Knowledge, Attitudes and Practices of COVID-19: A Case Study of Navakholo Sub-County, Kakamega, Kenya ()
1. Background
Coronavirus disease (COVID-19) is a newly found coronavirus-related infection. When an infected individual coughs or sneezes, the virus spreads mostly through saliva droplets or nasal discharge. The majority of people infected with the COVID-19 virus will develop mild to moderate respiratory symptoms and will recover without the need for special treatment. Older people and those with medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illnesses (Organization 2020) [1] . In December 2019, a new viral infection type appeared in Wuhan, China (Lu, Stratton et al. 2020) [2] ; it has been called novel coronavirus disease (abbreviated COVID-19) by the World Health Organization. The unknown nature of the virus has caused an outburst of health systems generating alarming death rates in many countries worldwide (Hepburn, O’Callaghan et al. 2020) [3] . From reports of previous epidemics, studies reveal that the dispersal capacity of the COVID-19 virus is much wider than SARS or MERS (Petrosillo et al. 2020) [4] . This indicates the possibility of greater risk, the current coronavirus may be exceeding the ratios of infected persons and deaths previously reported (Wang, Xu et al. 2021) [5] .
The coronavirus disease (COVID-19) has become an international health alarm (Organization 2020) [1] . Now, as the WHO reports, the number of people infected is around 148 million, and 3 million deaths across the globe by April 29, 2021 (Organization 2020) [1] . Because of Coronavirus disease has overcome geographical barriers, different countries started public health protocols to control the spread of the virus, much of them related to social distancing, hand washing, and lockdown of the cities (Zegarra-Valdivia, Vilca et al. 2020) [6] . Like other countries Ethiopia declared a state of health emergency and adopted public health measures that include the mandatory use of masks, contact tracing, self-isolation or quarantine, closure of workshop spacing, and the prohibition of gatherings (Beyene 2020) [7] . This critical condition has raised a variety of reactions among the population, causing distress, and massive fear.
The world community is fitting to slow down and finally stop the spread of COVID-19 that has claimed thousands of lives and sickened tens of thousands through improving the knowledge and practice of COVID-19 prevention methods, testing, and screening (Saqlain et al. 2020 [8] , Defar, Molla et al. 2021 [9] ). The battle against COVID-19 is continuing in China. To guarantee final success, people’s adherence to these control measures is essential, which is largely influenced by their knowledge, attitudes, and practices (KAP) towards COVID-19 according to KAP theory (Zhong, Luo, et al. 2020) [10] . In Africa, the burden and impacts of the pandemic are less compared with Europe and the USA. This may be attributed to the late coming of the pandemic, low seeding rate, youthful demographics, and possible prior immunity to coronavirus-like infections (Njenga et al., 2020) [11] . Still, the pandemic is accelerating in Africa and reached 5,637,942 million confirmed cases on July 4, 2021, according to the (Africa-CDC, 2020) [12] situation report.
In Kenya, since the announcement of its first case of COVID-19 in early March (Ministry of Health, 2020) [13] , there has been a rise in COVID-19 cases, estimated at 320 at the start of this study rising to 607 within a week (NERC, 2020) [14] . In response, the Kenya government implemented a mix of public health response measures, including messaging to create awareness of preventive measures, such as the use of masks, practicing hand hygiene, and social distancing. Additionally, there were international travel bans and cessation of movements in and out of areas that exhibited high rates of infections. The government also implemented a dusk-to-dawn curfew in all 47 counties and shut down public places including schools, churches, and other social gatherings, to slow down the spread of the virus.
One of the first and recent studies analyzing attitudes and knowledge, about Coronavirus carried out in Hubei, conclude that attitudes towards government measures to contain the epidemic are highly associated with the level of knowledge about COVID-19 (Ferdous, Islam et al. 2020 [15] , ZegarraValdivia, Vilca et al. 2020 [6] ). The authors detail that the higher the level of information, and education, the more the individuals would maintain a positive attitude towards COVID-19 preventive practices (Roy, Tripathy et al. 2020 [16] , Zegarra-Valdivia, Vilca et al. 2020 [6] ). A study conducted in the United States of America on awareness, attitudes, and actions related to COVID-19 revealed that seven out of ten participants (71.7%) correctly identified three COVID-19 symptoms and 69.8% were able to identify three prevention methods (Wolf, Serper et al. 2020) [17] . Another study in Bangladesh also indicated that 98.7% of students believed that hand washing with soap and water followed by avoiding touching your nose, mouth, and eyes with unwashed hands, the use of face mask/tissue when coughing or sneezing and wearing a clean surgical mask during their respiratory illness as the prevention methods for COVID-19 (Wadood, Mamun et al. 2020) [18] .
