Abstract
Background
Corona virus disease 2019 (COVID 19) is a potentially severe acute respiratory infection first reported in December 2019 in Wuhan, China. It is currently a global health issue and a public health emergency for the entire world, including Ethiopia. People with comorbidities of chronic disease are at higher risk for severe disease and death from this virus. Hence, in order to better control the COVID-19 pandemic, their understanding, attitude, and practice of COVID-19 prevention measures should be improved. Therefore, this study aimed to assess the knowledge, attitude, and practice of chronically ill patients toward COVID-19 among chronic disease patients.
Methods
An institutional-based cross-sectional study was employed among patients with chronic diseases visiting public hospitals in Mekelle, Tigray, Ethiopia, from April to June 2021. An interviewer-administered questionnaire was used to retrieve data from systematically selected 319 chronic disease patients. The data were entered using EpiData version 4.4.2.1 and analyzed by SPSS version 23. Both bivariate and multivariate logistic regression analyses were done to identify factors associated with the outcome variables. Significance was determined at a p value of <0.05, and association was described by using an odds ratio at a 95% confidence interval.
Results
A total of 319 patients with chronic diseases participated in this study, with a 100% response rate. Out of 319 study participants, 51.1% had good knowledge, 59.9% had a positive attitude, and about half (49.2%) had good practices toward the COVID-19 pandemic. Multivariate analysis revealed that study participants completed secondary school (AOR = 4.691, 95%CI = 1.846–11.918), had college or higher educational levels (AOR = 4.626, 95%CI = 1.790–11.955) were positively associated with good knowledge towards COVID 19 where as those who aged 50 and up (AOR = 0.415, 95%CI = 0.227–0.759), divorced (AOR = 0.298, 95%CI = 0.116–0.764), and widowed (AOR = 0.115, 95%CI = 0.025–0.528) were negatively associated with it. Positive attitude had a statistically significant association with sex, being male (AOR = 0.471, 95%CI = 0.265–0.837), and occupation, being merchants (AOR = 4.697, 95%CI = 1.174–18.795), private employees (AOR = 4.484, 95%CI = 1.182–17.008) and housewives (AOR = 5.292, 95%CI = 1.372–20.414). Moreover, good knowledge (AOR = 4.047,95%CI = 2.205–7.427) and a positive attitude (AOR = 5.756,95%CI = 3.244–10.211) were factors significantly associated with the good practices of study participants towards COVID-19.
Conclusion
Less than two thirds of the study participants had good knowledge, attitudes, and practices overall about the COVID-19 pandemic. Health professionals and other responsible bodies should provide public education about COVID-19 and its prevention measures to chronic disease patients.
Keywords: COVID-19, Knowledge, Attitude, Practice, Chronic disease, Hospitals, Mekelle
1. Introduction
Coronavirus disease 2019 (COVID-19) is a potentially severe, life-threatening acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In Wuhan City, Hubei Province, China, in December 2019, the virus was found to be the source of an outbreak of pneumonia with no known etiology [1]. This new virus was identified as a novel coronavirus and was thus initially named 2019-nCoV. Later, the virus was given the new designation severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2], and the disease it causes is now known as Coronavirus Disease-2019 (COVID-19) by the WHO (World Health Organization). The Chinese COVID-19 outbreak was deemed a public health emergency of worldwide concern by the WHO on January 30, 2020, posing a significant risk to nations with weak health systems. It has escalated rapidly, and the WHO formally recognized it as a pandemic on March 11, 2020 [1,3]. As of October 1, 2020, the WHO reported that there were 33,842,281 confirmed cases and 1,010,634 fatalities worldwide [4]. A recent systematic study and case report on the investigation of SARS-CoV-2 transmission channels indicate that the virus has an incubation period of 1–14 days, which is infectious and contagious. The respiratory tract is the primary site of viral transmission, and other pathways include contact, fecal-eye transmission, nasal-eye transmission, mouth-eye transmission, and transfer of eye fluids and tears [5]. The most common clinical symptoms of COVID-19 are fever, fatigue, myalgia, shortness of breath, and a dry cough [[6], [7], [8], [9], [10]]. The COVID-19 is a preventable disease, and the prevention methods include frequent hand washing, covering the mouth while sneezing and coughing, disinfection of frequently touched surfaces, and wearing a mask [1]. To stop the spread of the disease and promptly administer supportive treatment, early detection and quick diagnoses are particularly crucial. Quarantine of infected individuals and those who have come into contact with an infected individual is also necessary [[11], [12], [13], [14]].
Globally, of the total people infected by COVID-19, about one in five individuals could be at increased risk of severe COVID-19 infection and death due to their age and underlying health conditions [[15], [16], [17], [18], [19]]. The identified risk factors for the severe disease and mortality are older age and chronic diseases like cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer [[20], [21], [22], [23], [24], [25]]. Protecting and monitoring patients with comorbidities is one of the main remedial steps that can be undertaken to reduce the impact of COVID-19. Chronic pulmonary diseases (COPD) and chronic liver diseases (in particular cirrhosis) were modestly affected by the novel coronavirus, but diabetes, end-stage renal disease, and hypertension were demonstrated to be at high risk. All patients who have any of these illnesses should be provided with additional protection and at the very least informed of their condition and the additional safety measures they should be taking [22,24].
According to several studies, individuals' compliance with behavioral preventative measures is crucial to the pandemic’s successful containment, and these behaviors can be significantly influenced by people’s knowledge, attitudes, and practices towards COVID-19 and its prevention measures [26,27]. Additionally, it has been claimed that an individual’s knowledge of and perception of the risk associated with the disease, attitudes and beliefs regarding preventive measures, and their level of trust in the government’s health department all have a significant impact on the practice of infection prevention [28,29]. Yet, a lack of knowledge about COVID-19 and standardized prevention measures may have an effect on people’s beliefs and behaviors, directly increasing their risk of infection [30,31]. The research, which measured general public knowledge, attitudes, and practices about COVID-19 in eight nations reported an overall knowledge score of 9.7 out of 12 [32]. According to the study done in Ethiopia, the level of knowledge (41.3%) and desirable COVID-19 practices among visitors to the Jimma University Medical Center were insufficient to combat this rapidly spreading virus [33]. Another study done to assess the knowledge, attitude, and practice towards COVID-19 among the general population revealed that the study participants' practice and attitude were poor, which will affect combating the pandemic [34]. Several other studies have been carried out to assess the KAP of study participants towards COVID-19 and its prevention measures [[33], [34], [35], [36], [37], [38], [39]]. According to a study [40] conducted in Ethiopia, a high incidence of inadequate awareness and poor practice for COVID-19 was found among patients with chronic diseases, accounting for 33.9% and 47.3%, respectively.
Most studies on COVID-19 knowledge, attitudes, and practices worldwide concentrate on health professionals and the general public rather than high-risk groups, especially patients with chronic diseases who account for more than 70% of all fatalities globally. That account for more than 70% of all fatalities globally [18]. Therefore, this study aimed to assess the level of knowledge, attitude, and practice towards COVID-19 among chronic disease patients at public hospitals in Mekelle City, Tigray, Ethiopia.
