Assessing COVID-19 knowledge, attitudes, and practices among Goma’s displaced populations: A critical investigation in the wake of volcanic eruption and persistent armed conflict

Abstract

Introduction

In response to the rising number of confirmed COVID-19 cases in North Kivu province, particularly in Goma—a city marked by ongoing armed conflict and a recent volcanic eruption—it is crucial to assess the knowledge, attitudes, and practices (KAP) of internally displaced persons (IDPs) regarding the pandemic. This study aims to better understand the behaviours and perceptions of these vulnerable populations about COVID-19, to tailor health interventions better.

Methods

A cross-sectional study was conducted from September 1 to 30, 2021. A cluster survey was carried out among IDPs in Goma following the Nyiragongo volcanic eruption. The data collected were analyzed using bivariate and multivariate analyses with STATA 15 software.

Results

Among the 745 respondents, 82.7% demonstrated good knowledge of COVID-19, 86.6% exhibited positive attitudes towards the pandemic, and only 35.6% reported practising the recommended preventive measures. The mean duration of displacement was 9.2 ± 8.9 days (range: 1 to 60 days), with a mean distance of 83.0 ± 69.4 km (range: 8 to 360 km) between their homes and places of refuge. Factors associated with good knowledge included a higher/university educational level (AOR=2.2 [1.2–4.2]). Positive attitudes were predominantly linked to age ≥40 years (AOR=4.0 [1.3–12.3]) and higher/university educational level (AOR=2.2 [1.0–4.5]). Engagement in COVID-19 conferences or awareness sessions emerged as a significant factor for adhering to recommended preventive measures (AOR=2.0 [1.5–2.8]).

Conclusion

For effective pandemic management in this complex context of displacement and conflict, it is essential to strengthen risk communication by actively involving local communities. This strategy should be accompanied by efforts to make preventive measures accessible to all, particularly the most vulnerable populations.

Introduction

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), responsible for the COVID-19 pandemic, was first detected in Wuhan, China, in December 2019. Since then, the disease has rapidly spread globally, and the World Health Organization (WHO) declared it a pandemic on March 11, 2020 (World Health Organization, 2024; Mudenda, 2020). The Democratic Republic of the Congo (DRC) reported its first case of COVID-19 on March 10, 2020, and cases continued to rise, particularly in the capital city of Kinshasa and in the North Kivu province (Ministry of Health, 2024). In this province, the city of Goma, an epicenter of multiple crises, has been particularly affected by prolonged and severe humanitarian emergencies. North Kivu, already plagued by ongoing armed conflicts, experienced the eruption of Mount Nyiragongo on May 22, 2021, followed by significant earthquakes with magnitudes ranging from 4.4 to 4.7 on the Richter scale, which persisted for more than a week. This caused the destruction of houses, ground fissures, and a massive displacement of the population (Organisation Mondiale de la Santé, 2024). These circumstances have exacerbated the vulnerabilities of displaced populations, particularly in terms of COVID-19 prevention. The complexity of Goma’s environment is a key factor in analyzing the knowledge, attitudes, and practices (KAP) regarding COVID-19. The ongoing armed conflict in the region has subjected Goma to years of violence, leading to repeated and massive displacements of populations. These conflicts severely disrupt access to healthcare, information, and essential infrastructure (Pech and Lakes, 2017; Pech et al., 2018), further complicating the fight against COVID-19. Displaced populations are often concentrated in camps or overcrowded areas where space is limited, making it difficult to implement social distancing measures and basic hygiene practices. Additionally, the 2021 volcanic eruption of Mount Nyiragongo caused the displacement of tens of thousands more people, disrupting ongoing efforts to contain the spread of the virus, as resources were redirected to emergency relief and healthcare infrastructures were overwhelmed by the massive influx of internally displaced persons (IDPs). According to estimates, around 232,443 residents, or 27.7% of Goma’s population, were forced to relocate due to the volcanic eruption. These people moved northward to Rutshuru, Lubero, and Butembo, southward to Saké, Minova, and Bukavu, and some crossed into Rwanda (Organisation Mondiale de la Santé, 2024). The socio-economic vulnerability of IDPs, worsened by their precarious status, limits their access to reliable information, healthcare, and the resources needed to implement COVID-19 prevention practices. Access to essential items such as masks, disinfectants, or even clean water is often sporadic, further increasing their exposure to the virus and making it more difficult to implement preventive measures like social distancing and hand hygiene. Displaced populations generally have limited access to quality shelters, sanitary facilities, clean water, stable food supplies, and healthcare services, all of which exacerbate the challenges in containing the spread of COVID-19 (Iacobucci, 2020; Kluge et al., 2020; Raju and Ayeb-Karlsson, 2020).