It is also evident that besides their effect on human morbidity and mortality during the COVID-19 pandemic, there are equally troubling socio-economic consequences for affected countries and the whole world (Gopalan and Misra 2020) [19] . The government of Kenya is taking preventive measures but the number of people infected with COVID-19 has increased (Haftom et al. 2020) [20] . To strengthen prevention practice and restrict the spread of COVID-19, there is an urgent need to fill the knowledge, attitude, and practice gaps in terms of COVID-19 transmission mode and preventative techniques (Defar et al. 2021) [9] . In this study, we focused on the KAPs regarding COVID-19 specifically in the Navakholo sub-county community. Therefore, this study aimed to assess KAP towards vulnerable groups to inform Navakholo sub-county Public Health Institute’s COVID-19 pandemic preparedness and response to daily situation reports, and thus contribute to the design of health strategies that consider population-specific needs. This study was also meant to give an overall image of Navakholo sub-county COVID-19 prevention practices and this can better prepare the government to statement future health emergencies involving infectious diseases. The results of this study will be important to inform future efforts focusing on societal readiness to comply with pandemic control measures.
2. Methods
This study focused on gathering quantitative information through the implementation of a cross-sectional study design. Participants were excluded because of an incomplete questionnaire and others due to lack of a consent form. The purpose of the study and the procedures of the questionnaire were explained to the participants. Those who agreed to participate completed an informed consent form and the questionnaire. The participants completed the questionnaires in person enabling them to ask questions or withdraw from the study at any time during the data collection. No incentive was provided to participants. All study protocols and the survey instrument were approved by the University Human Research Ethics committees and conducted following the ethical principles of the Declaration of Helsinki.
2.1. Participants
The population for this study will include all the households and caregivers that care for COVID-19 patients in Bunyala East of Navakholo sub-county, Kakamega County. A similar view was articulated by Feitsma (2007) [21] on issues of population in a study focusing on a population comprising of poverty-stricken people. There are various existing home-based care centers in Navakholo and surrounding villages. Then the targets, sets of measures, exercise procedures, sampling days, and details of the study which were conducted according to the study process, were explained to the subjects, and they were asked to hand in the consent form and study and sign the written pledge. The inclusion criteria participants aged 18 years and above who would understand the content of the study and agree to participate in the study. Researchers excluded potential participants who did not meet these criteria from the study. In this study, simple random sampling was used to determine the sample size of the target population.
2.2. Protocol
In assessing KAP, a questionnaire was used. The questionnaires were self-administered to overcome the difficulties arising from peer assistance and minimize the non-respondent prevalence. The knowledge section of the questionnaire consisted of several questions: regarding the characteristics of the disease, the symptoms of the disease, and the prevention and control of the disease these questions will either be in the form of yes, no or I don’t know.
2.3. Statistical Analysis
The data collected was exported to Microsoft Excel 2016 for cleaning. All data were analyzed using IBM SPSS (statistical packages for social sciences) Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). Statistical analysis that was used in this study was descriptive statistics such as a table (Frequency and Cross-tables) to describe the frequency and percentage. We assessed the distribution of continuous variables using histograms, probability distribution plots, and the Shapiro-Wilk test. Continuous variables with a normal distribution were described using means ± standard deviations (SD) while the medians and interquartile ranges (IQR) were used for skewed variables. Categorical variables were reported as counts and percentages. The Chi-square test was used to compare categorical variables, while the Mann Whitney U and Kruskal Wallis tests were used for comparing medians of continuous variables between groups. Findings were considered significant at p < 0.05.
3. Results
The analysis was done based on the objectives of the research. Nine hundred and nineteen (919) respondents from 919 households were interviewed. Their median age (in years) was 40. The youngest was 14 years old while the eldest was 89 years old. The majority 653 (71%) were female and 861 (93.7%) were Christians. Five hundred and forty-six (59.4%) had attained a primary level of education and 716 (78%) were married. A higher proportion 449 (48.9%) were unemployed. The majority 689 (90.3%) reported having children as in Table 1.
3.1. Knowledge on COVID-19
Almost all the respondents interviewed 916 (99.7%) had heard about COVID-19.
