Adherence to COVID-19 preventive measures and associated factors among high school students in Northwest Ethiopia: a cross-sectional study

Abstract

Background

The novel coronavirus disease 2019 (COVID-19) is a respiratory infection that is spreading worldwide. The WHO has recommended public health preventive measures for COVID-19 prevention and control. Adherence to COVID-19 preventive measures is important for disease prevention and control of the disease’s spread. So, implementing preventive measures plays an essential role in reducing the spread of COVID-19 infection. This study aimed to assess the adherence status toward COVID-19 preventive measures and associated factors among high school students.

Methods

528 high school students participated in an institutional-based cross-sectional study. A multistage sampling technique and a systematic random sampling method were applied to select the study participants. The data was entered into EpiData V.3.1 and then exported to SPSS V.23 for analysis. Bivariate and multivariable logistic regressions were computed. The significance of the association was declared by a 95% CI of adjusted OR (AOR) and a p value<0.05 in the multivariate model.

Result

A total of 528 respondents participated in the study, with a 100% response rate. The overall adherence level of high school students toward COVID-19 prevention measures was 110 (20.8%, 95% CI: 17.4%, 24.6%). The mean(±SD) age of the respondents was 18 (SD 11±2) years, which ranges from 16 to 24 years, and 387 (73.3%) were in the age group of 19–20 years, The majority of the students (418; 79.2%, 95% CI: 75.4, 82.6) had poor adherence to COVID-19 preventive measures. 345 (65.3%) had good knowledge, 328 (62.1%) had unfavourable attitudes and 390 (73.9%) had poor risk perception for COVID-19 preventive measures. This study revealed that most (89.9%) of the high school students did not maintain a physical distance of 2 m away, 84.4% of the students had no regular handwashing practice, majority 71.4% of the students did not use facemasks/covered their face during coughing and 62.9% of the students had no face mask and 54% of the students did not use sanitiser or alcohol per recommendation. This study revealed that sex (AOR: 2.42, 95% CI: 1.46, 4.02), attitude (AOR: 4.04, 95% CI: 2.45, 6.68) and risk perception (AOR: 7.60, 95% CI: 4.62, 12.54) were significantly associated with poor adherence toward COVID-19 prevention measures.

Conclusion

This study’s findings revealed that adherence to COVID-19 preventive measures among high school students was very low. Therefore, promoting adherence to COVID-19 preventive measures demands awareness creation and risk communication to build an appropriate level of knowledge, attitude and risk perception.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Good knowledge status of people toward COVID-19 prevention measures was found to be good adherence practice toward COVID-19 prevention measures.

WHAT THIS STUDY ADDS

• Assessing adherence to COVID-19 prevention measures among students can provide valuable insights into their adherence to public prevention measure protocol and their impacts on controlling the spread of the virus within education settings.

• This could be due to most students unfavourable attitudes and low-risk perception towards COVID-19 prevention measures.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• By examining prevention measures among students, the study can evaluate student practice to prevention measures in reducing COVID-19 transmission. The findings from this study can provide practitioners (clinicians and educators) with evidence-based information to inform their practices. This finding might help health educational programmes to develop a guideline for implementing effective strategies in real-world settings to prevent the spread of infectious diseases.

Background

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 is a respiratory illness that affects the human respiratory system. COVID-19 has spread to practically all continents of the world. The COVID-19 disease has been a public health risk of international concern.¹ COVID-19 is a globally spreading respiratory disease also called the SARS-CoV-2 virus.² COVID-19 was first reported in December 2019, in Wuhan, Hubei province, China.³ The WHO declared the COVID-19 outbreak a public health emergency international concern on 30 January 2020.⁴ In a couple of weeks, the COVID-19 pandemic spread from Wuhan, China, to the rest of the world, with exponentially increasing numbers of infected patients and fatalities worldwide.⁵

On 12 March 2020, WHO labelled COVID-19 as a pandemic disease.⁶ Ethiopia’s Federal Ministry of Health announced a COVID-19 case in the capital, Addis Ababa, on 13 March 2020, which was the first case recorded in Ethiopia since the epidemic began.⁷ On 8 April 2020, a state of emergency was declared to prevent the spread of COVID-19. On the ground, however, none of the recommended preventive and control measures are practical. On the other hand, information about the disease and its preventive mechanisms were not widely distributed in rural communities.⁸