Refugees and migrants are some of the most vulnerable populations globally (Pech et al., 2018). The DRC hosts the second-largest number of IDPs worldwide (following Syria), with estimates surpassing 5.5 million (Internal Displacement Monitoring Centre, 2024). While many studies have investigated the repercussions of COVID-19 on a global scale, limited attention has been given to IDPs in the DRC (Claude et al., 2020), and none have specifically delved into the demographic impacted by the volcanic crisis and insecurity amidst the pandemic.

The present study aims to describe the KAP of IDPs regarding COVID-19 and its prevention, to identify factors associated with good knowledge, positive attitudes, and adequate practices, and to outline the circumstances related to their displacement during the volcanic eruption.

Material and methods

Study setting

Goma is a city in the eastern DRC, located at an elevation of about 1500 m in the Rift Valley. It is the capital of the North Kivu Province (Fig. 1), covering an area of 66.45 square kilometers characterized by a hilly landscape and volcanic rocks at the base of Mount Nyiragongo. Positioned along the shores of Lake Kivu at coordinates 29°14′ East longitude and 1°45′ South latitude, Goma is bordered by the Nyiragongo Territory to the north, Lake Kivu to the south, Rwanda to the east, and the Masisi Territory to the west. With a population density exceeding 2333 inhabitants per square kilometer, the city is organized into two municipalities (Goma and Karisimbi) and two health zones (Goma and Karisimbi), which contain 10 and 19 health areas respectively. The city’s administrative structure is divided into these two urban municipalities (Kiakuvue et al., 2024).

Fig. 1.

Geographic location of the Democratic Republic of the Congo, North Kivu Province, and the city of Goma.

Study design and tool

A cross-sectional survey was conducted from September 1st to 30, 2021, to assess the KAP regarding COVID-19 among IDPs in the city of Goma, DRC, following the May 2021 volcanic eruption. The survey instrument was adapted from previously validated COVID-19 knowledge questionnaires, including tools used in limited-resource settings and guidance from the WHO and the Centers for Disease Control and Prevention (CDC) on COVID-19 transmission and prevention (Claude et al., 2020; Olum et al., 2020; Alawa et al., 2020).

The survey consisted of 58 items divided into sections focusing on demographic information, KAP related to COVID-19, as well as details on the displacement resulting from the volcanic eruption. The demographic section gathered data on participants’ age, sex, educational level, marital status, occupation, and religion. Additional information was collected on sources of COVID-19 information, participation in COVID-19 awareness programs, and personal or family history of COVID-19 infection.

To assess COVID-19 knowledge, we utilized a 22-item tool adapted from Alawa et al. (Alawa et al., 2020), incorporating true-or-false statements on essential facts and prevalent misconceptions related to the disease. Attitudes towards COVID-19 were evaluated through a 3-point Likert scale (“agree,” “neutral,” “disagree”) to gauge participants’ alignment with different statements concerning the disease and preventive measures. Preventive practices were evaluated by inquiring whether participants had undertaken specific measures, such as practicing physical distancing and wearing masks, and if they faced any challenges in adhering to these practices.

The survey was designed to be contextually appropriate for low-resource settings and was reviewed by a local Congolese physician to ensure that the language and content were culturally sensitive and easily understood by participants. It was administered in French and Swahili, the two most common languages spoken in Goma.

