The applicability of basic preventive measures of the pandemic COVID-19 and associated factors among residents in Guraghe Zone

Introduction Internationally, countries have reacted to the COVID-19 outbreak by introducing key public health non-pharmaceutical interventions to protect vulnerable population groups. In response to COVID-19, the Government of Ethiopia has been taking a series of policy actions beyond public health initiatives alone. Therefore, this study was aimed to assess the applicability of basic preventive measures of the pandemic COVID-19 and associated factors among the residents of Guraghe Zone from 18th to 29th September, 2020. Methods Community based cross sectional study was conducted at Guraghe Zone from 18th to 29th September, 2020. Systematic random sampling method was applied among the predetermined 634 samples. Variables which had p-value less than 0.25 in bivariate analysis were considered as candidate for multivariable logistic regression model. P-value <0.05 was used as a cutoff point to determine statistical significance in multiple logistic regressions for the final model. Result In this study, 17.7% (95% CI: 14.7, 20.5) of the respondents apply the basic preventive measures towards the prevention of the pandemic COVID-19. In addition, being rural resident (AOR: 4.78,; 95%CI: 2.50, 8.90), being studied grade 1–8 (AOR: 3.70; 95%CI: 1.70, 7.90), being a farmer (AOR: 4.10; 95%CI: 1.25, 13.35), currently not married (AOR: 2.20, 95%CI: 1.24, 4.06), having family size 1-3(AOR: 6.50; 95%CI: 3.21, 3.35), have no diagnosed medical illness (AOR: 6.40; 95%CI: 3.85, 10.83) and having poor knowledge (AOR: 3.50; 95%CI: 1.60, 7.40) were factors which are statistically significant in multivariable logistic regression model. Conclusion Despite the application of preventive measures and vaccine delivery, the applicability of the pandemic COVID-19 preventive measures was too low, which indicate that the Zone is at risk for the infection. Rural residents, those who have lower educational level, farmers, non-marrieds, those who have lower family size, those who have diagnosed medical illnesses and those who have poor knowledge were prone to the infection with the pandemic COVID-19 due to the lower practice of applying the basic preventive measures. In addition, awareness creation should be in practice at all levels of the community especially lower educational classes and rural residents.


Introduction
Internationally, countries have reacted to the COVID-19 outbreak by introducing key public health non-pharmaceutical interventions to protect vulnerable population groups. In response to COVID-19, the Government of Ethiopia has been taking a series of policy actions beyond public health initiatives alone. The novelty of this disease, along with its uncertainties, makes it critical for health authorities to plan appropriate strategies to prepare and manage the public. Therefore, this study was aimed to determine the applicability of basic preventive measures of the pandemic COVID-19 and associated factors among the residents of Guraghe Zone from 18 th to 29 th September, 2020.

Methods
Community based cross sectional study was conducted at Guraghe zone from 18 th to 29 th September, 2020. Systematic random sampling method was applied among the predetermined 634 samples. Data were entered into Epi-data version 3.01 and exported to SPSS version 25 for analysis. Both bivariate and multivariable logistic regression model were fitted to assess the association between outcome and explanatory variables. Variables which had p-value less than 0.25 in bivariate analysis were considered as candidate for multivariable logistic regression model. P-value ≤ 0.05 was used as a cutoff point to determine statistical significance in multiple logistic regressions for the final model.

Conclusion
The applicability of the pandemic COVID -19 preventive measures was too low, which indicate that the Zone is at risk for the infection and, being rural residence, having lower educational level, being a farmer, being currently not married, having lower family size, not having diagnosed medical illnesses and poor knowledge level were factors associated with the applicability of the preventive measures of the pandemic COVID-19. In addition, awareness creation should be in practice at all levels of the community especially lower educational classes and rural residents.