The cases and deaths due to COVID-19 are still public health problems globally and concerning for developing countries. Globally, on 21 September 2023, there have been 770 778 396 confirmed cases of COVID-19, including 6 958 499 deaths.⁹ Researchers believe that the COVID-19 pandemic can seriously affect African nations because of the weak healthcare system, crowding, poor hygiene practices and poverty can make the epidemic out of control.¹⁰ In Africa, because of low testing capacity, weak contact tracing and poor reporting systems, the number of cases and deaths is low as compared with developed nations.¹¹ In Africa, as of 2 January 2023, 12 216 748 cases were recorded with 256 542 deaths and 11 517 41 recoveries having been reported.¹²

COVID-19 is transmitted from person to person mostly by respiratory droplets, close contact of healthy people with infected people (within 6 f) when talking, sneezing and coughing, and indirect contact with contaminated items or surfaces.^{13 14} The virus is typically spread from one person to another via respiratory droplets produced during coughing. It may also be spread by touching contaminated surfaces and then touching one’s face.¹⁵ Persons with confirmed COVID-19 viruses have clinical signs of fever, cough, shortness of breath, and sore throat within 14 days of the incubation period.^{16 17}

WHO highly recommends COVID-19 preventive measures to prevent the spread of the disease, including keeping a physical distance, avoiding going to crowed gatherings, regular handwashing with soap or sanitiser, wearing a face mask, covering the mouth when coughing and sneezing and avoiding the touch of mouth, nose and eye.^{18 19} African countries including Ethiopia have accepted and practiced WHO recommendations for preventive measures.²⁰

The adherence level to COVID-19 preventive measures in Africa was reported low, about 12.3% adhered to recommended COVID-19 preventive measure.^{21 22}

Poor adherence to the recommended public health prevention strategies and poor socioeconomic status are the main barriers to breaking the transmission of COVID-19 in its infancy stage.^{8 11}

Even though many countries in Africa scaled up their preparation and readiness to tackle the COVID-19 pandemic, shortages of testing kits, poor tracing systems, poor healthcare systems, PPE (personal protective equipment), shortage of laboratories and negligence of the public toward the preventive measures are the big challenges for the continent.^{11 23 24} The best way to transmission prevention measures depend on educating the public about the preventive measures including physical distancing, regular handwashing with soap or sanitiser, environmental cleaning, avoiding mass gatherings and mask wearing.²³

COVID-19 preventive measures implementation is very low in Ethiopia. A nationwide finding revealed that in Ethiopia only 24.3% of the respondents were engaged with the recommended preventive measures.⁸ Some research revealed that in Ethiopia adherence to preventive measures for COVID-19 was only 12.3% regardless of the knowledge and attitude towards the virus.¹⁴ In Ethiopia there were factors for poor control of the viral transmission and implementation of COVID-19 preventive measures, including limited supplies of handwashing sanitisers, high resistance to implementation of recommended prevention practice and low socioeconomic status.

Schools are one of the institutions that have a lot of students and teachers who come from different places and stay in congested areas like classrooms or staff rooms which increases the risk of COVID-19 transmission. Also, students come from different directions, and can easily increase the chance of COVID-19 spreading in the community other than other members of the community. The Ethiopian government announced school opening, while the level of adherence to preventive measures had not been reported in Ethiopia among students and there is an information gap, therefore, this study was conducted to fill the information gap on the level of adherence to COVID-19 preventive measures among students. Therefore it is important to assess student knowledge, attitude, practice status and factors affecting to practice of recommended public health prevention measures. School is also an important setting in applying and creating awareness in the community adhering to the recommended public health prevention measure. Repeated research has been done at the community level on COVID-19 prevention measures. However, there is a lack of evidence-based information on high school students. To the best of our knowledge, few studies have been conducted on the level of adherence and factors affecting students’ adherence to COVID-19 preventive measures. This study aimed to assess the adherence status of high school students toward COVID-19 preventive measures and associate factors with non-adherence to COVID-19 preventive measures. So, the findings of this study help strengthen preventive measures to reduce the spread of COVID-19, resulting in decreased morbidity and death due to COVID-19.