The majority 865 (94.4%) reported having heard of COVID-19 from the radio, 476 (52%) from healthcare workers, and only 220 (24%) reported the source as print media. (Figure 1) COVID-19 was reported as a viral infection disease by 732 (79.9%) of the respondents, 81 (8.8%) bacterial with 103 (11.3%) reporting as don’t know.
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Figure 1. Source of information on COVID-19.
Almost three-quarters 680 (74.2%) reported that COVID-19 is transmitted through droplets from sneezing or coughing followed by air 643 (70.2%). Still, 233 (25.4%) reported that it is transmitted through body fluids. (Figure 2) Over three-quarters reported symptoms of COVID-19 as fever of 702 (76.6%), dry cough 693 (75.7%) and difficulty in breathing 706 (76.6%) (Figure 3).
The majority 847 (92.5%) reported that it takes 2 - 14 days before the COVID-19 symptoms appear after infection. (Figure 4)
Regarding who is at risk of contracting COVID-19, the elderly were reported by the majority to be at risk from COVID-19 865 (94.4%) followed by those with other underlying conditions 545 (59.5%). (Figure 5) The least at-risk reported were pregnant women at 329 (35.9%). Table 2 shows the results of COVID-19 prevention measures.
3.2. Overall Knowledge Level on COVID-19
Respondents were asked several questions to gauge their understanding/knowledge of several aspects of COVID-19. The overall score of knowledge was computed as total correct responses on COVID-19 questions out of the total expected correct responses and expressed as a percentage. The percentage was later categorized as high (75% to 100%), Moderate (50% - 74.9%), and low (below 50%).
From the analysis, as indicated in Figure 6, 432 (47%) had a high level of knowledge of COVID-19 while 113 (12.3%) had a low level of knowledge. Analysis of variance (ANOVA) test was conducted to establish whether mean age varied significantly by level of knowledge on COVID-19. Results in Table 3 indicated that there was a significant difference in mean age by level of knowledge on COVID-19 (F = 13.19, p < 0.001). The level of knowledge decreased with an increase in age.
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Figure 4. Incubation period for COVID-19.
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Figure 6. Level of knowledge on COVID-19.
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Table 2. COVID-19 prevention measures.
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Table 3. Analysis of variance between age and level of knowledge on COVID-19.
To determine exactly between which knowledge levels the mean age varies significantly a Post hoc analysis using the Turkey method was done. The results in Table 4 indicated that the mean difference in age existed between those with high level and low level (p < 0.001) as well as those with low level vs moderate (p < 0.001).
A chi-square test was done to establish if there was a significant relationship between demographic variables/characteristics and level of knowledge on COVID-19. A significant relationship was observed between religion, education level, marital status, employment status, and level of knowledge on COVID-19 (all p < 0.05). A higher proportion of Muslims (63.2%) had a high level of knowledge of COVID-19 compared to 46% of Christians. The level of knowledge on COVID-19 increased with an increase in the level of education (primary (42%), secondary (56%), and college/university (63.9%). However, no significant relationship was observed between having children and the level of knowledge of COVID-19 (p = 0.598). A higher proportion of those who were single (53.5%) had a high level of knowledge compared to 46.5% of those married and 53.1% of the divorced/separated/widow. The majority of the employed (77.5%) had a high level of knowledge compared to students (53.1%), unemployed (45.2%), and self-employed (45.5%)
3.3. Multivariate Analysis (Multiple Linear Regression)
Multivariate multiple linear regression was conducted to identify demographic characteristics significantly associated with knowledge of COVID-19 controlling for confounders at a 95% confidence interval i.e. demographic characteristics that were significant at the bivariate level were run together in one model.
Findings in Table 5 indicated that respondent’s religion, level of education, and employment status were significant demographic characteristics influencing knowledge on COVID-19 (p < 0.05). Muslims were associated with a higher level of knowledge of COVID-19 compared to Christians (p = 0.003). Those with no education were associated with a lower level of knowledge of COVID-19 (p < 0.001). Those with secondary level education were associated with a higher level of knowledge on COVID-19 (p < 0.001) compared to those with primary. Students and those employed were associated with higher levels of knowledge on COVID-19 compared to the self-employed (p < 0.001 and p = 0.044) for employed and students respectively.
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Table 4. Correlation between demographic characteristics and level of knowledge on COVID-19.
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Table 5. Multiple linear regression.
