https://orcid.org/0000-0003-1719-6321
Figures
Abstract
Background
Globally, as of March 2024, the number of confirmed Coronavirus Disease 2019 (COVID-19) cases and deaths were over 774 million and seven million, respectively. Since there are no proven treatment in place against the disease, controlling strategy mainly rely on preventive measures. However, data on the extent of implementing physical distancing and other preventive measures during the pandemic of COVID-19 were inadequate in the study setting. This study is, therefore, documenting these gaps among people in Arba Minch town, South Ethiopia.
Methods
We conducted a community-based cross-sectional survey and qualitative study at Arba Minch in June 2020. Quantitative data were collected using an interviewer-administered questionnaire and check-list from study participants (head of household or any adult ≥18 years old in a household) and analyzed using SPSS version 20. Qualitative data were collected using key informant interviews (KIIs) and analyzed by using a thematic approach.
Results
Of the total surveyed adults (459), only 43.6% achieved above the mean score on adherence to implementing preventive measures of COVID-19. We found that 29.8% of participants kept physical distancing, only 37.7% of study participants had face-mask use practice, 20.5% had hand sanitizer use practice, 42.5% of participants avoided attendance in public gatherings, 44.7% stopped touching their nose, eye, and mouth, 55.6% practiced stay at home, and 60% had frequent hand washing practice. Besides, the main emerged barriers of adherence to implementing COVID-19 preventive measures were poverty, distrust of government, misbelief, lack of ownership, lack of attention and sustained actions, lack of ownership, socio-cultural influence, lack of coordination and leadership.
Conclusions
The finding of this study suggests inadequate adherence to implementing COVID-19 preventive measures in adults in Arba Minch. Although inadequately implemented, a lot of lessons have been learned from COVID-19 pandemic preventive measures that would help in prevention and control of such a pantomimic disease happened.
Citation: Wegayehu T, Yohannes T, Churko C, Bekele A, Asfaw MA (2024) Adherence to implementing physical distancing and other COVID-19 preventive measures and its barriers among adults in Arba Minch town, Southwest Ethiopia: A lesson learned from the pandemic. PLoS ONE 19(12): e0315204. https://doi.org/10.1371/journal.pone.0315204
Editor: Jianhong Zhou, PLOS: Public Library of Science, UNITED STATES OF AMERICA
Received: June 1, 2024; Accepted: November 20, 2024; Published: December 31, 2024
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: All relevant data are within the manuscript.
Funding: This research is funded by Arba Minch University (AMU) Research Core Process.
Competing interests: The authors have declared that no competing interests exist.
Introduction
The novel coronavirus disease 2019 (COVID-19) is a serious infectious disease, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [1, 2]. On 30 January 2020, the World Health Organization (WHO) declared COVID-19 as a public health emergency of international concern on 30 January 2020 [3]. Human-to-human infection of SARS-CoV-2 occurs mainly through air droplets, close contact with infected persons, particularly mucus membranes secretions from nose, mouth, or eyes, contaminated surfaces. Some studies have also suggested digestive tract transmission [4, 5]. Elder people and those with underlying medical conditions, such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer likely develop serious illnesses that may result in death [6–8].
Despite the level of advancement in the health system, COVID-19 were spread quickly across the United States, Europe, and South East-Asia early in the pandemic. As of 3 March 2024, over 774 million confirmed cases and over Seven million deaths have been reported globally [9]. Of these, Europe has reported the highest cases (36%) and death (32%); and Africa has reported the lowest case (1%) and death (2%). Although the number of confirmed novel COVID-19 cases reported in resource-poor settings is still relatively lower, this trend may be changed probably due to lack of adequate adherence to implementation of COVID-19 preventive measures. On the other hand, there is a high likelihood of the current number represents underestimates due to inadequate test accessibility [10].
After a decreasing trend since July 2021, case incidence rates in the African Region have begun to plateau, with over 20 000 new cases reported as of 7 November 2021. In Ethiopia, the first case was reported on March 13, 2020, at 48-year old Japanese in Addis Ababa [11]. Data for 5 February to 3 March 2024, Ethiopia has reported (40 new cases; <1 new case per 100 000) [9].
