Knowledge, Attitudes and Practices on COVID-19 among urban residents, Harare, Zimbabwe 2020: A Cross Sectional Study

Michelle Rutendo Gadzayi¹, Gladman Mubonani¹, Andrew Muza¹, Courage Muwishi¹, Farai Chirongoma¹, Nyaradzo Nyangani¹, Emmanuel Majuru¹, Fungai Dube¹, Simon Pomo¹, Brian Dhlandhlara¹, Luckson Muparanyama¹, Emmanuel Govha¹, Notion Tarafa Gombe¹, Tsitsi Juru¹, Mafuta Tshimanga¹

 

¹Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe

 

 

^&Corresponding author
Tsitsi Juru, Department of Primary Health Care Sciences, Faculty of Medicine Sciences, University of Harare, Harare, Zimbabwe. tsitsijuru@gmail.com

 

 

 

 

Coronavirus disease of 2019 (COVID-19) is a mild to severe respiratory illness caused by a novel coronavirus (Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) of the genus Betacoronavirus) [1]. The novel corona virus that causes COVID-19 is thought to have emerged from an animal source [2]. The virus was first recognised in humans as the causative agent in a viral pneumonia outbreak in Wuhan, China in December 2019 [3]. The virus is transmitted from person to person through close contact, within approximately two meters, with each other via respiratory droplets that are emitted when an infected individual coughs or sneezes. Touching a surface or an object that has been contaminated by an infectious person and then touching one´s face is another established route of infection [4].

 

Patients with COVID-19 present with mild (in 81% of the cases) to severe respiratory illness [5]. The symptoms include fever of 38°C and above, dry continuous cough, difficulty in breathing, headache and runny nose [4,6]. Severe complications from the virus include pneumonia, respiratory failure and multi-organ failure often leading to death [7,8]. Advancing age, cardiovascular disease, Diabetes and pre-existing respiratory disease are some of the recognized comorbidities that predispose to severe illness [9,10].

 

The World Health Organisation (WHO) recommended public health and social measures to protect oneself from the respiratory illness. These include avoiding close contact with people who are infected with the COVID 19 virus and touching one´s mouth, eyes and nose with unwashed hands, frequent hand washing with soap and water for a minimum of 20 seconds. If soap and water are not available a substitute of at least 60% alcohol-based sanitizer is recommended [11].

 

To prevent the spread of the illness, the measures that can be taken include staying at home when not feeling well, covering a sneeze or cough with a flexed elbow or tissue and throw in the bin, cleaning and disinfecting frequently touched surfaces or objects [12]. Those who have a history of travel to areas with local transmission should seek medical advice. They are mandated to inform health care workers of their travel, symptoms being presented with and self-isolate for 14 days after returning from travel whilst monitoring their health. To date, there is no vaccine or specific antiviral treatment for COVID-19. Individuals who are diagnosed with COVID-19 are given supportive and symptomatic treatment to relieve the symptoms.

 

The COVID-19 disease is an ongoing outbreak and has rapidly spread from China to all continents. As of April 2, 2020, the coronavirus COVID-19 had affected 203 countries and territories around the world, with a total of 936 958 cases and 47 264 deaths globally [13]. Africa, as of the 1st of April 2020 had a total of 5 999 confirmed cases of the coronavirus and 154 deaths. Within the continent, South Africa had the highest number of cases, 1 380 and five deaths while Algeria with 716 cases, had the highest number of COVID-19 deaths at 29 [14]. According to Zimbabwe´s Ministry of Health and Child Care situational report of 30th March, 2020, the country had eight confirmed COVID-19 cases and one death. Most of the cases were concentrated in the country´s capital, Harare with some evidence of local transmission [15,16]. The cases continued to rise steadily reaching the highest recorded cases in a day of 496 cases during the first wave on the 1st of August 2020. The country has since experienced two more subsequent waves. By 31 August 2021, Zimbabwe had recorded 124 960 cases and 4 419 deaths [13].

 

In Harare, Glen view and Budiriro residential areas have had several outbreaks from communicable diseases like cholera and typhoid. These areas are susceptible to outbreaks due to the high population density and the old infrastructure for water and sanitation. The unclear understanding and knowledge of the novel SARS CoV-2 infection among the general population may have a crucial role in the course of the COVID-19 pandemic. In view of this COVID-19 pandemic, and the vulnerability of Budiriro and Glen view areas to communicable disease, we conducted a knowledge, attitudes and practices (KAP) survey to understand the uptake of the preventive methods, bridging the gap between delivering health information to the community and to identify potential interventions that can be employed in order to improve attitudes and behavioural changes.