Method and material

Study area and period

The study was conducted among high school students in Assosa town, in the Benishangul-Gumuz regional state of Northwest Ethiopia from 15 April 2021 to 30 April 2021. Assosa town is 657 km from Addis Ababa (the capital city of Ethiopia). Assosa town is the capital city of the Benishangul-Gumuz regional state. The region is bordered by the Amhara region in the north and northeastern and the Oromia region in the east and south. The geographical location of Assosa is 10° 04' to 10° 67' north and 34° 31' to 34° 517' east.

Study design

An institutional-based cross-sectional study was conducted among high school students in Assosa town, Northwest Ethiopia.

Study population and study population

All high school students attending high school education in Assosa town, Benishangul Gumuz, Northwest Ethiopia, in 2021 were the source population. All randomly selected high school students (grades 9th and 12th) in Assosa town high schools during data collection were the study population.

Inclusion and exclusion criteria

A student who was healthy and available during the data collection was included in the study and students who were in severe health problems and not available during the data collection were excluded.

Sample size determination

The sample size was determined by using a formula for single population proportion by considering assumptions such as; a 95% confidence level, 5% margin of error and 50% proportion (there was no available previous research finding adherence status to COVID-19 preventive measures among students).

$${\displaystyle n=Z^{2}p(1-p)/w^2}$$ (1)

$${\displaystyle \frac{n=z\alpha /2^2\ast p(1-p)}{d2}\frac{n=(1.96{)}^{2}0.5(1-0.5)}{(0.05)2}=384}$$ (2)

Since it was a multistage sampling technique, a design effect of 1.5 was used to make our sample size more representative, 384×1.5=576

The population size of students was<10 000(N=2867), so the required minimum sample was obtained by using the correction formula, n/1+ (n/N) = 576/1+ (576/2867) = 480. By considering 10% for the non-response rate the final sample size was 528.

Sampling technique

A multistage sampling technique and then a systematic random sampling technique were employed to select study participants who fulfilled the inclusion criteria from high school students in Assosa town, Northwest Ethiopia. Students were selected using admission registration numbers from their roster and then students’ samples were proportionally selected from each high school.

Sampling procedure

Students were selected from four high schools, three governmental high schools and one private high school. Each high school’s students were selected by proportional allocation based on the number of students they enrolled in each high school. Finally, a systematic random sampling technique was employed to select study participants from four selected high schools. Students in each grade level were selected randomly. The first student was selected by the lottery method using their registration serial number, and the remaining students were selected at regular intervals of eight until the allocated sample size was reached.

Data collection instrument and procedure

A questionnaire was adapted after reviewing previous similar studies.^{20 25 26} A self-administered questionnaire with five parts was used for data collection. The first question concerns the socio-demographic background of students; the second question concerns the adherence level of students toward COVID-19 prevention measures; the third question concerns knowledge of COVID-19; the fourth question concerns attitude toward COVID-19; and the last question is concerned with the perception of COVID-19 prevention measures (online supplemental survey questionnaire 1).

Data quality control

Data collection was adapted from previous literature and adapted to the study setting with some modifications to the study area and participants. Before data collection, it was re-translated back to English to verify consistency. A pre-test was conducted among 5% of the study sample size that was randomly selected from participants out of the study to verify the appropriateness for validity, and then the data were checked for internal consistency and modifications were made accordingly. The data were checked at the moment of collection from students for completeness. Finally, data collection was supervised by a teacher for each class. Each student was responding to only the provided questionnaire.

Data processed and analysed

After data completeness and consistency were checked the collected data were coded and entered the data was entered into EpiData V.3.1 and then exported into SPSS V.23 software for analysis. Descriptive statistics were computed to measure the level of adherence to the COVID-19 preventive measure. Multicollinearity will be checked by using variance inflation factor, to test whether the associated independent variables were correlated or not. Hosmer-Lemeshow goodness-of-fit and the omnibus test were used to test the fattiness of the model. Bivariate logistic regression analysis was computed. Then multivariable logistic regression was computed for a variable with a p value<0.25 from binary logistic regression. From multivariable logistic regression p value<0.05 along with 95% CI and corresponding adjusted OR (AOR) was used to identify factors in the final multivariable model. Finally, the independent variables with a p value<0.05 with 95% CI were used to declare statistically significant with the outcome variable.