2. Materials and methods
2.1. Study area
This study was conducted in selected general and referral hospitals located in Mekelle, the capital city of Tigray regional state, located 780 km from the capital city of Ethiopia. According to the Tigray Central Statistical Agency, the city has a total population of 423,175 people (208,931 men and 214,241 women). Currently, the city has eight health centers, four public general hospitals, and one referral hospital. Mekelle General Hospital, Quiha General Hospital, and Ayder Comprehensive Specialized Hospital (ACSH) were chosen because they have regular follow-up of chronic disease patients, with 539, 86, and 854 average chronic patient flows per month, respectively.
2.2. Study design and period
An institution-based cross-sectional study was conducted in selected public hospitals in Mekelle, Tigray Region, from April to June 2021.
2.3. Study population
The study populations were Chronic Disease Patients who visited Mekelle City’s selected Public Hospitals during the data collection period.
2.4. Eligibility criteria
All chronic disease patients aged 18 years and older who visit the selected hospitals and available at the time of data collection were included in the study, whereas patients with chronic disease who are less than 18 years old, mentally impaired, and seriously ill, and who are unable to communicate due to an inability to speak or hear, were excluded from the study.
2.5. Sample size determination
The sample size for this study was calculated using a single population proportion formula, with the previous study level of good knowledge of chronic disease patients on COVID-19, 37.4% (P = 0.374) in Addis Zemen Hospital, Northwest Ethiopia [40] as the baseline.After considering the confidence level of 95%, the 5% significance level, and the 10% non-response rate, the total sample size determined was 319 clients.
2.6. Sampling technique and procedure
Currently in Mekelle city, there are 4 public general hospitals (Mekelle, Hewo, North Defense, and Qhuiha general hospitals) and 1 referral hospital, named Ayder Comprehensive Specialized Hospital. The hospitals with regular follow-up of patients with chronic diseases were chosen, and they are Mekelle General Hospital, Quiha General Hospital, and Ayder Comprehensive Specialized Hospital (ACSH), with average chronic patient flows of 539, 86, and 854 each month, respectively. The calculated sample was then proportionally allocated to the purposefully selected hospitals, namely Mekelle General Hospital (116), Quiha General Hospital (19) and Ayder Comprehensive Specialized Hospital (184), based on chronic patient load. A systematic random sampling method was employed to select the study participants every k th (1479/319 = 5), 5th patient starting at a random number (4) in their appointment log book.
2.7. Study variables
Chronic disease patients' knowledge, attitude, and practice toward COVID-19 are dependent variables, whereas socio-demographic factors such as age, religion, educational status, gender, occupation, and study participants' awareness of COVID-19 are independent variable.
2.8. Data collection tools and procedures
The data were collected using a pre-tested, structured interviewer-administered questionnaire which was adapted from similar literatures and WHO guidelines [33,40,41]. The questionnaire includes socio-demographic characteristics, awareness, and KAP towards COVID-19. The 16 questions assessing knowledge were answered on a true/false basis, with an additional “I don’t know” option. Similarly, the practice questions (16 in total) were answered on a yes or no basis. Study participants' attitudes toward COVID-19 were also assessed using 14 questions on five-point Likert scales (strongly disagree, disagree, neutral, agree, and strongly agree). The data were collected by six trained data collectors (3 BSc nurses and three public health officers) and one MSc supervisor while wearing a mask and glove in a well-ventilated location and maintaining a minimum distance of 2 m from the patients in order to prevent COVID-19 transmission.
2.9. Data quality management
The data collection tool was first prepared in English and then translated to Tigrigna (local language) for easy understanding and translated back to English for its consistency and analysis to ensure data quality. Furthermore, the accuracy of responses, clarity of language, and appropriateness of the tools were tested on 5% of the sample size in the non-selected hospital prior to the actual data collection period. Then, based on the results of the pretest, minor modifications were made to the questions accordingly. Before starting to collect data, supervisors and data collectors had a one-day training on the study’s goal, the procedure for gathering data, confidentiality, and informed consent.
After data collection, the principal investigator reviewed all the filled questionnaires on the spot and then carefully entered and thoroughly cleaned the data before the commencement of analysis. Supervisors and the principal investigator cross-checked, cleansed, and compiled the data on a daily basis to ensure its consistency and completeness.
2.10. Data processing and analysis
All collected data were cleaned, coded, and entered into Epi Data version 4.4.2.1 statistical software and then exported to and analyzed using SPSS version 23 statistical software. The analysis included both bivariate and multivariate techniques. In the univariate analysis, descriptive statistical analysis was done, and the continuous variables were described using mean and SD, and the categorical variables were described using frequency and percentage. In the bivariate analysis each independent factors of KAP were taken to see the association and the multivariate logistic regression included all variables with a p value less than 0.25. Computing the crude odds ratio (COR) and the adjusted odds ratio (AOR) with a 95% confidence interval (CI) by binary logistic regression was used to show the strength of the correlation between the independent variables and knowledge, attitude, and practice of study participants towards COVID-19. The data were then appropriately tabulated, graphically represented, and presented in narrative style. A P-value < 0.05 was considered statistically significant. For all of the analysis, the data were checked for normality, multi-colinearity, and reliability using Cronbach’s alpha (0.84 for knowledge, 0.74 for attitude, and 0.64 for practice), and there was no multi-collinearity between knowledge, attitude, and practice towards COVID-19 preventions among chronic patients since their VIF value was less than 10.
2.11. Operational definition
Knowledge: The total knowledge score ranges from 0 to 16. Participants' overall knowledge was categorized using the median score (14) of the correct answers for knowledge questions as good if the score was above the median score and poor if the score was lower than the median score.
Attitude: The attitude of study participants towards COVID-19 was assessed by using 14 questions. The attitude was classified as positive if the median score of the correct answers for attitude questions was above the median score (10) and as negative if the attitude score was less than the median score. From the likert scales, the categories of very high (easy), high (easy), and medium were considered positive, while the low (difficult) and very low (difficult) categories were considered to have a negative attitude.
Practice: A total of 16 questions were used to assess study participants' practice regarding COVID 19 prevention mechanisms. The overall practice score was classified as good if it was higher than the mean score (7.57) of the correct answers for practice questions, and poor if it was lower than the mean score. The mean score was used as a cut off point because the over all practice score was normally distributed. However medium score was utilized as a cut of point for knowledge and attitude because their overall score was not normally distributed.
2.12. Ethical consideration
Ethical approval and clearance (MU-IRB 1838/2021) was obtained from the Institutional Review Board of the College of Health Science, Mekelle University. Before beginning the actual data collection process, written informed consent from each participant was obtained, and their participation was voluntary. Furthermore, the confidentiality and privacy of the respondents were maintained.