The WHO advises people to adhere to different preventive measures of the COVID-19 pandemic. According to the WHO recommendations, the best way to halt transmission of human-to-human is being well informed about the virus, how it spreads and adhering to the preventive measures adequately [12]. In response to the COVID-19 pandemic, the WHO along with its partners has been leading global coordination to hold the spread and reduce devastating impact of the COVID-19 pandemic [13].
Since the first incidence of the virus in Ethiopia, the country has been implementing unprecedented measures to control the rapid spread of the ongoing COVID-19 [14, 15]. Ethiopia initiated a screening program, established quarantine, and treatment centers in addition to community awareness and strong enforcement to control the spread of the virus. However, anecdotally, it has been observed that communities are neglecting physical distancing and other preventive measures of COVID-19. Moreover, there are few published studies that assess implementation of preventive measures of COVID-19 among the general population in Ethiopia [16–21]. This study is, therefore, aimed to investigate the extent of physical distancing and other preventive measures among people in Arba Minch town, Southwest Ethiopia to document the lesson learned from the pandemic.
Methods
Study setting
This study was conducted in Arba Minch, a town of Gamo Zone, which is located at 505kms south of Addis Ababa, the capital of Ethiopia. The town has 11 kebeles (the smallest unit of the government administration). Based on the 2007 census conducted by central statistical agency, the total projected population for 2020 is 120, 736 (60, 127 men and 60, 609 women) [22]. As any part of the country, community members in Arba Minch are at-risk for getting the coronavirus infection probably due to the existence of strong social interaction in the society which could favour the virus transmission rapidly. Since the first incidence of COVID-19 cases in Ethiopia, quarantine, and treatment centers were established in the town. Since the first incidence of confirmed COVID-19 cases in Ethiopia, awareness creations campaign has been done; and quarantine and treatment center have been established in the town.
Study design and period
A mixed-study methods ─ combining a community-based cross-sectional survey and qualitative study was conducted at Arba Minch; from 15/06/2020–30/06/2020 to document the practice.
Study population
The study population was the head of household or any adult ≥18 years old in the selected households who were residents and available during the survey period. Individuals were excluded from the study in the case when they were seriously ill and unable to provide information. For qualitative data, kebele administrators, managers, health office heads, head of health centers, hotel managers, and transport office heads were involved as key informants.
Sample size and sampling technique
The sample size was determined using single proportion formula,
, where, p is 50% (proportion of people implementing preventive measures), since there are no previous studies conducted in the study area; Zα/2 is 1.96, the reliability coefficient of standard error at 5% level of significance, and desired degree of precision (d) of 5%; the estimated sample size was 385, and by adding 20% non-response rate, the total computed sample size was 462. Study participants were selected using systematic random sampling technique from each kebele with consideration given to equal probability proportionate to sample size. For qualitative data, data were collected from 17 key informants of all kebeles. The number of key informants was determined based on information saturation.
Study variables
Different variables were included in this study, such as socio-demographic and economic characteristics, source of information, knowledge, and perception on prevention and control of COVID-19, and hygiene-related factors. Implementation status of physical distance and other preventive measures were the main outcome variables.
Data collection
Data were collected using house-to-house visits using interviewer administered-questionnaires and observation checklists. Data quality was ensured by developing, adapting, and pre-testing standardized tool; which is adapted from the WHO guidelines; training of data collectors and supervisors; and daily checking of consistency and accuracy of data. Data collectors and supervisors used face masks and alcohol-based hand rub and kept physical distancing to safeguard them and participants while they collect data collect. Qualitative data were collected using key informant interviews (KIIs).
Data analysis
Data were edited, coded, and entered into Epidata version 4.4.2 and exported to SPSS version 25 software for analysis. Then, data were cleaned and frequencies and proportion analyses were done for the variables, and presented by figures and tables. For physical distancing, from each public gathering place, such as market, bank, church, ekub, hotels, bus station, and office distances between any two or more individuals were measured and study participants also reported their perceived practice of physical distancing. Differences in the implementation of preventive measures were assessed using the Chi-Square test (X2). Implementing preventive measures was measured using 12 questions and score was computed by counting values within a case. Qualitative data were analyzed using a thematic approach.