 

 

Study setting

 

We conducted the KAP survey in Budiriro and Glen view suburbs in Harare, the capital city of Zimbabwe. According to the Central Statistics Office census report of 2021, the estimated population for Glen view and Budiriro is 250 000. In these high density residential areas, there are water and sanitation challenges that have led to perennial water shortages. Sixty percent of the residents are in the informal economic sector which includes small-scale entrepreneurship and vending. Around Budiriro and Glen view, there are scattered furniture industries that offer informal employment for the residents.

 

Study design

 

We conducted a descriptive cross-sectional study from the 24th to the 28th of March 2020 when the country had recorded seven cases since the beginning of the pandemic. The participants were residents of Budiriro and Glenview suburbs who had lived in these suburbs for at least 3 months. Respondents who consented to participate were included in the study and visitors were not allowed to participate in the study.

 

Sample size

 

Using Dobson´s formula, n=Za2(p)(1-p)/d2, where Za=1.96, p=0.5 (we assumed that the prevalence of COVID-19 was 50%) and d=0.05, with a 95% confidence interval, we calculated a sample size of 384 participants. Two suburbs were purposively sampled (Budiriro and Glenview suburbs) as they had been prone to outbreaks in the preceding years. Glenview has 5 suburbs, and two suburbs (1 and 3) were randomly selected for the study. Budiriro has 5 suburbs and two suburbs (1 and 5) were randomly selected. Out of the four suburbs, 384 households were randomly selected.

 

Data collection

 

We used a pre-tested interviewer-administered questionnaire to collect data from the participants. The questionnaire had six questions which were focusing on the knowledge of participants on symptoms, transmission, prevention and treatment of COVID-19 Table 1. The participants were asked to mention the symptoms, mode of transmission and preventative measures. They were also asked if there was a cure for COVID-19 and the responses were yes, no or I do not know. The questionnaire had three questions on participant´s attitudes and three questions on practices during the COVID-19 pandemic. Data collection was done by 5 teams of public health officers who attended a one-day training on COVID-19 which focused on educating them on the COVID-19 disease and the data collection tools. Each team had at least two public health officers who were doing data collection.

 

Data analysis

 

Questionnaires were checked for completeness and internal consistency before being created in Epi info version 7.2.2.6. Data was cleaned for errors of entry and analyzed using Epi info. The software was used to generate frequencies, proportions and means. Frequencies and proportions were generated for demographic variables (gender, marital status, and level of education) and the number of respondents who answered questions correctly. The community´s knowledge level on COVID-19 was assessed basing on 18 questions weighing one point each. Each participant was given a total score, with the highest possible points being 18 and the lowest possible point being zero. The community´s attitude was assessed using based on seven questions, each weighing one point. Each participant was given a total score, with the highest possible points being seven and the lowest possible point being zero. Those scoring 0 - 3 were deemed to have a negative attitude while those who scored 4 - 7 had positive attitude.

 

Permission to conduct study and ethical considerations

 

Permission to conduct the study was sought from the Ministry of Health and Child Care, Health Studies Office, Director Health services Harare, District Officers Budiriro and Glen view. We obtained written informed, signed consents from all the respondents before the interviews. A detailed explanation of the study was given about the study for informed decision making and the participants preferred language was used during the interviews. Participants´ names or addresses of participants were not used during the study; unique identifiers were used instead. All the information concerning the study was kept in privacy and confidentiality was maintained.

 

 

Demographic characteristics

 

We recruited 384 respondents into our study. The majority, 73% (282/384), of our study participants were females and married people constituted a majority of 72% (279/384) of our study participants. Eighty-two percent (316/384) of the respondents had reached secondary level education while 0.5% (2/384) had not gone to school at all. The median age was 32 years (Q1=25; Q3 =41) Table 2.

 

Community knowledge levels

 

The majority 97% (373/384) of the participants had ever heard about COVID-19 and 77% (286/373) reported that they had heard about it from social media. The correct answer rates of the 18 questions on the COVID-19 knowledge questionnaire ranged from 9.4 - 69.8% Table 1. The average COVID-19 knowledge score was 7.3 (SD=3.4, range: 0 -18), suggesting an overall 40.1% (7.3/18*100) correct rate on the knowledge assessment. The demographic characteristics of study participants and their knowledge scores were comparable Table 3.