3.4. Attitude towards COVID-19
The majority of the respondents 756 (82.5%) were willing to do a voluntary COVID-19 test and 868 (94.8%) reported that COVID-19 is preventable with 596 (65%) reporting that it can be treated at home. Regarding rating personal chances (risk) of infection with COVID-19, 368 (40.1%) rated as moderate, 231 (25.2%) as high (Figure 7). Figure 8 shows the likelihood that COVID-19 will continue in the country.
Over three quarters 805 (79.5%) reported that they have confidence that we can win the battle against the COVID-19 virus. However, 97 (10.5%) disagreed that we can win the battle against the COVID-19 virus. (Figure 9) The scores for the eight items measuring attitude were summed and calculated as a percentage of the total. The percentage was then classified as positive attitude (≥75%) and negative attitude (<75%). Over half of the respondents 603 (65.6%) scored a positive attitude towards COVID-19 as in Figure 10.
A chi-square test was conducted to establish if there was a significant relationship between demographic variables/characteristics and respondents’ attitudes towards COVID-19. Results in Table 6 indicated that there was no significant relationship between demographic characteristics and attitude towards COVID-19 (all p > 0.05).
Independent samples t-test was conducted to establish whether there is a significant difference in age between those with positive attitudes and those with negative attitudes. The results as in Table 7 indicated that the mean age for those with positive attitudes was 40.9 ± 0.6 while for those with negative attitudes was 41.2 ± 0.8. However, the difference in the mean age between the two groups was not statistically significant (t = 0.382, p = 0.703). This means that the age of the respondents did not significantly influence their attitude towards COVID-19.
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Figure 7. Rating chances of infection with COVID-19.
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Figure 8. Likelihood that COVID-19 will continue in the country.
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Figure 9. Whether COVID-19 will finally be successfully controlled.
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Table 6. Correlation between demographic characteristics and attitude toward COVID-19.
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Table 7. Comparison of mean age by attitude.
3.5. Practice towards COVID-19 Prevention/Control
Majority of the respondents (89%) reported that It is crucial to report a suspected case to health authorities, will go for testing if they had fever and dry cough (79%), worn a mask when leaving home in recent days (99%), avoided going to any crowded place including religious events in recent days (80%), been washing your hands with soap and running water for at least 20 seconds each time in recent days (86%), been avoiding touching eyes, nose, and mouth with hand/fingers in recent days (77%), been covering mouth and nose when coughing or sneezing, and washing your hands after in recent days (90%), been avoiding close contact with anyone who is sick, especially those with flu or cold symptoms such as fever, cough, or sneezing in recent days (86%), been cleaning and disinfecting frequently touched objects and surfaces (83%), been staying at home if sick, except to get medical care (80%), been avoiding shaking hands with others (83%) and maintaining social distance (90%) among others as in Table 8.
4. Discussion
The objective of this study was to assess KAP among respondents on the COVID-19 pandemic. The majority of respondents know that there is a pandemic and COVID-19 is caused by a virus according to research done by (Qutob and Awartani, 2021 [22] ; Wu and Munthali, 2021 [23] ). Almost all of the respondents knew the means of reducing the transmission rates, ways of preventing the disease, the mode of transmission, and the causative agent of COVID-19 aligning with the works of (Gebretsadik et al., 2021 [24] ; Shrestha et al., 2021 [25] ) where the majority had similar knowledge. This can be credited to the efforts of various Government and Private Establishments in the circulation of information on COVID-19 in Africa. Sub-Saharan African countries used the invested responses to similar outbreaks in the past to sensitize and raise awareness of COVID-19 (Massinga Loembé et al., 2020) [26] .
The research showed that a high number of the respondents had a sufficient level of knowledge about COVID-19. This aligns with the reports of (Hager et al., 2020 [27] ; Lee et al., 2021 [28] ) who disagree with the findings of (Desalegn et al., 2021) [29] who had a lower level of knowledge. The high level of knowledge can be attributed to the level of alertness the world gave COVID-19 during the pandemic period. In addition, the median age of the respondents was 40 years, this age bracket has the highest internet usage (Chiedozie et al., 2021 [30] ; Pew Research Center, 2021 [31] ) and the Internet is a common source of COVID-19 information (Erinoso et al., 2021 [32] ; Olaimat et al., 2020 [33] ). A
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Table 8. Practices towards COVID-19.
significant relationship was observed between religion, education level, marital status, employment status, and level of knowledge on COVID-19 (all p < 0.05) hence this also supports this assumption.