Ethics statement
This study was reviewed and approved with the reference number of IRB/412/12 by the Institutional Research Ethics Review Board of College of Medicine and Health Sciences, Arba Minch University. Oral and written consents were received from sub-city administrators and heads of households before data collection started. Using information sheets and consent forms, written consent was obtained from study participants. The reason for taking written consent was to ensure participants are well informed about the study and agreed to involve in the study.
Results
Socio-demographic and economic characteristics
A total of 459 individuals participated in this study; which resulted in a response rate of 99.4%. Table 1 presents detail on socio-demographic and economic data. The mean number of individuals in a household was 4.9 (= ±1.95). Of the total participants, males were higher than females (56.4% versus 43.6%). Almost 32 (7%) respondents earned less than 1000 Ethiopian Birr (ETB) (~22.73 USD) per month, and 150 (32.7%) of them did not have hand washing facilities. Of the total participants, 86.5% accessed to COVID-19 related information from private television (TV), and 60.4% accessed from government TV. The remaining respondents got information from social media, friends, radio, family members, and town criers (Table 1).
Socio-demographic characteristics of key informants
Participants in KIIs were adults (≥18 years) who play key role in the community and act as potential source of information regarding barriers to implementing COVID-19 preventive measures.
Participant’s perception and other COVID-19 related information
Table 2 shows detail on perception and other COVID-19 related information among the study participants. Of the surveyed participants (459), nearly all (99.3%) were informed about COVID-19. However, only 128 (27.9%) responded that infected persons are the main source of infection, 339 (73.9%) knew COVID-19 symptoms, and 354 (77.1%) believed that COVID-19 can be prevented. In addition, 17 (3.7%) participants faced psychological violence while implementing preventive measures; 30 (6.5%) respondents had a history of in-country travel within the last 7 days of data collection, and 66 (14.4%) participants were worried about their health.
Status of implementing physical distancing
Of the 55 surveyed public gathering places, the measured physical distances between any two or more people were less than 1 meter in 45 (81.8%) of places, and, surprisingly the recommended physical distance (at least 2 meters) was not kept in any of those places (Fig 1). On the other hand, of the total respondents (459), only 29.8% (137) of participants self-reported as they maintained at least a 2-meter distance outside their home (Table 3).
Concerning to visiting crowded places, 252 (54.9%) of participants visited market and 32.8% went to religious centers (Churches and Mosques) in the last seven days ahead of data collection (Fig 2).
Status of implementing other preventive measures
We used 12 questions to assess the implementation of preventive measures against COVID-19. In total, 200 (43.6%) participants achieved above the mean score (6±1.97) on preventive measures. Of the surveyed individuals, only 173(37.7%) had face mask use practice, 67
(20.5%) had frequent hand sanitizer use practice, and 60 (13.1%) were measuring their body temperature every two weeks. Moreover, 195 (42.5%) avoided going to the public gathering places in the last 7 days; 205 (44.7%) stopped touching their nose, eye and mouth; and 255 255(55.6%) practiced stay-at-home if going outside is not mandatory, and 254 (60%) had frequent hand washing practice. In addition, the majority, 306 (66.7%) practiced covering their mouth and nose while coughing or sneezing with cloth or tissue; 317 (69.1%)practiced isolating themselves while having flue like symptoms; and mouth, 313 (68.2%) had treatment-seeking behavior if they experience flu like symptoms; and 410 (89.3%) avoided hand shaking. Among those who did not use a face mask, the main mentioned reason was not having money, 130 (45.5%) to purchase the mask (Table 3).
Difference in implementing preventive measures
A range of numerical differences in implementing COVID-19 preventive measures by socio-demographic variables was noted among study participants. Slightly more females (73%) had a practice of keeping physical distance compared to males (68%). Similarly, slightly more females (63%) had a practice of keeping physical distance compared to males (61.8%). In addition, individuals aged 40–49 had higher practice of keeping physical distancing and face mask use practice. Moreover, females had a higher practice of hand washing and stay at home practice. On the contrary, the difference in availability of hand washing was statistically significant with hand washing practice at p-value <0.05 (Table 4).