3. Results
3.1. Socio demographic and clinical characteristics of study participants
The socio-demographic characteristics of the study participants have been summarized in Table 1. In this study, a total of 319 chronic disease patients from three hospitals participated, with a 100% response rate. More than half 175(54.9%) of study participants were male, whereas the remaining percent were female. The majority, 274 (84.9%) of the respondents, were orthodox Christians. The median (Inter Quartile Range (IQR)) age of the study participants was 50(39, 60) years. Regarding marital status, most 204 (63.9%) of the respondents were married, followed by single participants (18.8%). In terms of educational status, the majority of respondents in this study (96.1%) attended college or higher, followed by primary school (92.8%) and no formal education (76.8%). The majority, 268 (84.0%) of the study participants, live in urban areas. Regarding the health background of the chronic disease patients, 138 (43.3%) of the study participants were diabetic patients, 128 (40.1%) were hypertensive, and 53 (16.6%) were both diabetic and hypertensive patients (Table 1).
Table 1.
Socio-demographic and medical feature of chronic disease patients, Mekelle, Tigray, Ethiopia 2021 (n = 319).
| Variables | Category | Frequency, n (%) |
|---|---|---|
| Sex | Male | 175(54.9) |
| Female | 144(45.1) | |
| Place of living | Rural | 33(10.3) |
| Urban | 268(84.0) | |
| Semi-urban | 18(5.6) | |
| Educational status | No formal education | 76(23.8) |
| Primary school | 92(28.8) | |
| Secondary school | 55(17.2) | |
| College and above | 96(30.1) | |
| Religion | Orthodox | 274(85.9) |
| Muslim | 34(10.7) | |
| Protestant | 3(.9) | |
| Catholic | 8(2.5) | |
| Marital status | Married | 204(63.9) |
| Single | 60(18.8) | |
| Divorced | 30(9.4) | |
| Widowed | 25(7.8) | |
| Service OPD name | DM Clinic ACSH | 104(32.6) |
| Cardiology Clinic ACSH | 80(25.1) | |
| DM Clinic MGH | 60(18.8) | |
| Cardiology Clinic MGH | 56(17.6) | |
| DM Clinic QGH | 10(3.1) | |
| Cardiology Clinic QGH | 9(2.8) | |
| Disease Type | DM | 138(43.3) |
| HTN | 128(40.1) | |
| DM & HTN | 53(16.6) | |
| Occupation | Government Employee | 63(19.7) |
| Merchant | 35(11.0) | |
| Private-employee | 81(25.4) | |
| House wife | 62(19.4) | |
| Farmer | 29(9.1) | |
| Student | 15(4.7) | |
| Other | 34(10.7) | |
| Age categorized by median score | Below 50 years | 148 (46.4) |
| 50 years and above | 171 (53.6) | |
| Minimum, Maximum | Median(IQR) | |
| Age | (19,83) | 50(39,60) |
N.B: Abbreviations; DM- Diabetes mellitus, HTN- Hypertension, ACSH- Ayder Comprehensive Specialized Hospital, MGH- Mekelle general Hospital, QGH- Quiha General Hospital, IQR- Inter Quartile Range.
3.2. Knowledge of chronic disease patients about COVID-19
In this study, out of 319 study participants, 163 (51.1%) (95% C.I. = 0.4551, 0.5649) had good knowledge while the remaining 156 (48.9%) had poor knowledge. Regarding transmission, the results revealed that traveling to an infectious area or meeting someone who traveled to that area is a risk for COVID-19, and also the respiratory droplets from infected people passing through the air during sneezing or coughing were reported as means of COVID-19 transmission by 285 (89.3%), 302 (94.7%), and 256 (80.3%) of the study participants, respectively. However, 88 (27.5%) participants reported that afebrile COVID-19 patients can’t infect others. Additionally, people should avoid congested areas, frequently wash their hands with soap and water for at least 20 s or use 60% alcohol-based hand sanitizer, and isolate and treat COVID-19-infected people, according to 259 (81.2%), 275 (86.2%), and 268 (84%) of the study participants, respectively (Table 2).
Table 2.
Knowledge of chronic disease patients about COVID-19 in Mekelle, Tigray, Ethiopia 2021(n = 319).
| S.N | Knowledge Questions | Frequency, n(%) |
||
|---|---|---|---|---|
| Yes | No | I don’t know | ||
| 1. | Main clinical symptoms of COVID-19 are fever, cough, shortness of breath, and fatigue | 315(98.7) | 0 | 4(1.3) |
| 2. | Stuffy nose, runny nose, and sneezing are less common symptoms in COVID-19 | 145(45.5) | 146(45.8) | 28(8.8) |
| 3. | COVID-19 symptoms appear within 2–14 days | 190(59.6) | 17(5.3) | 112(35.1) |
| 4. | Symptomatic and supportive treatment can help COVID-19 patients | 258(80.9) | 15(4.7) | 46(14.4) |
| 5. | Elderly, have chronic illnesses, and with suppressed immunity are more likely to be severe cases | 264(82.8) | 16(5) | 39(12.2) |
| 6. | Touching hands of an infected person would result in the infection by the COVID-19 virus | 285(89.3) | 15(4.7) | 19(6) |
| 7. | Touching your mouth, nose, or eyes with contaminated hand result in COVID-19 | 285(89.3) | 17(5.3) | 17(5.3) |
| 8. | Droplets of infected people’s respiratory fluid are how the COVID-19 virus spreads | 256(80.3) | 21(6.6) | 42(13.2) |
| 9. | Afebrile COVID-19 patients can’t infect others | 88(27.6) | 143(44.8) | 88(27.6) |
| 10. | Ordinary residents can wear medical masks | 249(78.1) | 33(10.3) | 37(11.6) |
| 11. | It is not necessary for children and young adults to take COVID-19 prevention measures | 64(20.1) | 232(72.7) | 23(7.2) |
| 12. | To prevent the infection by COVID-19, individuals should avoid going to crowded area | 259(81.2) | 42(13.2) | 18(5.6) |
| 13. | Washing hands frequently with soap and water for at least 20 s or use 60% alcohol-based hand sanitizer is important to prevent infection with COVD-19 | 275(86.2) | 14(4.4) | 30(9.4) |
| 14. | Traveling to infectious area or meeting someone traveled to that area is risk for COVID-19. | 302(94.7) | 3(0.9) | 14(4.4) |
| 15. | Isolation and treatment of COVID-19 infected people are effective ways to reduce its spread | 268(84) | 27(8.5) | 24(7.5) |
| 16. | People who have contact history with COVID-19 case should be immediately isolated in a proper place. | 284(89) | 13(4.1) | 22(6.9) |
| Overall knowledge | Freq. (n) | Percentage (%) | ||
| Poor Knowledge | 156 | 48.9 | ||
| Good Knowledge | 163 | 51.1 | ||
3.3. Attitude of chronic disease patients towards COVID-19
In this study, more than half 191 (59.9%) (95% C.I. = 0.5452, 0.6528) of the study participants have a positive attitude towards COVID-19 control and prevention mechanism. This finding also revealed that one third of the study participants (33.2%) reported that they have a very high risk of infection with COVID-19, whereas about half 153 (48%) of the study participants believed that they had medium level self-protection. Regarding their perceptions towards the difficulty of the COVID-19 prevention methods, 161 (50.5%) and 87 (27.3%) of the study participants perceived that it is easy to wash hands properly and avoid touching faces with unwashed hands, respectively. However, 88(27.6%), 99 (31%), and 106 (33.2%) of the study participants perceived that it is difficult to avoid shaking others, practice physical distancing, and not go to crowded places, including religious places. About half, 155 (48.6%) and 158 (49.5%) of the total participants, believed that it is easy to cover mouth or nose during a cough or sneeze with elbow or tissue and use a mask, respectively, whereas 109 (34.2%) of the respondents perceived that it is difficult to stay at home to minimize the risk of COVID-19 infection (Table 3 and Fig. 1).