Operational definitions

Adherence to COVID-19 prevention measures is a variable that can be generated from keeping physical distancing 2 m and above, frequent handwashing, avoiding overcrowded places, staying home, using sanitiser or alcohol and wearing face masks so the individual was considered to have good adherence if he/she can response ‘YES’ to the median and above of the mentioned variables.

Knowledge: Participants who responded with a median and above score on the knowledge items about COVID-19 were labelled as having good knowledge whereas those below the median were labelled as having poor knowledge

Attitude: Participants who responded with a median and above score on the attitude questions about COVID-19 and its preventive measures were labelled as having a favourable attitude whereas below the median were labelled with an unfavourable attitude.

Risk perception of COVID-19 infection: Risk perception was measured by parameters; perceived susceptibility and perceived severity. The first dimension was proxies by how likely one considered oneself would be infected with COVID-19 if no preventive measures were taken. The second dimension was proxies by how one rated the seriousness of symptoms caused by COVID-19, their perceived chance of having COVID-19 cured and that of survival if infected with COVID-19. By combining the two dimensions, response options were asked to determine the respondents’ levels of risk perception.

Patient and public involvement

No patients or the public were involved in the development of the research question, design, conduct, analysis and interpretation of study results.

Results

Respondents’ socio-demographic characteristics

In this study, a total of 528 respondents participated. The mean (±SD) age of the respondents was 18 (SD 11±2) years, which ranges from 16 to 24 years. Above half of the respondents, 387 (73.3%) were in the age group of 19–20 years. Out of all respondents, more than half 273 (51.7%) of them were male and 255 (48.3%) were female. 201 (38.1%) of the participants were from the Amhara ethnic group and 136 (25.8%) were from the Oromo ethnic group. More than half 331 (62.68%) of the study participants were Orthodox religious followers. Regarding occupation, more than one-third 234 (44.3%) and 283 (53.6%) of the participant’s mothers and fathers are government employees, respectively. Furthermore, on average more than half 427 (80.9%) of the family members are four and above in the same household (table 1).

Table 1. Respondents’ socio-demographic characteristics among high school students in Assosa town, Northwest Ethiopia.

Variable	Frequency	Per cent (%)
Sex
Male	273	51.7
Female	255	48.3
Age group
16–18	115	21.8
19–20	387	73.3
21–24	26	4.9
Religion
Orthodox	331	62.68
Muslim	99	18.8
Protestant	91	17.2
Other	7	1.32
Ethnicity
Amhara	201	38.1
Oromo	136	25.8
Shinasha	65	12.3
Gumuz	67	12.7
Berta	41	7.8
Others	18	3.4
Mother education status
No formal education	164	31.1
Formal education	364	68.9
Father education status
No formal education	75	14.21
Formal education	453	85.79
Mother occupation
Governmental employee	234	44.3
Private employee	22	6.6
Merchant	102	19.32
Housewife	121	22.9
Daily worker	34	6.4
Others	5	0.9
Father occupation
Governmental employee	283	53.6
Private employee	16	3.03
Daily worker	58	11
Merchant	138	26.1
Driver	33	6.2
Number of family members
≥4	427	80.9
<4	101	19.1

Adherence to COVID-19 prevention measures

This study found that the overall adherence toward COVID-19 preventive measures was 110 (20.8%, 95% CI: 17.4%, 24.6%) among high school students. while the remaining 418 (79.2%) the majority of students had poor adherence to the COVID-19 preventive measure (figure 1).

Figure 1. Adherence to COVID-19 preventive measures among high school students in Assosa town, Northwest Ethiopia 2021.

Among the preventive measures wearing face masks were not practiced by 332 (62.9%) of the students. More than two-thirds 383 (72.5%) of the students do not keep physical distancing as recommended. Similarly, about 446 (84.4%) of the students did not practice regular handwashing with soap as recommended (table 2).

Table 2. Adherence toward COVID-19 preventive measures among high school students in Assosa town, Northwest Ethiopia.