Study sample

A sample of 850 participants was selected from households in two health zones of Goma (Goma and Karisimbi) through a cluster random sampling method, where the two municipalities of Goma served as clusters. The sample size was calculated using the formula: n = z² . p (1 – p) / m²; where z represents the confidence level (1.96 for 95% confidence), p is the estimated population proportion (set at 0.5), and m is the margin of error (5%). A sample size of 384 was calculated, which was then adjusted to account for potential non-responses (10%) and the cluster sampling effect by doubling the final sample size to 850.

Participants were eligible if they were residents of Goma, aged 18 years or older, had been displaced due to the volcanic eruption, and had returned to their homes by the time of the survey. Data collection took place from September 1st to 30, 2021, and was conducted by 20 trained interviewers (10 per health zone), who administered structured interviews in participants’ homes.

Data collection technique

Data were collected through face-to-face interviews using a structured questionnaire specifically designed for this study. The questionnaire was adapted from validated English-language instruments and translated into Swahili and French using a forward–backward translation process conducted by bilingual public health professionals to ensure semantic equivalence and content validity. The questionnaire was piloted among 20 internally displaced adults (aged ≥18 years) with socio-demographic characteristics similar to those of the study population; these participants were excluded from the final analysis, although the site itself was included in the main study. Minor revisions, mainly related to wording and question sequencing, were made to improve clarity and cultural appropriateness without altering the core content or structure of the instrument. Each interviewer was responsible for enrolling at least 10 participants per day over the 5-day data collection period.

Data analysis

Survey responses were entered into Microsoft Excel and analyzed using Epi-Info 7.2 and STATA 15 software. Descriptive statistics were calculated, including frequencies for categorical variables and means with standard deviations for continuous variables. Knowledge scores were computed by assigning 1 point for each correct answer and 0 for incorrect answers. Participants were considered to have "good" knowledge if their score exceeded 60%. Attitudes were evaluated using a scoring system from -10 to 10, with positive scores indicating favorable attitudes towards COVID-19 prevention. Preventive practices were scored based on whether participants adhered to recommended behaviors, with 1 point for “adequatepractice” and 0 for “inadequatepractice”.

Bivariate and multivariate logistic regression analyses were performed to determine the factors linked to good knowledge, positive attitudes, and adequatepractices concerning COVID-19 prevention. Odds ratios (ORs) along with 95% confidence intervals (95% CIs) were computed to assess the magnitude of associations. Statistical significance was considered at p < 0.05.

Ethical considerations

The study received approval from the School of Public of the University of Goma (UNIGOM/ESAPU/018/2021) and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. All participants provided written informed consent prior to data collection. To ensure participants’ privacy, all personal data were anonymized during the data entry process, preventing any identifiable health information from being linked to the participants for analysis or publication. Strict confidentiality measures were observed, with only authorized research personnel granted access to the anonymized data. Moreover, COVID-19 prevention protocols, including the use of face masks, hand sanitizers, and physical distancing, were rigorously implemented during the entire data collection process.

Results

A total of 850 questionnaires were distributed, and 786 were returned. Out of the returned questionnaires, 745 were fully completed and included in the subsequent analysis, indicating an effective response rate of 87.6%.

Sociodemographic characteristics of respondents

The sociodemographic characteristics of the study participants are outlined in Table 1. Of the 745 participants, 59.2% were male, resulting in a sex ratio of 1.45. The largest proportion of respondents (40.7%) fell within the 20–24 age bracket, and the majority (60.1%) were single. A significant portion of the participants (over 90%) had received some form of education, with most holding either a secondary level (34.2%) or higher/university educational level (56.6%). More than half of the surveyed individuals resided in the Karisimbi health zone (51.0%). In terms of religious affiliation, the surveyed population encompassed 36.6% Catholics, 35.7% Protestants, 12.1% Muslims, and 15.6% from other religious backgrounds. Furthermore, a majority of participants (51.4%) were unemployed.

Table 1.

Distribution of respondents based on their sociodemographic characteristics.