Barriers for adherence to implementing COVID-19 preventive measures
The main identified barriers for adherence to implementing COVID-19 preventive measures among adults were poverty, lack of attention and sustained actions, distrust of government, misbelief, lack of ownership, lack of ownership, socio-cultural factors, lack of coordination, and leadership.
“Poverty”.
“…Individuals in our community are very poor primarily due to high unemployment rate; as a result, people say ‘better to die from the coronavirus than from hunger’…” [Village chief]
“Lack of attention and sustained action”.
“…Implementing prevention activity among community members was good when people heard occurrence of the virus for the first time, but these days people thought as coronavirus has been eliminated ─ community members have neglected implementing the preventive measures. We failed to adhere with the COVID-19 preventive measures…” [Village chief…]
“…Physical distancing is difficult to implement in our community, especially in market and funeral places…” [Ekub leader]
“…Even public servant organization do not give the due attention to implement COVID-19 preventive measures…” [Health facility head]
“…Now I lose hope to prevent coronavirus because everybody has stopped to adhere with COVID-19 preventive measures…” [Village chief]
“Distrust of government” ─ “…There is no coronavirus ─ there is politics…” [Community member]
“Misbelief”.
“…My creature can save me; I do not need to implement the preventive measures…” [Community member]
“…Many individuals believe that COVID-19 came to us from God because of our sin…”
[Village chief]
“Lack of ownership and community engagement”.
“…People wear a face mask only when they come to the office; surprisingly even there are few individuals that share face masks by taking from colleagues to enter into office. This mainly due to lack of ownership, awareness and community engagement…” [Village chief]
“Socio-cultural influence”.
“…People in our community have a culture of eating together ─ sharing on a single dish. So, our cultures also adversely affect adherence to COVID-19 preventive measures…” [Hotel manager]
“…There is strong social interaction in our community, and it is difficult to keep physical distance…” [Village chief]
“Lack of leadership and coordination”.
“…Even leaders are not implementing the preventive measures; they have to act as a model and should coordinate activities…” [Village chief]
Discussion
Evidence of this study provides insights on adherence to the recommended COVID-19 preventive measures among adults in Arba Minch, Southwest Ethiopia. The study showed that adherence to implementing COVID-19 preventive measures was found to be low in adults. Besides, poverty, lack of attention and sustained action, distrust of government, misbelief, lack of ownership, lack of sustained action, lack of ownership, socio-cultural factors, lack of coordination and leadership were identified as the main barriers for adherence to preventing measures of coronavirus. While almost all participants (99.3%) were informed on COVID-19, we found that only 43.6% of participants achieved above the mean score (6±1.97) regarding preventive measures. The low adherence of participants to the COVID-19 preventive measures might be due to a lack of community engagement, ownership, and participation in playing a part to tackle the COVID-19 pandemic.
In the current study, only 29.8% of participants self-reported as they kept recommended physical distance (at least 2 meters) outside their home. Besides, the possible reason for the low implementation of physical distancing in this study is the strong socio-cultural interaction that exists in society. Consistent with this finding, a facility based study conducted in another part of Ethiopia (Jimma) showed a slightly higher practice of avoiding physical proximity [19]. Our finding is much lower than a finding among Vietnamese people where 88.2% of the participants adhere to the physical distancing rule [23]. Likewise, Block and colleagues ascribed that 67% of African Americans adhere to maintain physical distancing [24]. The possible reason for low implementation of physical distancing in our study is probably due to the strong social interaction norms that exist in the society.
In this study, only 37.7% of participants had face mask use practice when leaving out home, which is relatively higher than the face mask use practice among Residents of Dirashe District (20.5%). Southern Ethiopia [16]. Participants in this study had low face mask use practice when leaving out home in comparison with face mask use practice of study participants in a study done in Vietnamese people (99.5%), Malaysia (51.2%), Saudi Arabia (75%) and China (98%) [23, 25–27]. The lower practice of face masks in our study might be due to the low economic status of study participants to purchase face masks, as justified by data of our study.