 

The majority, 66% (248/384) of the participants reported that COVID-19 did not have a specific cure. However, the participants reported that if they were to get infected with the virus, they would use different methods to curb the disease. These included keeping warm by 16% (63/384) of the participants through sun-bathing, drinking hot fluids including water and steaming. Eleven percent (44/384) reported that they would use lemons, and this saw an increase in the price of lemons at the vegetable market. Other methods of easing the symptoms of COVID-19 that were reported by the participants were the use of ginger and garlic which were mentioned by 6% (22/384) each, 2% (6/384) reported that they would use antibiotics and <1% (1/384) would use anti-retroviral medicines for HIV.

 

Community attitude

 

The attitude of the study participants was noted to be generally positive with 84% (315/384) of the study participants stating that they would still wash hands despite the difficulties which the communities face in trying to find water for domestic use; and the majority, 75% (280/384) of the study participants stated that they could avoid going to crowded places Table 4.

 

Community practices

 

The study participant´s practices during the COVID pandemic were assessed with two questions as shown in Table 5 below. The study participants had developed good practices during this pandemic as 90% (333/384) of the study participants reported that they had increased the number of times that they wash their hands. However, the use of face masks was quite low amongst the study participants as only 4% (14/384) reported that they had managed to buy face masks for use during the pandemic.

 

 

Our study showed that the residents of Budiriro and Glen view were aware of COVID-19, however they had low knowledge levels of the disease. This was contrary to study findings by Wadhwani G. G. et al., 2021 in their COVID-19 KAP survey in South Africa that showed increased public understanding of the disease. At the time of their study, South Africa had breached the 1 000 cap in their cases and the country was already in lockdown. Thus, the localised spread of SARS CoV-2 infection influenced the good levels of knowledge about the disease among the general population in South Africa [17] . The low knowledge levels in our study might be due to the low numbers of COVID-19 in Zimbabwe.

 

Also, since it is a novel virus, there is still limited information which constantly changing about the disease. Prior to this KAP survey, COVID-19 related risk communication and community engagement strategies such as national radio, national TV, electronic and social media, mass mobile messaging in Zimbabwe had been ongoing, however they were believed to not reaching all populations. Due to high power-cuts in Zimbabwe, most people relied on WhatsApp social media platforms rather than the official messages. These findings are similar to findings by Bhagavathula et al. 2020, who reported that the majority of the health workers obtained information on COVID-19 from social media [18]. Social media platforms do not make it easier as there is a lot of speculation and there is the circulation of unverified messaging, like using herbs in the management. In our case, a tenth of the study participants believed lemons to be an appropriate treatment for COVID-19.

 

The study participant´s attitudes concerning going to crowded places during the COVID pandemic in Glenview and Budiriro was affected by the socio-economic situation that is prevailing in the country. Two-thirds of the study participants reported that they had been to crowded places despite knowing that there is a COVID-19 pandemic. These two suburbs are high-density suburbs where people have communal boreholes as their water sources, therefore they have limited options when trying to avoid crowded places. These communities also relied on public transport to get to their places of work and into the city center. The available modes of transport, the Zimbabwe United Passenger Company buses are often overloaded. These factors had a negative effect on the practices that study participants exhibited during this pandemic.

 

Our study found out that poor knowledge levels were associated with lower educational levels. These findings are similar to studies by Zhao et al., 2019, in their KAP survey on haze pollution in China. They found out that people with lower educational levels had poor knowledge about pollution and they recommended health education that was tailor-made to suit these people´s needs [19].

 

In our study, a minority of the participants reported that they had bought face masks that they intended to use for the prevention of the COVID-19 infection. The majority of participants cited financial constraints as a barrier to buying face masks. The cost of buying face masks had increased since the beginning of the pandemic and the masks were not readily available on the market. These findings are similar to findings by Feng et al. 2020, where the use of masks by the general population led to sky-high prices of the masks and shortages on the market [20]. Only a tenth of the study participants mentioned the use of face masks as a prevention strategy for COVID and this could also have contributed to the low number of people who had bought the face masks. This could also be the result of people taking heed of the WHO recommendations that masks should be reserved for people with respiratory symptoms and healthcare workers [21]. The utilization of these masks, however was not clear among study participants as they did not know how they were supposed to be properly put on, removed or disposed of.