Table 3.
Attitude of chronic disease patients towards COVID-19, Mekelle, Tigray, Ethiopia 2021 (n = 319).
| Frequency, n (%) |
||||||
|---|---|---|---|---|---|---|
| S. No | Attitude questions | VH | High | Medium | Low | VL |
| 1. | How likely you are to contract COVD-19 | 106(33.2) | 98(30.7) | 93(29.2) | 19(6) | 3(0.9) |
| 2. | Your level of self-protection from COVD-19 | 57(17.9) | 68(21.3) | 153(48) | 32(10) | 9(2.8) |
| 3. | What is Being infected with COVD 19 to you? |
VT 150(47) |
Threatening 149(46.7) |
Medium 17(5.3) |
LT 2(0.6) |
NT 1(0.3) |
| 4. | How difficult is washing hands frequently for 20 s with soap or using sanitizer? |
VE 40(12.5) |
Easy 161(50.5) | Medium 69(21.6) | Difficult 37(11.6) |
VD 12(3.8) |
| 5. | How difficult is avoiding touching face with unwashed hands? | 34(10.7) | 87(27.3) | 73(22.9) | 82(25.7) | 43(13.5) |
| 6. | How difficult is avoiding shaking others? | 38(11.9) | 104(32.6) | 43(13.5) | 88(27.6) | 46(14.4) |
| 7. | How difficult is, not going to crowded places? | 34(10.7) | 73(22.9) | 61(19.1) | 106(33.2) | 45(14.1) |
| 8. | How difficult is practicing physical distancing? | 16(5) | 73(22.9) | 55(17.2) | 99(31) | 76(23.8) |
| 9. | How challenging is using an elbow or tissue to cover your mouth or nose while you cough or sneeze? | 75(23.5) | 155(48.6) | 59(18.5) | 24(7.5) | 6(1.9) |
| 10. | How difficult is avoiding contact with sick people? | 62(19.4) | 116(36.4) | 54(16.9) | 65(20.4) | 22(6.9) |
| 11. | How difficult is using a mask? | 56(17.6) | 158(49.5) | 64(20.1) | 30(9.4) | 11(3.4) |
| 12. | How difficult is it to obey state and local authorities' COVID-19 instructions? | 17(5.3) | 96(30.1) | 112(35.1) | 70(21.9) | 24(7.5) |
| 13. | How difficult is isolating oneself, if get sick to avoid the spread of virus? | 39(12.2) | 106(33.2) | 57(17.9) | 94(29.5) | 23(7.2) |
| 14. | How difficult is staying at home to minimize the risk of infection? | 21(6.6) | 96(30.1) | 58(18.2) | 109(34.2) | 35(11) |
| 15. | Overall Attitude* |
Positive 191(59.9%) |
Negative 128(40.1%) |
|||
Note: VH=Very High, VL= Very Low, VT= Very threatening, LT = Less threatening, NT= None-threatening, VE= Very easy, VD= Very difficult, * = Attitude calculated using the median score (10).
Fig. 1.
Dichotomized attitude of the chronic disease patients toward COVID-19 Prevention measures, Mekelle, Tigray, Ethiopia −2021(n = 319).
3.4. Practice of chronic disease patients towards COVID-19
Out of the total study participants, half 162(50.8%) (95% C.I. = 0.4371, 0.5469) of them had good practice towards COVID-19 prevention mechanisms. Only 66 (20.7%) of the study participants reported that they don’t participate in social events with large crowds of people. The majority, 216 (67.7%) of the respondents, had worn a mask while leaving home, but only 105 (48.6%) and 71 (32.9%) of them did not touch the front of the mask when taking it off and didn’t reuse a mask. One hundred ninety-six (61.4%) of the respondents wash their hands with soap and water frequently for at least 20 s or use sanitizer containing 60% alcohol, whereas 144 (45.1%) of the respondents touch their eyes, nose, and or mouth with unwashed hands. The result also revealed that only 69 (21.6%) and 124 (389.%) of respondents practice “physical distancing” and limit themselves from handshakes, respectively. Regarding the appropriate measures during coughing and sneezing, 245 (76.8%) participants covered their nose and mouth during coughing or sneezing with their elbow or a tissue (Table 4).
Table 4.
Practice of Chronic Disease Patients towards COVID-19 prevention in Mekelle, Tigray, Ethiopia −2021(n = 319).
| S.No | Practice Questions | Frequency, n (%) |
|
|---|---|---|---|
| Yes | No | ||
| 1. | Do you participate in social gatherings? | 253(79.3) | 66(20.7) |
| 2. | Have you recently donned a mask when leaving the house? | 216(67.7) | 103(32.3) |
| 3. | If so, do you contact the front of the mask when removing it? | 111(51.4) | 105(48.6) |
| 4. | Do you reuse a mask? | 145(67.1) | 71(32.9) |
| 5. | Do you routinely use 60% alcohol hand sanitizer or wash your hands with soap and water for at least 20 s? | 196(61.4) | 123(38.6) |
| 6. | Do you touch your eyes, nose, and mouth with unwashed hands? | 144(45.1) | 175(54.9) |
| 7. | Do you sanitize and clean regularly touched items and surfaces? | 136(42.6) | 183(57.4) |
| 8. | Do you always keep a 2-m distance between you and other people as “physical distance”? | 69(21.6) | 250(78.4) |
| 9. | Do you utilize the phones, desks, offices, or other tools and equipment used at work by other employees? | 167(52.4) | 152(47.6) |
| 10. | Do you limit handshakes? | 124(38.9) | 195(61.1) |
| 11. | Do you use unclean hands to contact your eyes, nose, or mouth? | 133(41.7) | 186(58.3) |
| 12. | Do you listen and follow the direction of your state and local authorities? | 169(53) | 150(47) |
| 13. | Do you stay at home to prevent COVID-19? | 141(44.2) | 178(55.8) |
| 14. | Do you stay at home if you have a cold-like illness during the time when it is most contagious? | 149(46.7) | 170(53.3) |
| 15. | Do you use an elbow or a tissue to cover your mouth and nose when you cough or sneeze? | 245(76.8) | 74(23.2) |
| 16. | If yes, do you dispose the used tissue appropriately? | 215(67.4) | 104(32.6) |
| Overall Practice* | Frequency | Percent (%) | |
| Poor Practice | 162 | 50.8 | |
| Good Practice | 157 | 49.2 | |
Note: Frequency of correct/acceptable practices is written in bold. = valid percent, * Using the mean score (7.57).