Introduction
The pandemic of coronavirus disease 2019 (COVID-19) started in December 2019 in Wuhan, China. Currently, the virus causing the disease is approaches each continent throughout the world and continues to spread at an alarming rate.
Globally, countries have acted up on the COVID-19 outbreak through introducing key public health non-pharmaceutical interventions to protect vulnerable population groups (1). Lock down, washing hands frequently using soap in mashing for more than 20 seconds, maintain physical distancing, stay informed and follow advice given by healthcare professionals and seeking medical advice if develop cough or fever or experience difficulty of breathing and call in advance the center assigned for COVID 19 response were the recommended measures to reduce the transmission of COVID 19 by world health Organization (WHO).
COVID 19 can results in a severe national problems. In addition; it results in severe psychological, economic crisis across the globe (2-5). As the disease progressed, concerns regarding health, economy, and livelihood increased day-to-day. The findings of the pandemic's impact on these issues could help inform health officials and the public to provide mental health interventions to those who are in need(5).
The first case of COVID-19 in Ethiopia was detected on 13 th March 2020 involving two tourists from Japan (6). In response to COVID-19, the Government of Ethiopia has been taking a series of policy actions beyond public health initiatives alone (7). These include closing schools, restricting use of public transportation, banning large meetings, and suspending sporting and religious gatherings. A state of emergency has been put in effect and staying at home and working from there has been strongly advised(8).
In accordance with the applied case definition and testing strategies, till 8 th of February, 2021, the number of peoples infected with the pandemic COVID 19 in the world was 105,805,951, of them, 2,663, 529 were in Africa and of them, 142,994 were in Ethiopia. Among them, 2,312,278 were dyed in the world, of them, 4,490 were in Africa and of them, 2,156 were in Ethiopia (9).
Despite the implementation of such strategies, the occurrence of the pandemic COVID-19 is still increasing.
Therefore, this study focus on the evaluation of the applicability of basic prevention methods of the pandemic COVID may help to the populations at risk to reduce the risk of mortality.

Study Design, Area and Period
A community based cross-sectional study was conducted at Guraghe zone from 18 th to 29 th September, 2020. Guraghe Zone is one of the 13 zones encountered at South Nations Nationalities and Peoples regional state (SNNPR). Wolkite town is its capital and located at 158 km south from Addis Ababa. Based on the 2007 Ethiopian national population and housing census, the population of the Zone is projected to be about 1,609,908 and 51.38% are females.
Administratively the Zone is divided in to 13 districts and 2 city administration.

Populations
In this study, all the residents at the Guraghe zone were considered as a source population and all the selected populations in the Guraghe zone from 18 th to 29 th September, 2020 from the source population were termed as study populations.

Inclusion and exclusion criteria
All the ambulatory residents of the Guraghe zone were included into the study and residents of Guraghe zone who cannot able to communicate (unable to listen and talk) and children who have age less than 15 were excluded from the study.

Sample size determination and sampling procedures
The required sample size was determined using formula for single population proportion formula n = ɑ 2 2 (1− ) 2 , Where n denotes the sample size, ɑ 2 denotes the reliability coefficient of standard error, at 5% level of significance (which is 1.96), P = proportion of residents applicability of basic preventive measures at Gurage zone (Which is 50% because there was no study conducted before) and d = margin of error. Therefore, the calculated sample size was 384. Using design effect for the sample in using interclass correlation (δ) = 1.5, it became 576. Through considering 10% for non-response rate, the final sample size for the study was 634. 5 The calculated sample size was proportionally allocated to the randomly selected districts (Abeshge, Emdeber, Enemor, Edja, Gumer, Meskan and Wolkite town administration). Similar procedure was undergone for the Kebelles and sub city for town administrations with in each selected districts. Finally systematic random sampling method was applied to found each of the household. Within each of the selected household, one individual was taken, primarily the house hold head (father) or the mother or kids based on the hierarchy (highest to lowest).

Study variables
The dependent variable for this study was the applicability of basic COVID-19 preventive measures and the independent variables were socio demographic variables (age, sex, residence, Proper hand washing practice: If the respondent wash his/her hands using soap and water in mashing his hands for more than 20 seconds or using hand sanitizers. 6