Variable	Number (n = 745)	Percentage
Age
20–24 years	303	40.7
25–29 years	183	24.6
30–39 years	150	20.1
≥40 years	109	14.6
Sex
Male	441	59.2
Female	304	40.8
Marital status
Married	255	34.2
Single	448	60.1
Widowed/Divorced	42	5.7
Educational level
None	43	5.8
Primary	25	3.4
Secondary	255	34.2
Higher/University	422	56.6
Municipality of residence
Goma	365	49.0
Karisimbi	380	51.0
Religion
Catholic	273	36.6
Protestant/Pentecostal	266	35.7
Muslim	90	12.1
Others	116	15.6
Professional occupation
Unemployed	383	51.4
Employed	362	48.6

Respondents’ information regarding COVID-19

13.2% of participants reported having contracted COVID-19. Approximately 26% of respondents had a family member or close relative who had suffered from COVID-19. The primary sources of information on COVID-19 among the participants were international radio (28.5%), social media (18.4%), and television (17.3%). However, 32.8% of them had attended a conference, meeting, or discussion on COVID-19 (Table 2).

Table 2.

Distribution of respondents based on COVID-19 information.

Variable	Number (n = 745)	Percentage
Have you ever had COVID-19?
Yes	98	13.2
No	647	86.8
Do you have a family member or close contact who has had COVID-19?
Yes	195	26.2
No	550	73.8
Source of information on COVID-19
International radio	212	28.5
Social media (Facebook, Twitter, WhatsApp, etc.)	137	18.4
Television	129	17.3
Local radio	103	13.8
Family members and friends	56	7.5
Churches	49	6.6
Non-gouvernemental organizations	30	4.0
No response	29	3.9
Have you ever attended any conferences or discussions on COVID-19?
Yes	244	32.8
No	501	67.2

Participants’ knowledge of COVID-19

Participants’ responses to COVID-19 knowledge questions are detailed in Table 3. A majority (61.2%) understood that asymptomatic individuals could transmit the virus, and 81.9% recognized the risk of infection from touching contaminated surfaces. However, 39.2% mistakenly believed that antibiotics could treat COVID-19, and 29.7% thought they could prevent infection. The majority (83.1%) knew that COVID-19 could affect individuals of all ages, and 87.0% acknowledged its impact on people from diverse racial, religious, and ethnic backgrounds. In terms of transmission, 75.7% correctly identified respiratory droplets as the primary mode, while only 45.2% were aware of fecal-oral transmission. A mere 27.2% knew that consuming garlic, ginger, black pepper, or lemon does not reduce the risk of infection, and 22.3% mistakenly believed that limiting meat, eggs, and fish could prevent COVID-19. Participants highlighted preventive measures such as handwashing (91.4%), avoiding handshakes (89.7%), refraining from touching the face (84.7%), using an elbow or clothing to cough or sneeze (86.7%), practicing social distancing (86.3%), wearing a mask (81.6%), and staying home (81.7%). Nearly 79% correctly identified individuals with pre-existing conditions as high-risk, and 70.3% were aware of the recovery possibilities for COVID-19 patients. Furthermore, 77.6% grasped that the elderly were not the sole demographic affected.

Table 3.

Percentage of responses to COVID-19 knowledge questions among 745 respondents.

