifiers. Data collectors wear a facemask 371 and keep a physical distancing of two feet. Facemask was provided for the study participants 372 who did not wear it during the data collection. Data and all the materials will be available from the corresponding author upon request. 379 The authors declare that they have no conflicts of interest.

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