Data collection tool and procedures
The data collection tool was adapted from WHO resources and similar studies. Initially, it was prepared in English and was translated to Amharic by language experts to ensure consistency.
The data was collected using structured interviewer administered questionnaires. The data were collected by 15-experienced BSC nurses and were supervised by three Msc holders in health science through the entire data collection process.
The knowledge questions have 14 items. These items include the participant knowledge about clinical presentations (items 1-4), transmission routes (items 5-8) and prevention and control (items 9-14) of COVID-19. Participants were given "true," "false," or "I don't know" response options to these items. A correct response to an item were assigns 1 point, while an incorrect/don't know response assigned 0 points. The maximum total score ranged from 0-13, with a higher score indicating better knowledge about COVID-19.
To measure attitudes towards COVID-19, 10 items (with minimum score 10 and maximum score 50) were used. Response of each item was recorded on 5-point Likert scale as follows strongly disagree (1-point), disagree (2-point), neutral (3-point), agree (4-point), and strongly agree (5point). The overall level of attitude was categorized using original Bloom's cut-off point, as positive if the score was 80-100%(40-50), neutral if the score was 60-79% (30-40) and negative if the score was less than 60 (<10-29). A mean score >30 was carried out as a favorable attitude and a score less than 30 indicated an unfavorable attitude toward COVID-19

Data quality management
Data quality was assured by caring out careful design of data collection tool and appropriate modification was made, appropriate recruitment and one day training was given on the objective of the study, selection of study participants, how to keep confidentiality of the collected data, how to fill the data collection format and data quality management and follow-up for data collectors and supervisors. Intensive supervision was done by investigators and supervisors during the whole period of data collection.
A random sample of questionnaires were reviewed by the supervisors and the investigators to conform reliability of data before data collection and the investigators also made random cross 7 checked for their completeness, accuracy, and consistency at the end of each day and corrective discussion was undertaken with all the research team members. The data was checked for completeness and consistency and then it was coded, entered and stored into the computer using Epi data version 3.01 statistical software. Pretest was done at Butajira town on 5% of study subjects and modification will be made accordingly. Both the validity and the reliability test were checked.

Data processing and analysis
Data were cleaned, edited, coded and entered into Epi-data version 3.1 and exported to SPSS version 25 for Windows, and then exploratory data analysis was carried out to check the levels of missing values, presence of influential outliers, multi-co linearity. Crude odd ratios and AOR were computed to assess the presence of degree of association between the outcome variable and the explanatory variables.
Both bivariate and multivariable logistic regression model were fitted to assess the association between outcome and explanatory variables. Those independent variables that had p-value less than 0.25 in bivariate analysis were entered in to the multivariable logistic regressions model. Backward stepwise regression was used for choosing determinant variables. Extent of strength was presented using odds ratios and its 95% confidence intervals. P-value ≤ 0.05 was used as a cutoff point to determine statistical significance in multiple logistic regressions for the final model. Hosmer and Lemeshow as well as omnibus test were used to test the model fitness.
Multicollineaity was checked using standard error. Finally, the result was presented using texts, tables, charts and graphs.

Ethical consideration
Ethical clearance was obtained from Wolkite University College of medicine and health sciences ethical review board and permission letter was obtained from the Guraghe zone health department and the corresponding Woreda health care administrative offices. An informed consent was obtained from the respondents. All the necessary measures were taken to maintain and assure the confidentiality and all benefits of the patients. 8

The socio-demographic characteristics of the respondents
The minimum and maximum age of the respondents was 18 years old and 75 years old respectively, with the mean of 33.72+11.58 years. Nearly, half (49.4%) of the respondents had age between 36 to 64 years old. In this study, the number of males and females were almost equal, 50.5% and 49.5% were males and females respectively. Regarding the marital status, more than half (54.6%) of the respondents were married and maximum of the respondents (42.9%) were studied college and above.
Among the urban residents (142), 18(12.7%) were applied the basic preventive measures. In addition, these basic preventive measures were applied by one fourth (19.1%) of the rural residents. Among respondents who studied college and above (272), these preventive measures were applied only by 41 (15.1%) and around three fourths (74.4%) of those respondents who studied grade 1-8 did not apply these preventive measures.
Regarding the marital status of the respondent, 241(38.0%), 362(57.1%), 13(2.1%) and 18(2.8%) of the respondents were single, married, divorced and widowed respectively. Around one fourths (25.2%) of the respondents were students and nearly half (49.4%) of the respondents have 4-6 family members within the household. More than on fifth (21.9%) of the students and around one fourth (24.3%) of the currently not employed study subjects were applied the basic preventive measures. Regarding mass media, 526 (83.0%) of the respondents have mass media.
Among those who have mass media (526), 445 (84.6%) of the respondents did not apply the basic preventive measures ( Table 1).