3.5. Factors associated with KAP of study participants towards COVID 19
In logistic regression analysis, the bivariate output showed that age, level of education, religion, marital status, and occupation were associated with the respondents knowledge of COVID 19. However, only age, educational level, and marital status were found to be significantly associated in the multivariable logistic regression model. Study participants aged 50 and older were 58.5% less likely to have good knowledge compared to those who were younger (AOR = 0.415, 95% CI: 0.227, 0.759). Additionally, the educational status, study participants who completed secondary school, college, and higher levels were 4.7 and 4.6 times more knowledgeable than those who did not start formal education (AOR = 4.691, 95% CI = 1.846–11.918; AOR = 4.629, 95% CI = 1.790–11.955), respectively. Moreover, study participants who were divorced or widowed had 70.2% and 88.5% less odds of good knowledge compared to married respondents (AOR = 0.298, 95% CI = 0.116–764; AOR = 0.115, 95% CI = 0.025–0.528), respectively) (Table 5). The multivariate logistic regression analysis result showed that sex and occupation variables were found to be significantly associated with the attitudes of the respondents, and the result has been summarized in Table 5. The female sex respondents were 52.9% less likely to have a positive attitude than male respondents (AOR = 0.471, 95% CI = 265–0.837). Moreover, by occupation, merchants, private employees, and housewives were 4.7, 4.5, and 5.3 times more likely to have a positive attitude compared to farmer respondents (AOR = 4.697, 95% CI = 1.174–18.795; AOR = 4.484, 95% CI = 1.182–17.008; and AOR = 5.292, 95% CI = 1.372–20.414) (Table 5). Results also revealed that socio-demographic characteristics of the study participants, such as age, place of residence, educational level, religion, marital status, and occupational status, were not associated with the practice of the participants towards COVID-19 prevention measures, whereas knowledge and attitude of the study participants were found to be significantly associated with the practice of the respondents towards COVID-19.
Table 5.
Factors associated with KAP of study participants in Mekelle City, Tigray, Ethiopia, 2021 (n = 319).
| Variable | Knowledge |
COR (95% CI) | AOR (95% CI) | P-value* | |
|---|---|---|---|---|---|
| Good knowledge | Poor knowledge | ||||
| Sex | 94(53.7%) 69(47.9%) |
81(46.3%) 75(52.1%) |
1 0.793(0.510–1.233) |
0.303 | |
| Male | |||||
| Female | |||||
| Age | |||||
| Below 50 years | 102(68.9%) | 46(31.1%) | 1 | ||
| 50 years and above | 61(35.7%) | 110(64.3%) | 0.250(0.157–.399) | 0.415(0.227–.759) | 0.004 |
| Place of living | |||||
| Rural | 16(48.5%) | 17(51.5%) | 1 | ||
| Urban | 138(51.5%) | 130(48.5%) | 1.128(0.547–2.325) | 0.744 | |
| Semi-urban | 9(50%) | 9(50%) | 1.062(0.337–3.352) | 0.918 | |
| Educational status | |||||
| No formal education | 19(25%) | 57(75%) | 1 | ||
| Primary school | 35(38%) | 57(62%) | 1.842(0.944–3.594) | 1.432(0.674–3.041) | 0.350 |
| Secondary school | 40(72.7%) | 15(27.3%) | 8.000(3.636–17.600) | 4.691(1.846–11.918) | 0.001 |
| College and above | 69(71.9%) | 27(28.1%) | 7.667(3.869–15.190) | 4.626(1.790–11.955) | 0.002 |
| Religion | |||||
| Orthodox | 143(52.2%) | 131(47.8%) | 1 | ||
| Muslim | 12(35.3%) | 22(64.7%) | 0.500(0.238–1.050) | 0.452(0.186–1.095) | 0.079 |
| Protestant | 2(66.7%) | 1(33.3%) | 1.832(0.164–20.443) | 0.452(0.037–5.457) | 0.532 |
| Catholic | 6(75%) | 2(25%) | 2.748(0.545–13.856) | 1.159(0.185–7.262) | 0.875 |
| Marital status | |||||
| Married | 115(56.4%) | 89(43.6%) | 1 | ||
| Single | 37(61.7%) | 23(38.3%) | 1.245(0.691–2.245) | 0.634(0.294–1.370) | 0.247 |
| Divorced | 9(30%) | 21(70%) | 0.332(0.145–.759) | 0.298(0.116–.764) | 0.012 |
| Widowed | 2(8%) | 23(92%) | .067(0.015–.293) | 0.115(0.025–.528) | 0.005 |
| Occupation | |||||
| Government Employee | 41(65.1%) | 22(34.9%) | 1.997(0.817–4.881) | 0.604(0.184–1.977) | 0.404 |
| Merchant | 15(42.9%) | 20(57.1%) | 0.804(0.299–2.161) | 0.582(0.184–1.846) | 0.358 |
| Private-employee | 36(44.4%) | 45(55.6%) | 0.857 (0.366–2.005) | 0.513(0.189–1.394) | 0.191 |
| House wife | 27(43.5%) | 35(56.5%) | 0.827(0.341–2.002) | 1.067(0.381–2.985) | 0.902 |
| Farmer | 14(48.3%) | 15(51.7%) | 1 | ||
| Student | 13(86.7%) | 2(13.3%) | 6.964(1.328–36.529) | 1.927(0.284–13.065) | 0.502 |
| Other | 17(50.0%) | 17(50.0%) | 1.071(0.398–2.887) | 0.818(0.251–2.662) | 0.738 |
| Attitude |
Attitude |
COR (95% CI) | AOR (95% CI) | P-value* | |
|---|---|---|---|---|---|
|
Positive Attitude |
Negative Attitude |
||||
|
Sex Male |
115(65.7%) | 60(34.3%) | 1 | ||
| Female | 76(52.8%) | 68(47.2%) | 0.583(0.371–0.917) | 0.471(0.265–0.837) | 0.01 |
| Age | |||||
| Below 50 years | 87(58.8%) | 61(41.2%) | 1 | ||
| 50 years and above | 104(60.8%) | 67(39.2%) | 1.088(0.695–1.705) | 0.712 | |