 

Hand washing is one of the key prevention strategies for COVID-19 [3,5]. In our study, the participants resembled a positive attitude toward hand washing despite the water shortages in these suburbs. These findings are similar to study findings in the United States of America (USA) where 72% of the participants were practising hand hygiene to prevent COVID-19 [22]. However, our study showed that males were less likely to wash hands, while individuals with live-in partners were more likely to wash their hands.

 

Our study showed that three-quarters of the participants were willing and able to avoid crowded places. Those that reported that they were not able to avoid crowded places included people who needed to go to work since they were in the informal economic sector. The majority of the participants in the survey conducted in the USA were also in support of avoiding crowds, however some people needed to go to work [22].

 

Our study had limitations, we only focused on the urban areas, the KAP survey cannot be generalised for the rural communities. The respondents in this study where predominantly female. Considering that the study was carried out before the national lockdown was imposed it is plausible that their male partners where engaged in various economic activities as a similar proportion of respondents reported being in married relationships (72%), and as such the findings may not represent the accurately the views of male members of the same community. It is important to conduct further KAP research of COVID-19 to cover these population groups.

 

Notably, this study was conducted at the beginning of the pandemic, and the information on COVID-19 has changed rapidly, hence our findings may have been overtaken by events. Since the outbreak has evolved, we also recommend a follow up study to capture how the interventions have influenced the variables we assessed in this study.

 

 

The findings from the KAP survey indicated that the community was aware of COVID-19. However, they had poor knowledge of the symptoms, transmission and prevention of COVID-19. There are myths and misconceptions which need to be clarified through continuous engagement and awareness campaigns. Despite the socio-economic hardships, the community members exhibited positive attitudes and good practices.

 

We therefore recommended cascading health education to other towns, cities and rural areas to demystify myths and misconceptions and distribution of information and education communication (IEC) material on COVID-19. We also recommended sending regular COVID-19 updates by the Ministry of Health and Child Care.

 

As public health actions, we conducted door-to-door community awareness to 1 200 households with a total of 4 706 individuals. We also distributed IEC materials.

 

 

The authors declare no competing interests.

 

 

MRG: conception, design, acquisition, analysis and interpretation of data and drafting the manuscript. MRG, GTM, AFM, CM, FCC, NTAN, EM, FD, SP, BD, LM: conception, design, acquisition, analysis and interpretation of data and drafting the manuscript. EG, TJ, NTG: conception, design, data collection, analysis, interpretation and reviewing of several drafts of the manuscript for important intellectual content. MT: conception, design, data collection, analysis, interpretation and reviewing of several drafts of the manuscript for important intellectual content. All authors read and approved the final manuscript.

 

 

We would want to express our gratitude to the Ministry of Health and Child Care, Health Studies Office, Director Health services Harare, District Officers Budiriro and Glen view, for all the help they rendered. Many thanks go to all the study participants.

 

 

Table 1: Questionnaire of knowledge on COVID-19

Table 2: Demographic characteristics of COVID-19 KAP study participants in Harare, 2020

Table 3: Knowledge score of COVID-19 by demographic variables in Harare, 2020

Table 4: Study participants´ attitudes towards COVID 19 in Harare, 2020

Table 5: Study participants´ practices during COVID 19 pandemic in Harare, 2020

 

 

1. Merriam-Webster.com Dictionary[Internet]. Springfield (MA): Merriam-Webster Incorporated; COVID-19;[cited 2022 Dec 29]; [about 1 screen].


2. UpToDate. Coronavirus disease 2019 (COVID-19)[Internet]. UpToDate;[cited 2022 Dec 18].


3. Yu P, Zhu J, Zhang Z, Han Y. A familial cluster of infection associated with the 2019 novel coronavirus indicating possible person-to-person transmission during the incubation period. J Infect Dis[Internet]. 2020 May 11[cited 2023 Jan 30]; 221(11):1757-61. https://doi.org/10.1093/infdis/jiaa077 . PubMed | Google Scholar


4. WHO. Coronavirus disease (COVID-19) Outbreak[Internet]. WHO Western Pacific|WHO; 2022[cited 2022 Dec 15].


5. WHO. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: interim guidance, 28 January 2020[Internet]. WHO; 2020 [cited 2022 Dec 15]. Report No.: WHO/nCoV/Clinical/2020.3.