Variable	Frequency	Per cent (%)
Do you keep physical distance of 2 m and above (6 feet apart)?
Yes	145	27.5
No	383	72.5
Wearing face mask
Yes	196	37.1
No	332	62.9
Do you avoid greeting with handshaking, embracing and checking, to kiss?
Yes	145	27.5
No	383	72.5
Do you use any cover/elbow during coughing and sneezing?
Yes	151	28.6
No	377	71.4
Do you avoid touching your eyes, nose and mouth with unwashed hands or fingers?
Yes	192	36.4
No	336	63.6
Regular handwashing with soap
Yes	82	15.6
No	446	84.4
Do you use sanitiser or alcohol for disinfection of the surface and hand?
Yes	243	46
No	285	54
Have you been practicing stay-at-home rule/avoid unnecessary group at home
Yes	192	36.4
No	336	63.6
Did you go to crowded places like markets or ceremony during the COVID-19 pandemic?
Yes	428	81.1
No	100	18.9
Do you share personal properties (pen, book, drawing materials) with other students?
Yes	327	61.9
No	201	38.1
Do you remove your uniform immediately when you reach home and put it in a separate place?
Yes	381	72.2
No	147	27.8
Is water and soap easily available in your school?
Yes	191	36.2
No	337	63.8
Is your class cleaned daily by using soap, water and sanitiser regularly?
Yes	108	20.5
No	420	79.5
Is there any rule that punishes student who fails to practice COVID-19 prevention measures in your school?
Yes	120	22.72
No	408	78.28

Knowledge of COVID-19 prevention measures among high school students in Assosa town, Northwest Ethiopia

More than half of the study participants 345 (65.3%) had good knowledge of COVID-19 and the rest 183 (34.7%) had poor knowledge. Of the respondents, 435 (82.4) know the main clinical symptom of COVID-19, 47 (8.9%) believe that a person who has no symptoms of COVID-19 cannot transmit the disease to others and 185 (35%) of the study participants believe that a COVID-19 positive person can show no symptoms, 378 (71.6) of the participants are aware that not going to crowded places is one way of preventing COVID-19. This study also revealed that 481 (80.68%) of students are not aware that a person with no COVID-19 symptoms can transmit the virus to others and infect them (table 3).

Table 3. Knowledge of COVID-19 prevention measures among high school students in Assosa town, Northwest Ethiopia.

Variable		Frequency	Per cent (%)
Is the main clinical symptom of COVID-19 are fever, fatigue, dry cough and body aches?
	Yes	435	82.4
	No	93	17.6
A person infected with COVID-19 had a severe headache, stuffy nose, runny nose and sneezing
	Yes	320	60.61
	No	208	39.39
Currently, there is no effective cure for COVID-19 patients
	Yes	149	28.2
	No	379	71.8
Not all persons with COVID-19 develop into severe cases
	Yes	330	62.5
	No	198	37.5
A person with no COVID-19 symptoms can transmit COVID-19 to others and infect
	Yes	102	19.32
	No	481	80.68
COVID-19 virus spreads via respiratory droplets of infected individuals during coughing/sneezing
	Yes	287	54.4
	No	241	45.6
COVID-19 disease transmission can be prevented by avoiding going to crowded places and mass gathering events
	Yes	378	71.6
	No	150	28.4
Isolation and quarantine of people infected with COVID-19 virus can reduce the spread of the virus
	Yes	201	38.1
	No	327	61.9
People in contact with those infected with the COVID-19 virus should be immediately isolated and quarantined for 14 days
	Yes	372	70.45
	No	156	29.55
COVID-19 disease prevention is not touching the eye, nose or mouth with unwashed hands
	Yes	384	72.7
	No	144	27.3
Frequent handwashing with soap and water is a COVID-19 prevention measure
	Yes	294	55.7
	No	234	44.3
Anyone can be infected or can get infected with COVID-19 disease?
	Yes	436	82.6
	No	92	17.4
Have you heard about preventive measures taken by the government/health professionals
	Yes	476	90.2
	No	52	9.8
Do you know common COVID-19 transmission ways?
	Yes	340	64.39
	No	188	35.61
Do you know COVID-19 transmission preventive measures?
	Yes	190	35.98
	No	338	64.02
Which of the following practices can prevent COVID-19 transmission?
Regular handwashing with soap and water	Yes	185	35.03
	No	343	64.97
Use of hand sanitisers after touching material	Yes	127	24.05
	No	401	75.95
Wearing a face mask	Yes	215	40.72
	No	313	59.28
Keeping physical distance for about 2 feet (2 m)	Yes	146	27.65
	No	382	72.35

Attitude towards COVID-19 prevention measures among high school students in Assosa town, Northwest Ethiopia

This study found that more than half of the study participants 328 (62.1%) had unfavourable attitudes. More than half 300 (56.8%) of the participants believe that COVID-19 disease is not preventable and 289 (54.7%) believe that COVID-19 disease is not curable. 309 (58.5%) of the students responded that they believe that COVID-19 disease is God’s punishment (table 4).