| Place of living | |||||
| Rural | 13(39.4%) | 20(60.6%) | 1 | 1 | |
| Urban | 168(62.7%) | 100(37.3%) | 2.585(1.232–5.422) | 1.119(0.360–3.480) | 0.846 |
| Semi-urban | 10(55.6%) | 8(44.4%) | 1.923(0.601–6.151) | 1.114(0.284–4.376) | 0.877 |
| Educational status | |||||
| No formal education | 37(48.7%) | 39(51.3%) | 1 | 1 | |
| Primary school | 56(60.9%) | 36(39.1%) | 1.640(0.887–3.031) | 1.218(0.621–2.390) | 0.566 |
| Secondary school | 32(58.2%) | 23(41.8%) | 1.467(0.729–2.952) | 1.251 (0.578–2.707) | 0.569 |
| College and above | 66(68.8%) | 30(31.3%) | 2.319(1.243–4.325) | 2.174 (0.919–5.142) | 0.077 |
| Religion | |||||
| Orthodox | 165(60.2%) | 109(39.8%) | 1 | ||
| Muslim | 20(58.8%) | 14(41.2%) | .944(0.457–1.948) | 0.875 | |
| Protestant | 2(66.7%) | 1(33.3%) | 1.321(0.118–14.749) | 0.821 | |
| Catholic | 4(50.0%) | 4(50.0%) | 0.661(0.162–2.697) | 0.564 | |
| Marital status | |||||
| Married | 126(61.8%) | 78(38.2%) | 1 | ||
| Single | 38(63.3%) | 22(36.7%) | 1.069(0.589–1.941) | .955(0.471–1.939) | 0.899 |
| Divorced | 16(53.3%) | 14(46.7%) | .707(0.327–1.529) | 1.065(0.457–2.482) | 0.884 |
| Widowed | 11(44.0%) | 14(56.0%) | .486(0.210–1.125) | .611(0.239–1.567) | 0.305 |
| Occupation | |||||
| Government Employee | 39(61.9%) | 24(38.1%) | 3.611(1.415–9.214) | 2.085(0.492–8.840) | 0.319 |
| Merchant | 25(71.4%) | 10(28.6%) | 5.556(1.895–16.286) | 4.697(1.174–18.795) | 0.029 |
| Private-employee | 55(67.9%) | 26(32.1%) | 4.701(1.884–11.732) | 4.484(1.182–17.008) | 0.027 |
| House wife | 36(58.1%) | 26(41.9%) | 3.077(1.209–7.834) | 5.292(1.372–20.414) | 0.016 |
| Farmer | 9(31.0%) | 20(69.0%) | 1 | 1 | |
| Student | 10(66.7%) | 5(33.3%) | 4.444(1.174–16.820) | 3.212(0.527–19.571) | 0.206 |
| Other | 17(50.0%) | 17(50.0%) | 2.222(.790–6.255) | 1.917(0.455–8.075) | 0.375 |
| Practice |
Practice |
COR (95% CI) | AOR (95% CI) | P-value* | |
|---|---|---|---|---|---|
| Good Practice | Poor Practice | ||||
| Male | 86(49.1%) | 89(50.9%) | 1 | 0.977 | |
| Female | 71(49.3%) | 73(50.7%) | 1.007 (.648–1.565) | ||
| Age | |||||
| Below 50 years | 79(53.4%) | 69(46.6%) | 1 | ||
| 50 years and above | 78(45.6%) | 93(54.4%) | .733(.471–1.139) | 1.022(.540–1.937) | 0.946 |
| Place of living | |||||
| Rural | 11(33.3%) | 22(66.7%) | 1 | 1 | |
| Urban | 135(50.4%) | 133(49.6%) | 2.030(.947–4.351) | 1.053(.297–3.738) | 0.936 |
| Semi-urban | 11(61.1%) | 7(38.9%) | 3.143(.954–10.356) | 1.961(.431–8.925) | 0.384 |
| Educational status | |||||
| No formal education | 30(39.5%) | 46(60.5%) | 1 | 1 | |
| Primary school | 38(41.3%) | 54(58.7%) | 1.079(.581–2.005) | .733(.347–1.551) | 0.417 |
| Secondary school | 35(63.6%) | 20(36.4%) | 2.683(1.311–5.494) | 1.659(.642–4.285) | 0.296 |
| College and above | 54(56.3%) | 42(43.8%) | 1.971(1.069–3.634) | .874(.331–2.307) | 0.786 |
| Religion | |||||
| Orthodox | 136(49.6%) | 138(50.4%) | 1 | 1 | |
| Muslim | 17(50.0%) | 17(50.0%) | 2.957(.586–14.906) | 1.291(.544–3.060) | 0.562 |
| Protestant | 2(66.7%) | 1(33.3%) | 3.000(.529–17.020) | 1.478(.098–22.325) | 0.778 |
| Catholic | 2(25.0%) | 6(75.0%) | 6.000(.335–107.420) | .301(.050–1.794) | 0.187 |
| Marital status | |||||
| Married | 104(51.0%) | 100(49.0%) | 1 | 1 | |
| Single | 32(53.3%) | 28(46.7%) | 1.099(.617–1.956) | 1.260(.592–2.683) | 0.548 |
| Divorced | 11(36.7%) | 19(63.3%) | .557(.252–1.229) | .632(.242–1.650) | 0.349 |
| Widowed | 10(40.0%) | 15(60.0%) | .641(.275–1.494) | 1.298(.467–3.608) | 0.617 |
| Occupation | |||||
| Government Employee | 33(52.4%) | 30(47.6%) | 2.887(1.114–7.486) | 1.848(.369–9.253) | 0.455 |
| Merchant | 22(62.9%) | 13(37.1%) | 4.442(1.532–12.880) | 3.427(.708–16.598) | 0.126 |
| Private-employee | 34(42.0%) | 47(58.0%) | 1.899(.752–4.795) | 1.194(.267–5.330) | 0.816 |
| House wife | 32(51.6%) | 30(48.4%) | 2.800(1.078–7.273) | 2.279(.540–9.626) | 0.262 |
| Farmer | 8(27.6%) | 21(72.4%) | 1 | 1 | |
| Student | 8(53.3%) | 7(46.7%) | 3.000(.817–11.017) | 1.048(.149–7.368) | 0.962 |
| Other(**) | 20(58.8%) | 14(41.2%) | 3.750(1.296–10.854) | 3.672(.714–18.871) | 0.119 |
| Overall knowledge | |||||
| Poor knowledge | 56(35.9%) | 100(64.1%) | 1 | 1 | |
| Good Knowledge | 101(62.0%) | 62(38.0%) | 2.909(1.846–4.585) | 4.047(2.205–7.427) | 0.000 |
| Overall attitude | |||||
| Negative attitude | 37(28.9%) | 91(71.1%) | 1 | 1 | |
| Positive attitude | 120(62.8%) | 71(37.2%) | 4.157(2.567–6.730) | 5.756(3.244–10.211) | 0.000 |
**Retired … * bivariate p < 0.25, multivariate p < 0.05 were considered significant.
The knowledgeable respondents were four times more likely to have good practices than respondents with poor knowledge (AOR = 4.047, 95% CI = 2.205–7.427). The respondents with positive attitudes were 5.8 times more likely to practice good behavior compared to those with negative attitudes (AOR = 5.756, 95% CI = 3.244–10.211) (Table 5).