6. Weiss SR, Navas-Martin S. Coronavirus pathogenesis and the emerging pathogen severe acute respiratory syndrome coronavirus. Microbiol Mol Biol Rev[Internet]. 2005 Dec[cited 2022 Dec 15]; 69(4):635-64. https://doi.org/10.1128/mmbr.69.4.635-664.2005 . PubMed | Google Scholar


7. Government of Canada. COVID-19: Symptoms, treatment, what to do if you feel sick[Internet]. Government of Canada; 2022[updated 2023 Jan 27; cited 2022 Jan 30]. English, French.


8. Mayo Clinic. Coronavirus disease 2019 (COVID-19) - Symptoms and causes[Internet]. Mayo Foundation for Medical Education and Research (MFMER);[2023 Jan 30]


9. DAYLY SABAH WITH AA. Facts vs. myths: 10 common misconceptions about COVID-19 and coronavirus debunked[Internet]. Daily Sabah; 2020[cited 2022 Dec 16].


10. Scott D. The Covid-19 risks for different age groups, explained[Internet]. Vox; 2020 Mar 23[cited 2022 Dec 16].


11. WHO. Advice for the public: Coronavirus disease (COVID-19)[Internet]. WHO;[updated 2022 May 10; cited 2022 Dec 16].


12. WHO. CORONAVIRUS DISEASE (COVID-19) OUTBREAK: RIGHTS, ROLES AND RESPONSIBILITIES OF HEALTH WORKERS, INCLUDING KEY CONSIDERATIONS FOR OCCUPATIONAL SAFETY AND HEALTH[Internet]. WHO;[cited 2022 Dec 16].


13. Worldmeter. Coronavirus Update (Live): 936,958 Cases and 47,264 Deaths from COVID-19 Virus Outbreak - Worldometer. Covid live - coronavirus statistics[Internet]. Worldmeter;[cited 2020 Apr 2].


14. African Arguments. Coronavirus in Africa Tracker: How many covid-19 cases & where? [Internet]. African Arguments; 2021 June 9[cited 2022 Dec 16].


15. Mathieu E, Ritchie H, Rodés-Guirao L, Appel C, Giattino C, Hasell J, Macdonald B, Dattani S, Beltekian D, Ortiz-Ospina E, Roser M. Coronavirus Pandemic (COVID-19)[Internet]. Our World in Data; 2000[cited 2022 Dec 17].


16. WHO. Coronavirus disease (COVID-19) Weekly Epidemiological Updates and Monthly Operational Updates[Internet]. WHO;[cited 2022 Dec 18].


17. Wadhwani GG, Scott L, Nienhuis C, Chella L, Chadha A, Ferrucci L. Exploring knowledge, attitudes and practices towards COVID-19 amongst the residents in South Africa: a quick online survey. Int J Community Med Public Health[Internet]. 2021 Feb 24[cited 2022 Dec 18]; 8(3):1331. https://doi.org/10.18203/2394-6040.ijcmph20210822


18. Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and Perceptions of COVID-19 Among Health Care Workers: Cross-Sectional Study. JMIR Public Health Surveill[Internet]. 2020 Apr 30[cited 2023 Jan 30]; 6(2):e19160. https://doi.org/10.2196/19160 . PubMed | Google Scholar


19. Zhao M, Zhang M, Ying J, Wang S, Shi Y, Li H, Li Y, Xing Z, Sun J. Knowledge, attitudes, practices and information demand in relation to haze in China: a cross-sectional study. BMC Public Health[Internet]. 2019 Dec[cited 2022 Dec 16]; 19(1):1396. https://doi.org/10.1186/s12889-019-7772-3 . PubMed | Google Scholar


20. Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine[Internet]. 2020 May[cited 2022 Dec 16]; 8(5):434-6. https://doi.org/10.1016/s2213-2600(20)30134-x . Google Scholar


21. WHO. Coronavirus disease (COVID-19) advice for the public: When and how to use masks[Internet]. WHO; 2019[updated 2021 December; cited 2022 Dec 16].


22. RTI. Results from RTI´s Coronavirus Survey: Americans´ Knowledge of the Coronavirus and Support for Community Mitigation Strategies[Internet]. RTI; 2020[cited 2022 Dec 16]. Google Scholar