Questions	True	False	Do not know
People showing no symptoms of being sick can spread a virus or contagious disease (true)	61.2%	23.6%	15.2%
It is possible to contract a virus or contagious disease by touching a surface or object that has the virus on it (true)	81.9%	8.9%	9.2%
Antibiotics can be used to treat COVID-19 (false)	39.2%	37.3%	23.5%
Antibiotics can be used to prevent infection from COVID-19 (false)	29.7%	44.7%	25.6%
People of all ages can become infected with COVID-19 (true)	83.1%	9.7%	7.2%
People of all racial, religious and ethnic groups can become infected with COVID-19/coronavirus (true)	87.0%	6.4%	6.6%
Eating garlic, ginger, black pepper or lemon can lower your chances of getting infected with COVID-19 (false)	43.5%	29.3%	27.2%
COVID-19 spread from humans to humans, mainly through respiratory droplets (true)	75.7%	12.2%	12.1%
COVID-19 can also spread from feco–oral route (true)	45.2%	29.3%	25.5%
Maintaining good personal hygiene and being socially responsible would help limit the spread of COVID-19 (true)	84.7%	8.2%	7.1%
Washing hands frequently using soap or the use of sanitizer would help limit the spread of COVID-19 (true)	91.4%	5.2%	3.4%
Avoiding handshaking behaviour would help limit the spread of COVID-19 (true)	89.7%	7.5%	2.8%
Avoiding placing fingers into eyes, nose and mouth would help limit the spread of COVID-19 (true)	84.7%	8.5%	6.8%
Coughing and sneezing into the elbow or within the clothing is an adequate practice in helping to limit the spread of COVID-19 (true)	86.7%	7.3%	6.0%
Limiting eating meat, eggs and fishes would help limit the spread of COVID-19 (false)	22.3%	56.6%	21.1%
Following social distancing measures and avoiding crowded places would help limit the spread of COVID-19 (true)	86.3%	7.7%	6.0%
For someone without any symptoms of COVID-19, wearing a face mask is considered an appropriate and protective measure against COVID-19 (true)	86.2%	7.8%	6.0%
Proper usage of face mask during an outbreak should include covering nose, mouth and chin with the coloured side facing outside (true)	81.6%	7.3%	11.1%
Staying at home would play a significant role in helping to limit the spread of COVID-19 (true)	81.7%	13.6%	4.7%
A person with pre-existing medical conditions such as heart diseases, diabetes, hypertension and cancer are at greater risk of COVID-19 related infection (true)	78.8%	7.9%	13.3%
COVID-19 can only infect old people (false)	14.4%	77.5%	8.1%
There is no chance of survival once the person is infected with COVID-19 (false)	16.1%	70.3%	13.6%

Note: Percentages were calculated for all 745 respondents. Each row shows the proportion of participants answering True, False, or Do not know, summing to 100%.

Among the 745 participants, 616 (82.7%) demonstrated good knowledge, while 129 (17.3%) exhibited insufficient knowledge. The mean knowledge score was 15.7 ± 3.4 out of 22 points (range: 0 to 22).

Participants’ attitudes towards COVID-19

Fig. 2 shows participants’ responses to questions about attitudes towards COVID-19 prevention. Around 80.1% agreed that COVID-19 is a serious disease, 68.3% were afraid of it, and 76.2% stated they would go to the hospital if infected. About 93.0% believed physical distancing is crucial to prevent COVID-19. However, only 33.7% had a positive attitude towards sacrificing daily activities to stop the virus. Additionally, 53.27% struggled to distinguish reliable COVID-19 information. Around 48% trusted the government’s COVID-19 policies, while 51.7% believed there was significant corruption in handling the pandemic. About 33% thought COVID-19 was a conspiracy to vaccinate everyone, and 41.1% believed it was created in a Chinese lab.

Fig. 2.

Percentages of responses to attitude questions on COVID-19.

Out of the 745 participants, 645 (86.6%) exhibited positive attitudes, while 100 (13.4%) demonstrated negative attitudes. The mean attitude score was 3.1 ± 2.5 out of 10 points (range:7 to 9).

Participants’ preventive practices against COVID-19

Participants’ responses to questions about preventive practices are shown in Fig. 3. The most common measures reported were regular handwashing (63.1%), wearing a face mask (59.1%), physical distancing (43.4%), using disinfectants (56.2%), avoiding touching the eyes, nose, and mouth (43.5%), and staying at home (20.5%). Only 35.6% (265/745) of participants consistently practiced preventive measures against COVID-19, while 64.4% (480/745) did not. The mean practice score was 4.3 ± 2.5 out of 10 points (range: 0 to 10).

Fig. 3.

Preventive practices during your displacement following the volcanic eruption.

Questions related to respondents’ displacement due to the volcanic eruption

Regarding the circumstances of displacement (Table 4), 51.4% of respondents reported that they evacuated immediately upon being informed of the volcanic eruption. The mean duration of displacement was 9.2 ± 8.9 days (range: 1 to 60 days), and the mean distance between their homes and refuge locations was 83.0 ± 69.4 km (range: 8 to 360 km). Modes of transport used during the displacement included walking (45.6%), cars (40.3%), and boats (14.1%). Only 35.6% of respondents have thought about the COVID-19 pandemic during their displacement. The majority of respondents noted the absence of Non-Governmental Organizations (NGOs) addressing COVID-19 (82.7%) and humanitarian aid (87.0%). The main reasons for returning to Goma were permission from authorities (33.6%), cessation of earthquakes (33.0%), lack of shelter (28.0%), and the need to resume work (5.4%).