Table 4. Attitude towards COVID-19 prevention measures among high school students in Assosa town, Northwest Ethiopia.

Variable		Frequency	Per cent (%)
Do you agree/believe early recognition can improve treatment and recovery from COVID-19?
	Yes	299	56.6
	No	229	43.3
Do you believe COVID-19 is preventable?
	Yes	228	43.2
	No	300	56.8
Do you believe that health education can prevent the infection?
	Yes	172	32.6
	No	356	67.4
Do you believe COVID-19 can be prevented by the practice of preventive measures?
	Yes	244	46.2
	No	284	53.8
Do you believe COVID-19 patients should disclose their exposure?
	Yes	25	4.7
	No	503	91.3
When you meet your friends do you believe you will not be great with a handshake/hug?
	Yes	110	20.8
	No	418	79.2
Do you believe that COVID-19 is a curable disease?
	Yes	239	45.3
	No	289	54.7
Do you agree COVID-19 disease will not always lead to death?
	Yes	153	29
	No	375	71
If you become a contacted person, do you agree you will inform to health authorities?
	Yes	200	37.9
	No	328	62.1
Do you believe herbal and traditional medicine is not always effectively used to treat COVID-19?
	Yes	356	67.4
	No	172	32.6
Do you believe COVID-19 is God’s punishment?
	YesNo	309219	58.541.5
Student compliance with the preventive measures will reduce the spread of disease in the community.
	YesNo	314214	59.540.5
Do you believe authorities should close schools if cases increase?
	YesNo	62466	11.788.2
Do you believe healthy foods can increase body immunity?
	Yes	294	55.7
	No	234	44.3
Do you believe contacted people should immediately be quarantined?
	Yes	298	56.4
	No	230	43.6
Do you agree COVID-19 disease could be controlled by the effective practice of preventive measures?
	Yes	274	51.9
	No	254	48.1
Do you consider COVID-19 a threat to the whole community?
	Yes	82	15.5
	No	446	84.5
Do you believe an infected person can transmit COVID-19 to others without developing symptoms?
	Yes	86	16.3
	No	442	83.8
Do you believe travelling to crowded places can increase COVID-19 transmission?
	Yes	362	68.6
	No	166	31.4
Do you agree viruses can be transmitted from animals to humans and vice versa?
	Yes	120	22.73
	No	528	77.27
Do you believe that drinking local alcohol cannot prevent the risk of COVID-19?
	Yes	337	63.8
	No	191	36.2

Risk perception related to COVID-19 among high school students in Assosa town, Northwest Ethiopia

This study revealed that the majority 390 (73.9%) of the students responded they had a low-risk perception of COVID-19 disease and the remaining students 138 (26.1) had a high-risk perception. 383 (72.5%) of the students responded getting sick with COVID-19 cannot result in a series of health problems and more than half 353 (66.9%) of the students responded that COVID-19 disease can not cause death (table 5).

Table 5. Risk perception related to COVID-19 among high school students in Assosa town, Northwest Ethiopia.

Variable		Frequency	Per cent (%)
Getting sick with COVID-19 can result series health problem
	Yes	145	27.5
	No	383	72.5
COVID-19 can cause death
	Yes	175	33.1
	No	353	66.9
COVID-19 can severely damage my health if I contract the disease
	Yes	412	78.03
	No	116	21.97
Have you ever perceived the dangerousness of COVID-19?
	Yes	333	72.6
	No	145	27.4
Have you ever worried about COVID-19 disease and your health?
	Yes	151	28.6
	No	377	71.4
Have ever perceived COVID-19 disease is highly contagious?
	Yes	230	43.56
	No	298	56.54
Do you feel you are at high risk of contracting COVID-19 infection?
	Yes	103	19.5
	No	425	80.5
Do you perceive that all people are equally at risk of contracting COVID-19 infection
	Yes	369	69.89
	No	159	30.11

Preventive measure practice of high school students toward COVID-19

This study revealed that most (89.9%) of the high school students did not adhere to keeping physical distance of 2 m away. About 84.4% of the students had no regular handwashing practice. The majority (71.4%) of the students did not use facemasks/cover their face during coughing and more than half (62.9%) of the students had no face mask. More than half (54%) of the students did not use sanitiser or alcohol per recommendation (figure 2).