4. Discussion
For effective prevention and control of the COVID-19 pandemic, improving chronic disease patients' knowledge, attitude, and practice (KAP) towards COVID-19 is a critical factor (20–25). Previous studies also stated that having good knowledge, attitude, and practices are instruments that can hopefully be utilized to restrict the spread of COVID-19 [[40], [41], [42]]. Therefore, this study aimed to assess the KAP towards COVID-19 and associated factors among chronic disease patients in public hospitals in Mekelle, Tigray, Ethiopia. In this study, out of a total of 319 study participants, 51.1% (95% C.I. = 0.4551, 0.5649) had good knowledge regarding the COVID-19 pandemic. This result is higher than those of studies done in North West Ethiopia (33.9%) [40], Jimma, Ethiopia (41.3%) [33], Sidama, Ethiopia (43.9%) [43], Egypt (13.39%) [44], and India (12%) [45]. The disparity could be caused by variations in the cut-values used to classify the knowledge levels (in this study, poor and good knowledge were dichotomized using the median knowledge score as the cutoff value) and the socio-demographic characteristics of the study participants. Study setting differences may be another reason for result variation. However, it is lower than the findings from south west Ethiopia (81.8%) [46], Iran (90%) [47], and Pakistan (93.2%) [48]. These inconsistencies may be related to variations in socio-demographic characteristics, study settings, the cut-values employed to classify study participants' knowledge levels, study participants, and the ability of the health care systems of the countries to raise awareness of the pandemic (health care facilities were looted and damaged as a result of the ongoing fighting in the region, which includes the study area). For instance, this study was entirely done in a study setting when there is very limited mass media and other media exposure due to ongoing war and being the region under blockage, whereas other studies done in study settings having access to mass media and other high levels of social media exposure that help respondents to keep oneself informed about COVID-19. Online access to health information that can enhance respondents' knowledge and practice is growing [49], but it was unavailable to the Tigray region due to the ongoing war. Furthermore, similar finding with current result was reported by the study conducted at Debre Tabor, northwest Ethiopia (52.1%) [50]. Regarding COVID-19 transmission, the result revealed that traveling to an infectious area, meeting someone who traveled to an infectious area and respiratory droplets of infected individuals through the air during sneezing or coughing were reported as means of COVID-19 transmission by 89.3%, 94.7%, and 80.3% of the study participants respectively. However, only 27.6% of study participants stated that COVID-19 patients who are afebrile cannot spread the virus to others, which is less than the study’s finding that 56.4% of respondents recognized that people with COVID-19 cannot spread the virus to others if they are symptom-free [40]. But this finding is higher than a study done in a similar setting where only 15.7% of the respondents knew the possibility for asymptomatic transmission of COVID-19 [51]. This is insufficient because everyone should be aware of it and take precautions against the pandemic, even if they are asymptomatic. In terms of COVID-19 prevention methods, avoiding crowded places (81.2%), frequently washing hands with soap and water for at least 20 s or using 60% alcohol-based hand sanitizer (86.2%), and isolating and treating COVID-19 infected individuals (84%) were cited as the most effective strategies. The management of the COVID-19 disease would be significantly altered if this knowledge had been put into practice. This is consistent with other study done in addis zemen hospital, Northwest Ethiopia [40].
Additionally, the current study also revealed that more than half, 59.9% (95% C.I. = 0.5452, 0.6528) of the chronic disease patients had a positive attitude towards COVID-19 precautions. This finding is in line with a study done among chronic disease patients in Ethiopia, Axum (59.5%) [52]. This similarity might be due to the same characteristics (both chronically ill patients) of the respondents having a similar setting and the similar methods of data analysis. However, this finding is lower than the study done among chronic disease patients in Dessie Town, Ethiopia (81.4%) [51], Sudan [53] and Kigali, Rwanda (74%) [54]. This might be due to differences in socio-demographic characteristics of the respondents and lack of information access in the Tigray regional state due to ongoing war while it was available in the Amhara region of Ethiopia and Rwanda at the study periods. Furthermore, it was also noted that the result of the current study is higher than other studies done among the general public such as studies done in Sidama, Ethiopia (37.5%) [43], Mizan Tepi University, Ethiopia (54.0%) [55], and Bangladeshis (52.4%) [56]. The difference in the study population which shows that people with chronic diseases have a more positive attitude toward the COVID-19 preventative strategies, and the discrepancies in the study periods and methodologies may be the reason for variation in results. Moreover, one third of the study participants (33.2%) perceive that their risk of infection is relatively great with COVID-19 and about 32.6% of these study participants perceive that it is easy to avoid shaking others' hands. This study finding is higher than the study done in Addis Zemen Hospital, Northwest Ethiopia (19.8% high risk) and 21% respectively [40].
Regarding the practice of these chronic disease patients towards COVID-19, about half, 49.2% (95% C.I. = 0.4371, 0.5469) of them had good practice. This study result is higher than studies done among similar study populations in Dessie town, Ethiopia (40.7%) (48) and in Addis Zemen Hospital, Northwest Ethiopia (25.9%) [40]. This discrepancy may be due to the difference in socio-demographic characteristics, the study periods, study methods and the difference among the states on the practice of precaution methods. However, this finding (49.2%) is lower than the study done among people living with HIV/AIDS in Kigali, Rwanda (90%) [54]. This might be due to the difference in the access of information about COVID-19, socio-demographic characteristics and study setting. Moreover the present research finding is higher as compared with general community based study done in Mizan Tepi University, Southwest Ethiopia (42.8%) [55]. But, it is lower than results reported by study done in Sidama, Ethiopia (65%) [43]. The reason for this inconsistency could be due to the difference in the type of study population, sample size, study period and access to information about COVID 19. A prior study conducted in Bangladesh (44.8%) showed study results that were similar to the findings of the current research work [56]. It was also noted that only 20.7% of the study participants had reported that they don’t participate in social gatherings where mass of people present. This finding is not parallel with the study done in Axum, Ethiopia (37.7%) [52], Jimma, Ethiopia (33.7%) [33], Addis Zemen, Ethiopia (38.1%) [40], Mizan Tepi University, Ethiopia (61.4%) [55] and Bangladesh (80.49%) [56] which reported a higher percentage of study participants who avoided social gathering than did this study. However it is higher than the study conducted in Malaysia (16.4%) [57]. Moreover, majority (67.7%) of the study participants had worn a mask while leaving home which is comparable to the study conducted in Sidama, Ethiopia (67.1%) [43]. But this study result is higher than the findings of the study done in Axum, Ethiopia (33.4%) [52], Jimma, Ethiopia (14.2%) [33], Addis Zemen, Ethiopia (36%) [40], Mizan Tepi University Ethiopia (45%) [55], Malaysia (50.7%) [57], and Syria (27.9%) [58]. However, it is lower than the result reported by a study done in Ethiopia (77.2%) [51], Bangladesh (79.23%) [56] and China (98%) [59]. In addition to this, more than half (61.4%) of study participants wash their hands with soap and water frequently for at least 20 s or use sanitizer with 60% alcohol. This result is less than studies in Axum, Ethiopia (64.5%) [52], Addis Zemen, Ethiopia (65.5%) [40], Mizan Tepi University, Ethiopia (64.2%) [55], Sidama, Ethiopia (96%) [43], Malaysia (87%) [57], Pakistan (85.5%) [48], Sudan (69.3%) [53] and India (100%) [44]. The study’s findings also showed that only 21.6% of respondents practice physical distancing which is also lower than studies done in Axum, Ethiopia (28.4%) [52], Dessie, Ethiopia (81.6%) [51], Addis Zemen, Ethiopia (29.9%) [40], Mizan Tepi University, Ethiopia (39.3%) [55], Sidama, Ethiopia (56.8%) [43], Sudan (60.9%) [53], Pakistan (92.8%) [48] and study in India (96%) [45]. Less than half (38.9%) of the study participants in this study restrict themselves to a handshake, which is also lower than studies conducted in Ethiopia: Axum (73.9%) [52], Addis Zemen (71.7%) [40], Jimma (53.8%) [33], Sidama (81%) [43], and studies done in Syria (82%) [58]. However, the current finding is higher than the study done in Sudan (27%) [53]. These discrepancies might be due to the variation in access to information about COVID-19 prevention measures, which is limited in the Tigray regional state of Ethiopia due to ongoing conflict, the type of study participants, and their socio-demographic features.