Table 4.

Distribution of respondents based on circumstances related to displacement during the volcanic eruption.

Variable	Number (n = 745)	Percentage
Did you leave your home immediately when you heard about the volcanic eruption?
Yes	383	51.4
No	359	48.6
Distance between Goma and the place of refuge (km)
Mean ± standard deviation (range)	83.0±69.4	(8 – 360)
Means of transportation used for displacement
On foot	340	45.6
By car	300	40.3
By boat	105	14.1
Did you think about the COVID-19 pandemic during your displacement?
Yes	265	35.6
No	480	64.4
Was there an NGO involved in the fight against COVID-19?
Yes	129	17.3
No	616	82.7
Was there an NGO involved in providing humanitarian aid?
Yes	171	23.0
No	574	87.0
How long did you stay away from your home? (in days)
Mean ± standard deviation (range)	9.2 ± 8.9	(1 – 60)
What was your motivation for returning to Goma?
Authorization to return by the authorities	250	33.6
End of earthquakes	246	33.0
Lack of shelter and food	209	28.0
Resumption of professional activities	40	5.4

Factors determining good knowledge, positive attitudes, and adequate practices regarding COVID-19 preventive measures

The bivariate and multivariate analyses of factors determining good knowledge of COVID-19 are presented in Table 5. The primary determinant of good knowledge was higher/university educational level (Adjusted OR = 2.2; 95% CI: 1.2 – 4.2). Similarly, the analyses of factors influencing positive attitudes towards COVID-19 are shown in Table 6. Positive attitudes were mainly determined by being aged 40 or older (Adjusted OR = 4.0; 95% CI: 1.3 – 12.3) and having a higher/university educational level (Adjusted OR = 2.2; 95% CI: 1.0 – 4.5). Finally, Table 7 reports the analyses of factors influencing adequate practices regarding COVID-19 preventive measures. Participation in COVID-19 awareness conferences or sensitization sessions was the primary determinant of adequate practices (Adjusted OR = 2.0; 95% CI: 1.5 – 2.8). Age was indeed significantly associated with COVID-19 preventive practices in the unadjusted analysis, with participants aged ≥40 years showing lower adherence to preventive measures (OR = 0.5; 95% CI: 0.3–0.8; p = 0.005). However, this association was no longer significant after adjustment for other factors (Adjusted OR = 0.6; 95% CI: 0.3–1.2; p = 0.117).

Table 5.

Association between COVID-19 knowledge level and participants’ sociodemographic variables.