Figure 2. Variable used to measure the level of adherence status among high school students in Assosa town, Northwest Ethiopia.

Factors associated with adherence to COVID-19 prevention measures

Based on this study finding, male respondents had two times poorer adherence to COVID-19 prevention measures than females (AOR; 2.42, 95% CI: 1.46, 4.02). A student with an unfavourable attitude about COVID-19 viruses was four times less likely to adhere to the prevention measures of COVID-19 than their counterparts (AOR: 4.04, 95% CI: 2.45, 6.68). Students with less risk perception toward COVID-19 were about eight times poor adherence to COVID-19 prevention measures as compared with students who had a risk perception to ward against COVID-19 disease (AOR: 7.60, 95% CI: 4.62, 12.54) (table 6).

Table 6. Bivariate and multivariate logistic regression to determine factors associated with adherence towards COVID-19 prevention measures among high school students in Assosa town, Northwest Ethiopia.

Variable	Good adherence	Poor adherence	COR (95% Cl)	AOR (95% Cl)	P value
Sex
Female	75		2.83 (1.82, 4.42)	2.42 (1.46, 4.02)	0.001*
Male	35	1
Educational status of mothers
No formal education	23	141	0.51 (0.17, 0.88)	0.22 (0.16, 1.10)	0.72
Formal education	87	277	1
Knowledge
Poor knowledge	28	155	0.57 (0.13, 0.87)	0.70 (0.59, 2.84)	0.56
Good knowledge	82	263	1
Attitude
Favourable	72		4.29 (2.72, 6.70)	4.04 (2.45, 6.68)	0.0001†
Unfavourable	38		1
Risk perception
Yes	40	350	9.00 (5.65, 14.37)	7.60 (4.62, 12.54)	0.0001†
No	70	68	1

^*Significant at less than a p value of 0.05.

^†Strongly significant. 1.00: consider as reference category.

AORadjusted ORCORcrude OR

Discussion

This study determined the level of adherence and factors associated with COVID-19 preventive measures among high school students in Northwest Ethiopia. This study found that the overall adherence level of high school students toward COVID-19 prevention measures was 110 (20.8%, 95% CI: 17.4%, 24.6%) whereas the rest (79.2%) had poor adherence. This study revealed that the majority of students had poor adherence to the COVID-19 preventive measure 418 (79.2%; 95% CI: 75.4%, 82.6%). The overall knowledge score of the study participants was 65.3%. The majority of the students, 390 (73.9%), responded they had a low-risk perception of COVID-19 disease. This study revealed that sex, attitude toward COVID-19 and risk perception of COVID-19 were significantly associated with adherence status toward COVID-19 prevention measures.

This study revealed that the adherence status of students was about 20.8% (95% CI: 17.4%, 24.6%) which agreed with a study done in Shashamane, Central Ethiopia, of 19.5%.¹⁰ This study found that adherence to COVID-19 was lower than a study done in North Shoa Zone, Ethiopia (44.1%),²⁷ Gondar (50.01%)²⁰ and Gondar city residents (51.04%).²⁰ The possible explanation for this discrepancy would be poor rules and regulations to punish any student for not applying the prevention measure, which may be due to differences in study settings and participants. The other possible reason was a socio-demographic difference in the population. This study finding revealed that the adherence status of students was higher than the study finding in Dirashe District, Southern Ethiopia (12.3%)⁸ and Jimma town, Southwest Ethiopia (14.7%). This is probably due to the study participant’s differences, means of data collection, measurement tools and cut-off points used to categorise good/poor practice.