The multivariate analysis result revealed that the socio-demographic variables age, education level, and marital status were significantly associated with having good knowledge. Accordingly, chronic disease patients aged 50 or older were 58.5% less likely to have good knowledge compared to those who were younger than 50 years old. This finding is in parallel with a study done in Axum, Ethiopia [52] and Addis Zemen, Ethiopia [40], which reported that older age is associated with poor knowledge. As age increases, hearing ability and visual performance decrease due to physiological changes, making it challenging to access information as easily as when you were younger. But this result is not in agreement with a study done in Sudan [53], which revealed that better knowledge was associated with older age. This contradiction might be attributed to the cuts of points utilized in order to categorize the age, which was 50 years and older in our case but 30 years and older in their case, and the difference in the types of study participants (chronic disease patients and the general population). Regarding the educational status, study participants who completed secondary school, college, or levels above were 4.7 and 4.6 times more knowledgeable than those who did not start formal education, respectively. This result is consistent with that of the studies in Addis Zemen, Ethiopia [36], Axum, Ethiopia [52], Dessie, Ethiopia [51], and Debre Tabor, Ethiopia [50], which showed that participants who didn’t start formal education or were illiterate were more likely to be associated with poor knowledge than those with an educational status of secondary or above, which could be because patients with higher levels of education would have more knowledge than those who are illiterate, who may have a diminished capacity for understanding health information and COVID-19 prevention activities. Study participants who were divorced and widowed had 70.2% and 88.5% times less odds of having good knowledge compared to married respondents, respectively, which is not consistent with many other studies done in similar settings to find a significant association between marital status and good knowledge, but this may be justified with the possible reason that married participants could have a stable life and information access. According to our findings, customized techniques for particular socio-demographic groups like the elderly, uneducated, divorced, and those with widowed marital status are crucial for improving public education support programs for COVID-19 understanding. Concerning the association of socio-demographic factors with positive attitude, the multivariate logistic regression analysis result showed that sex and occupation variables were found to be significantly associated with the attitude of the respondents. The female sex respondents were 52.9% less likely to have a positive attitude than male respondents. This finding is in line with the study done in Syria [58], which showed that male participants were more associated with having positive attitudes towards COVID-19 prevention methods compared to their female counterparts. The possible justification for this result could be that the male gender is the one who gets much exposure to community, media, and other communication channels compared to females, especially in this study setting at this time. But, this finding is not in agreement with the finding of a study done in Dessie, Ethiopia [51] which revealed that females are more likely to have positive attitudes toward COVID-19 preventions. Our study also showed that merchants, private employees, and housewives were 4.7, 4.5, and 5.3 times more likely to have a positive attitude compared to farmer respondents, respectively. This finding is similar to that of a study done in Rwanda [54] that showed self-employed individuals had higher attitude scores. This can be justified by the fact that farmer respondents in our setting have a lesser opportunity for health information access because they are mostly residents of rural areas where there is limited health information access. Good knowledge and a positive attitude of the study participants were found to be significantly associated with the respondents good practices towards COVID-19 prevention and control methods, while other socio-demographic variables were not significantly associated. The knowledgeable respondents and the respondents with a positive attitude were 4 times and 5.8 times more likely to have good practices compared to respondents with poor knowledge and a negative attitude, respectively. This finding is consistent with the studies done in Addis Zemen, Ethiopia [40], Dessie, Ethiopia [51], Mizan Tepi University, Ethiopia [55], and Sidama, Ethiopia [43], which found that good knowledge and a positive attitude towards COVID-19 were significantly associated with good practice towards it. The Knowledge-Attitude-Practice (KAP) hypothesis, which contends that changing one’s behavior involves a step-by-step process that starts with acquiring knowledge, progresses to attitude formation, and ends with the adoption of practice supports the current finding [60]. However, this finding is contrary to the study done in Sudan [53], which found no association between the knowledge and attitude of respondents' with their practices towards COVID-19 prevention.
5. Strengths and limitations of the study
As strength, this study used a systematic random sampling technique to avoid subjective selection bias, which was lacking in past comparable investigations. To the best of our knowledge, this is the first study to assess the level of knowledge, attitude, and practices about COVID-19 among patients with diabetes mellitus and hypertension, who are frequently at a higher risk for more serious infection related effects. Moreover, policymakers and program implementers who are working to improve the KAP of chronic disease patients towards COVID-19 via health education will be encouraged and alerted by the study’s findings. Despite its strength, this study has significant drawbacks that should be taken into account when interpreting the findings. This study was conducted among chronic disease patients, so it was unable to compare the knowledge, attitude, and practice of individuals with and without chronic diseases. Furthermore, because the study was cross-sectional, we were unable to demonstrate the cause-and-effect relationship between an independent variable and the outcome variables. Further research should include people with HIV, chronic heart disease, and other chronic diseases since this study only takes into account the patients with DM and hypertension.
6. Conclusion
In conclusion, this study showed that only two-thirds of chronic disease patients had good knowledge, attitude, and practice towards the COVID-19 preventive mechanism. Socio-demographic variables like age (younger than 50 years old), completion of secondary school, college, and higher educational levels, and being married were positively associated with having good knowledge. Male sex and occupation (merchants, private employees, and housewives) were significantly associated with a positive attitude. Additionally, positive attitudes and adequate understanding of COVID-19 were factors significantly associated with study participants’ good practices towards COVID-19 prevention and control. Therefore, health authorities should focus on improving the knowledge, attitude, and practice of chronic disease patients towards the COVID-19 pandemic via health education programs. In addition, the healthcare professionals working in the chronic outpatient department should give their patients thorough information on COVID-19, especially if they are older, have less education than a high school diploma, are single, female, or farmers.
Declarations
Author contribution statement
Yonas Moges Legese; Shifare Berhe Gebru: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.
Asqual Gebreslassie Gebremariam; Zewde Abraha Tesfay: Analyzed and interpreted the data.
Funding statement
The funding for this research was provided by Mekelle University, College of Health Sciences, under project number RDPDO/MU/CHS/GeneralJunier/024/13.
Data availability statement
Data will be made available on request.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
Acknowledgments
The authors would like to thank Mekelle University for funding this research work. We also want to convey our sincere gratitude to the study's participants for giving up their time during the interviews and to the data collectors for their dedication throughout the research period.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2023.e17734.
Appendix A. Supplementary data
The following is the Supplementary data to this article.
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Associated Data
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Supplementary Materials
Data Availability Statement
Data will be made available on request.