Variable	Total (n = 745)	Knowledge level		Crude odds ratio [95% confidence interval]	p-value	Adjusted odds ratio [95% confidence interval]	p-value
		Good (n = 616)	Poor (n = 129)
Age
20–24 years	303	251 (82.8%)	52 (17.2%)	1.0		1.0
25–29 years	183	154 (84.2%)	29 (15.8%)	1.1 [0.7–1.8]	0.802	1.1 [0.7–2.0]	0.633
30–39 years	150	122 (81.3%)	28 (18.7%)	0.9 [0.5–1.5]	0.791	1.2 [0.6–2.4]	0.600
≥40 years	109	89 (81.7%)	20 (18.3%)	0.9 [0.5–1.6]	0.894	1.5 [0.6–3.5]	0.341
Sex
Male	441	375 (85.0%)	66 (15.0%)	1.5 [1.0–2.2]	0.041	1.4 [0.9–2.2]	0.076
Female	304	241 (79.3%)	63 (20.7%)	1.0		1.0
Marital status
Single	448	377 (84.2%)	71 (15.8%)	1.9 [0.9–3.9]	0.133	1.6 [0.6–4.4]	0.350
Married	255	208 (81.6%)	47 (18.4%)	0.8 [0.6–1.3]	0.438	1.4 [0.6–3.2]	0.457
Widowed/Divorced	42	31 (73.8%)	11 (26.2%)	1.0		1.0
Educational level
None/Primary	68	49 (72.1%)	19 (27.9%)	1.0		1.0
Secondary	255	203 (79.6%)	52 (20.4%)	1.5 [0.8–2.8]	0.242	1.5 [0.8–2.9]	0.205
Higher/Universy	422	364 (86.3%)	58 (13.7%)	2.4 [1.3–4.4]	0.005	2.2 [1.2–4.2]	0.012
Profesional occupation
Unemployed	383	324 (84.6%)	59 (15.4%)	1.0		1.0
Employed	362	292 (80.7%)	70 (19.3%)	0.8 [0.5–1.1]	0.187	0.8 [0.5–1.3]	0.394
Religion
Catholic	273	228 (83.5%)	45 (16.5%)	1.0		1.0
Protestant/Pentecostal	266	220 (82.7%)	46 (17.3%)	0.9 [0.6–1.5]	0.892	1.0 [0.6–1.5]	0.843
Muslim	90	70 (77.8%)	20 (22.2%)	0.7 [0.4–1.2]	0.283	0.7 [0.4–1.2]	0.205
Others	116	98 (84.5%)	18 (15.5%)	1.1 [0.6–1.9]	0.931	1.0 [0.5–1.8]	0.975
Having contracted COVID-19
Yes	98	74 (75.5%)	24 (24.5%)	0.6 [0.4–1.0]	0.061	0.6 [0.3–1.1]	0.085
No	647	542 (83.8%)	105 (16.2%)	1.0		1.0
Having a family member or close contact who has had COVID-19
Yes	195	305 (89.7%)	35 (10.3%)	0.6 [0.4–0.8]	0.007	1.1 [0.7–1.7]	0.777
No	550	456 (82.9%)	94 (17.1%)	1.0		1.0
Attending any conferences or discussions on COVID-19
Yes	244	198 (81.1%)	46 (18.9%)	0.9 [0.6–1.3]	0.502	0.7 [0.5–1.1]	0.165
No	501	418 (83.4%)	83 (16.6%)	1.0		1.0

Table 6.

Association between attitude towards COVID-19 and participants’ sociodemographic variables.

Variable	Total (n = 745)	Attitude		Crude odds ratio [95% confidence interval]	p-value	Adjusted odds ratio [95% confidence interval]	p-value
		Positive (n = 645)	Negative (n = 100)
Age
20–24 years	303	252 (83.2%)	51 (16.8%)	1.0		1.0
25–29 years	183	158 (86.3%)	25 (13.7%)	1.3 [0.8–2.1]	0.422	1.2 [0.7–2.1]	0.553
30–39 years	150	133 (88.7%)	17 (11.3%)	1.6 [0.9–2.8]	0.161	1.9 [0.8–4.1]	0.130
≥40 years	109	102 (93.6%)	7 (6.4%)	2.9 [1.3–6.7]	0.011	4.0 [1.3–12.3]	0.014
Sex
Male	441	379 (85.9%)	62 (14,1%)	1.0		1.0
Female	304	266 (87.5%)	38 (12.5%)	1.1 [0.7–1.8]	0.614	0.8 [0.5–1.2]	0.226
Marital status
Single	448	381 (85.0%)	67 (15.0%)	0.9 [0.4–2.3]	1.000	3.0 [0.9–10.2]	0.081
Married	255	228 (89.4%)	27 (10.6%)	1.4 [0.5–3.6]	0.659	2.2 [0.7–6.4]	0.168
Widowed/Divorced	42	36 (85.7%)	6 (14.3%)	1.0		1.0
Educational level
None/Primary	68	55 (80.9%)	13 (19.1%)	1.0		1.0
Secondary	255	218 (85.5%)	37 (14.5%)	1.4 [0.7–2.8]	0.456	1.5 [0.7–3.3]	0.249
Higher/Universy	422	372 (88.2%)	50 (11.8%)	1.8 [0.9–3.4]	0.142	2.2 [1.0–4.5]	0.042
Profesional occupation
Unemployed	383	321 (83.8%)	62 (16.2%)	1.0		1.0
Employed	362	324 (89.5%)	38 (10.5%)	1.6 [1.1–2.5]	0.030	1.6 [0.9–2.7]	0.067
Religion
Catholic	273	239 (87.6%)	34 (12.4%)	1.0		1.0
Protestant/Pentecostal	266	228 (85.7%)	38 (14.3%)	0.9 [0.5–1.4]	0.618	0.8 [0.5–1.4]	0.470
Muslim	90	80 (88.9%)	10 (11.1%)	1.1 [0.5–2.5]	0.879	1.1 [0.5–2.3]	0.851
Others	116	98 (84.5%)	18 (15.5%)	0.8 [0.4–1.4]	0.516	0.7 [0.4–1.4]	0.307
Having contracted COVID-19
Yes	98	90 (91.8%)	8 (8.2%)	1.0		1.0
No	647	555 (85.8%)	92 (14.2%)	0.5 [0.3–1.1]	0.139	1.6 [0.7–3.6]	0.248
Having a family member or close contact who has had COVID-19
Yes	195	174 (89.2%)	21 (10.8%)	1.0		1.00
No	550	471 (85.6%)	79 (14.4%)	0.7 [0.4–1.2]	0.253	1.2 [0.7–2.0]	0.605
Attending any conferences or discussions on COVID-19
Yes	244	214 (87.7%)	30 (12.3%)	1.0
No	501	431 (86.0%)	70 (14.0%)	0.9 [0.5–1.4]	0.606	1.1 [0.7–1.85]	0.627