Discussion
This study assesses the magnitude of the respondents who apply the basic preventive measures of the pandemic COVID 19 and associated factors among the residents of Guraghe Zone.
Considering the fact that Ethiopia is a multi-ethnic country with vastly different economic source, education levels, traditions, it is expected that the levels of knowledge, attitude, and applicability of basic preventive measures will also markedly differ in the population.
The magnitude of residents who apply the basic preventive measures to the pandemic COVID 19 was 17.70% (95% CI: 14.70, 20.50). This study finding was less than the study conducted at Nepal, which was 78.9% (9). This might be due to the difference in the socio economic status of the countries. In low income countries, the individuals did not apply the lockdown to sustain their daily lives and they cannot invest any cost in purchasing the personal protective devices.
The magnitude of residents who have good knowledge was 21.9%. This study finding is less than the study conducted at Nepal, Uganda and Henan China; which was 76%, 69% and 89% respectively (7,9,11). This discrepancy in knowledge level may be related to the better preparedness for the worst and the number of residents who were severely affected with the infection especially in Henan China.
The proportion of individuals who have favorable attitude towards COVID-19 prevention methods was 94.2%. This study finding was greater than the study conducted at Nepal was 54.7% (9) and which was less than the study conducted at China (98%)(8). These discrepancies might be due to the residents' knowledge level, level of health information dissemination, government implementation policies and the residents' adherence towards the prevention methods.
Consistent with the study conducted in Bangladesh (12) In addition; the urban populations were more prone to the information disseminations regarding the preventive measures of the pandemic COVID 19. In addition, the rural residents are prone to the cultural prejudices as compared with the urban residents (14). Information sources are more available and spread faster in cities, and people can obtain first-hand information quickly as compared with the rural residents (15).
Inconsistent with the study conducted at Nepal and Bangladesh (9,12), respondents who studied grade 1-8 were 3 times more likely not to apply the basic preventive measures as compared with those who studied college and above (AOR: 3.7; 95%CI: 1.7, 7.9). This is commonly due to lower grade studies were prone to lower knowledge and a weak learning ability, making it harder to grasp the relevant knowledge regarding COVID-19, unable to adopt a protective attitude and be less positive. It has been suggested that health education should be targeted at people with different educational levels and different needs for health education. For the less educated population, easy-to-understand publicity materials may be more effective. with preventive behaviors and are more careful in the prevention of diseases (13). In addition, it might be due to that, individuals who have chronic diseases have information about its feature of being serious illness on those who have a chronic diseases and elder populations.
Knowledge became one of the associated factors for the applicability of the basic prevention measures of the pandemic COVID-19. Individuals who have poor knowledge were 3 times more likely to fail to apply the basic preventive measures of the pandemic COVID-19 (AOR: 3.5; 95%CI: 1.60, 7.40). This is due to knowledgeable individuals are more careful and responsible for the application of the preventive measures. In addition, knowledgeable individuals know the way of prevention, mode of transmission and the risk if it was not prevented appropriately.

Conclusion
The applicability of the pandemic COVID-19 preventive measures in Guraghe Zone was too low as compared with other areas, which indicate that it is at risk for the infection. In addition, being rural residence, lower educational level, occupational status, being single in marital status, having lower family size, having diagnosed medical illnesses and poor knowledge level were factors associated with the applicability of the preventive measures of the pandemic COVID-19.

Recommendations
 Awareness creation should be in practice at for all the community especially lower educational classes.

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 Individuals who have lower family size should be highly followed and a follow up link should be created between them and health extension practitioners and health facilities.
 Especial emphasis should be given for the rural residents to increase their practice level.
 Should supply the basic preventive measures such as mask and sanitizers for financially poor individuals  Should strictly follow and encourage the rural residents.
 Must work more than the usual to increase the awareness of the residents.
 Residents must practice the information gained through different sources.
 Individuals who have no diagnosed medical illnesses should apply the basic preventive measures.