The overall knowledge score of the study participants was 65.3%. This finding is in agreement with previous studies in Dirashe district, Southern Ethiopia (63.51%),²⁸ college students in the Amhara region (69.6%),²⁶ Nigeria (61.6%)²⁹ and Iran (63%).³⁰ This study finding was higher than a study done on university students in Arbaminch University (25%),³¹ Jimma Ethiopia (41.3%),³² secondary school Gonder (52.2%)²⁰ and university students in Sudan (58.8%).³³ The discrepancy could be due to differences in cut-values used to categorise the knowledge levels, sample size and sociocultural variables between study settings. In addition, students may have more information access than the residents of the community. However, this study result was lower than the study conducted in Egypt (94%),³⁴ China (90%)³⁵ and Malaysia (80.5%).³⁶ The possible reason could be due to different students’ levels of education and their level of exposure to information. In addition, the discrepancies might be due to differences level of awareness creation activities, and access to channels of information dissemination in study settings.

This study showed that 200 (37.9%) students had a favourable attitude toward COVID-19. However, this study finding was higher than the study finding in the Oromia regional state of Ethiopia (32.2%).²¹ The difference could be the socio-demographic status of the population. Because this study was done on students who could be different from the general population. However, this study finding was lower than a study done on college students in Amhara (45.4%),²⁰ Indian medical students (93.7%), Sudan (81.8%), Uganda (72.4%) and Pakistan (44%). This difference could be students in this study were high school students who had a lower level of education status than college students. The discrepancy could be due to differences in cut-values to measure the level of attitude. In addition, the discrepancies might be due to differences in the sociodemography of study participants.

This study found that sex was one of the determinant of adherence to recommended COVID-19 prevention measures. According to the current finding male students were about two times less likely adherence to COVID-19 prevention measures than females (AOR; 2.42, 95% CI: 1.46, 4.02). This finding is in line with studies conducted in Gonder City, Ethiopia,²⁰ Switzerland³⁷ and the USA.³⁸ The possible justification might be that the majority of male students spent outside their homes after school, and may have moved from one place to another for play. The other explanation was a culture where females are restricted to home activities so it indirectly enforce to keep physical distance and avoiding mass gathering.

Students with a favourable attitude had about four times as good adherence to COVID-19 prevention measures as compared with students with an unfavourable attitude toward COVID-19 (AOR; 4.04: 95% CI: 2.45, 6.68). This is supported by a study done in Shashamane, Central Ethiopia,¹⁰ Dirashe District, Southern Ethiopia (54.5%)²⁸ and South Korea.³⁹ This discrepancy could be a positive attitude to encourage students to adopt prevention measures and practice new behaviours than their counterparts. The other possible explanation could be due to students with negative attitudes believe that young people are not at risk of COVID-19.

This study revealed that those respondents who had a perceived risk of COVID-19 were about eight times more adhere to the prevention measure than their counterparts (AOR=7.60, 95% CI: 4.62, 12.54). This finding is consistent with a study done in Shashamane, Central Ethiopia.¹⁰ This can be explained by the direct association between fearing the disease and adhering more because as a result of their fear they become more careful in their activities regarding the pandemic.

Study limitations and strengths

First, this is a cross-sectional analysis, the temporal significance of the results may be a shift from other advanced study designs. To the best of our knowledge, there have been no similar published studies in Ethiopia and there was a limitation to discussing and comparing the findings of this study. However, this study has a privilege compared with other studies as it was conducted where lack of timely information about students regarding COVID-19 prevention is, especially in low-income countries like Ethiopia, despite they are the most potential to spread the disease into the community and therefore, it will be able to generate information about adherence and factors of practice among students that finally helps to intervene against potential factors that hinder adherence as learning continues.

Conclusions

This study revealed that the overall level of adherence status to COVID-19 preventive measures among high school students in Assosa town, Northwest Ethiopia, was low. The adherence level of high school students to COVID-19 preventive measures was 110 (20.8%). The overall knowledge score of the study participants was toward COVID-19 prevention measures 65.3% which demands further community awareness.

This study revealed that sex, attitude toward COVID-19 and risk perception of COVID-19 were significantly associated with adherence status toward COVID-19 prevention measures. This indicates that it needs further public health intervention and imposing rules that are mandatory for students to adhere to and mitigation measures to reduce the spread of diseases. This finding recommends awareness and risk communication to build an appropriate level of knowledge, attitude and risk perception to reduce the spread of the disease. This study finding may recommend policymakers to the urgent need for a health education campaign targeting school students’ emphasis on behavioural change through improving their attitude and knowledge. Sustainable COVID-19 prevention and control intervention should include school students through effective risk communication to emphasise on key recommended preventive measures.

Data availability statement

Data are available upon reasonable request.