Finding of the current study showed that only 20.5% and 60% of participant had frequent use of hand sanitizer and hand washing practice, respectively. Likewise, Bedane and colleagues ascribed only 11.1% of Jimma town inhabitants frequently use hand sanitizer [18]. The reason behind for the low utilization of hand sanitizer in our study might be related to lack of access to hand sanitizer at an affordable cost. On the other hand, findings of studies conducted in Vietnamese people (97.4%), African Americans (72%), Malaysia (87.8%) and Philippines (82.2%) revealed much better hand washing practice [23–25, 28]. The inadequate hand washing practice observed in this study could be due to lack of sustainable social behavioral change communication (SBCC).
In this study, less than half (42.5%) of participants avoided going to public gathering places in the last 7 days, and many people move to market areas to purchase their groceries. Inconsistent with this finding, a study conducted in Jimma town (Ethiopia) [18] and Malaysia [25] demonstrated a higher avoidance of going to public place. This result might be due to the fact that strong social interaction norms exist in society, and this finding is also justified by our data.
With regard to stopping touching nose, eye and mouth practice, in our study, 44.7% of participants stopped touching their nose, eye and mouth. The finding is also lower than that of the African Americans who avoid touching face by 55% [24]. This finding indicated that still more intervention is required to bring behavioral change. This study demonstrated that more than half of participants practiced stay at home preventive measure. However, data of our study showed that a substantial number of participants mentioned that stay at home is very challenging as a result of economic problems, which force people to go outside their home to look for their daily breads.
Data of our study revealed that 66.7% of respondents had practice of covering their mouth and nose while coughing or sneezing. This is much lower than practice of cover mouth and nose during coughing or sneezing by Vietnamese people (94.9%) [23]. Inadequate mouth and nose covering while coughing or sneezing with cloth, mask or tissue observed in this study could be due to lack of SBCC. In the current study, a substantial of participants had treatment-seeking behavior if they experience flue like symptoms. This might be due to people having high fear of the virus as it could result in death. Moreover, 69.1% of participants practiced isolating themselves while having flue like symptoms. Consistent with this finding, a bi-national study conducted in Africa (Nigeria and Egypt) revealed that “as many as 96% of study participants practiced self-isolation and social distancing” [29].
In this study, although high proportion of participants avoided handshaking practice, the percentages of people who believe infected people are the main source of infection was low. This might be lack of awareness related to coronavirus transmission and prevention. On the contrary, a lower practice of handshaking was observed in a study conducted in another part of Ethiopia (53.8%) [19].
Furthermore, poverty, lack of attention, distrust of government, misbelief, lack of ownership, lack of attention and sustained actions, lack of ownership, socio-cultural influence, lack of coordination and leadership were identified as main barriers of adherence to implementing COVID-19 preventing measures. These challenges could be addressed by integrating health information related to COVID-19 in the exiting health extension program of community health platform of Ethiopia. Moreover, to the best of our knowledge scarce evidence exists in this regard, and we could not discuss the implication of these study findings in comparison with other studies’ findings.
Indeed, the pandemic of COVID-19 was a public health as well as socio-economic problem around the world. We lost our relatives, colleagues and friends by death. Its burden has been reflected on communicable and non-communicable diseases as the health facilities were focused on COVID-19 prevention. The global economy was seriously impacted to the extent of shut the system. However, with these all-observable challenges and problems our study found out that only 43.6% of participants achieved above the mean score (6±1.97) on preventive measures. The current study, in fact, exposes the need for more comprehensive education programs with focus on consistency of information for newly emerging pathogens like COVID-19.
The main strength is that we possibly assessing community’s adherence to the recommended preventive measures of COVID-19 pandemic at community level and its barriers which address an important national research priority. While interpreting data presented in this study, the following limitations need to be considered. First, findings are relying on self-reported practices of participants. Second, participant may report for the purpose of social desirability.
Conclusions
The finding of this study suggests that inadequate adherence to implementing COVID-19 preventive measures in adults in Arba Minch, Southwest Ethiopia. Thus, lesson learned from the preventive measures of COVID-19 would help to take action, if such a pandemic will be happened.
Acknowledgments
Authors would like to thank Arba Minch University, study participants, data collectors, and administrative officials of Arba Minch town.
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