Assessment of the level of Attitude towards COVID-19 showed that the respondents had a high attitude towards COVID-19. 79.5% of them believe that COVID-19 can be successfully controlled, agreeing with the findings of (Pal et al., 2020) [34] . This can be attributed to the various information that has been passed across on the various means of transmitting COVID-19. 94.8% reported that COVID-19 is preventable with 65% reporting that it can be treated at home. This belief can be ascribed to the successful control of recent outbreaks such as Ebola in Africa. Similar research in Nigeria (Isah et al., 2020) [35] , Ethiopia (Aynalem et al., 2021) [36] , and Tanzania (Rugarabamu et al., 2020) [37] also showed the belief of the respondents in the control of COVID-19. Regarding rating personal chances (risk) of infection with COVID-19, 40.1% rated it as moderate, 25.2% as high, and many believed that the climate in Africa helped reduce spread. Chitungo et al. (2020) [38] reckoned that low testing and under-reporting of cases should not be strictly taken as the major causes of low cases in Africa because most African governments showed the political will to put measures in place at the onset of the pandemic. Chitungo et al. (2020) [38] also agreed with Hopman et al. (2020) [39] that climatic conditions can affect the low cases thou there is no evidence backing it.
The level of practice among the respondents was high. This high level of practice towards COVID-19 is good as there is also a high level of knowledge and Attitude towards COVID-19. This high level of practice is inconsistent with studies in Malawi (Li et al., 2021) [40] and Nigeria (Habib et al., 2021) [41] . The majority of the respondents wear facemasks always in public. However, washing hands after touching surfaces was ignored by the majority of respondents, this can be due to behavioral patterns and inadequate Water Sanitation Hygiene (WASH) facilities in the region. The availability of water affects the rate of handwashing (Dagne et al., 2018) [42] . Most of the respondents continue with their normal activities when they have flu-like symptoms. This aligns with (Tartari et al., 2020) [43] , a global survey carried out before the COVID-19 pandemic.
The study also explored the relationship between sociodemographic characteristics and knowledge and attitude. Gender, religion, marital status, level of education, occupation, and employment status were the significant predictors of Knowledge. This corresponds with similar research on COVID-19 (Desalegn et al., 2021 [29] ; Ngwewondo et al., 2020 [44] ). As stated by Ngwewondo et al. (2020) [44] , these factors will be essential for health workers and policymakers in identifying the target population. The mean level of knowledge among respondents who have started or finished tertiary level of education was higher than those who have not reached tertiary level corresponding with (Al-Hanawi et al., 2020) [45] . People who have started or finished tertiary level of education are expected to be more exposed and knowledgeable, hence the higher level of knowledge.
5. Conclusion
In conclusion, the overall computation revealed that generally majority of the respondents had high knowledge of COVID-19. The study also found that there was a significant difference in mean age by level of knowledge on COVID-19. A significant relationship was observed between religion, education level, marital status, employment status, and level of knowledge of COVID-19. The majority of the respondents showed a positive attitude. Moreover, results indicated that there was no significant relationship between demographic characteristics and attitudes toward COVID-19. With regards to practices, the majority of the respondents reported that it was crucial to report a suspected case to health authorities, would go for testing if they had a fever and dry cough, and had worn a mask when leaving home in recent days. Limitations of the study were that during the data collection process, some persons were unwilling to click on the link to the online form as they expressed the fear of clicking on scam links thus reducing the number of respondents. Also, the use of an online form of survey prevented people without internet service or smartphones from participating in the survey. The strength of this research can be seen in its target population as it this among the first to investigate the knowledge, attitude, practice, and misconception towards COVID-19-related research in Kenya.
6. Recommendation
The study recommends that the government should collaborate with telecom operators to disseminate COVID-19 messages promptly to their subscribers. Social media companies should enhance their fact-checking operations while search engines should limit information on COVID-19 from unverified websites. In addition, Governments should distribute COVID-19 information promptly and widely to prevent misinterpretation of the information by rumor mongers.
Ethics Approval
Ethical clearance was obtained from the Masinde Muliro University of Science and Technology Ethics Committee. Consent.
Funding
This study was funded by the university research fund (URF) of Masinde Muliro University of Science and Technology
Disclaimer
The findings and conclusions presented in this manuscript are those of the authors and do not necessarily reflect the official position of Masinde Muliro University.