Table 7.

Association between COVID-19 preventive practices and participants’ sociodemographic variables.

Variable	Total (n = 745)	Preventive practices		Crude odds ratio [95% confidence interval]	p-value	Adjusted odds ratio [95% confidence interval]	p-value
		Adequate (n = 265)	Inadequate(n = 480)
Age
20–24 years	303	120 (39.6%)	183 (60.4%)	1.0		1.0
25–29 years	183	66 (36.1%)	117 (63.9%)	0.9 [0.6–1.3]	0.496	1.0 [0.6–1.4]	0.809
30–39 years	150	53 (35.3%)	97 (64.7%)	0.8 [0.6–1.3]	0.438	1.0 [0.6–1.8]	0.918
≥40 years	109	26 (23.8%)	83 (76.2%)	0.5 [0.3–0.8]	0.005	0.6 [0.3–1.2]	0.117
Sex
Male	441	146 (33.1%)	295 (66.9%)	1.0		1.0
Female	304	119 (39.1%)	185 (60.9%)	1.3 [0.9–1.8]	0.106	0.7 [0.5–1.0]	0.051
Marital status
Single	448	174 (38.8%)	274 (61.2%)	1.4 [0.7–2.8]	0.401	1.0 [0.4–2.5]	0.969
Married	255	78 (30.6%)	177 (69.4%)	1.0 [0.5–2.0]	1.000	0.9 [0.4–2.0]	0.844
Widowed/Divorced	42	13 (30.9%)	29 (69.1%)	1.0		1.0
Educational level
None/Primary	68	25 (36.8%)	43 (63.2%)	1.0		1.0
Secondary	255	82 (32.2%)	173 (67.8%)	0.8 [0.5–1.4]	0.567	0.7 [0.4–1.3]	0.299
Higher/Universy	422	158 (37.4%)	264 (62.6%)	1.0 [0.6–1.8]	1.000	0.8 [0.5–1.4]	0.462
Profesional occupation
Unemployed	383	155 (40.5%)	228 (59.5%)	1.6 [1.2–2.0]	0.005	1.3 [0.9–1.9]	0.127
Employed	362	110 (30.4%)	252 (69.6%)	1.0		1.00
Religion
Catholic	273	107 (39.2%)	166 (60.8%)	1.0		1.00
Protestant/Pentecostal	266	97 (36.5%)	169 (63.5%)	0.9 [0.6–1.3]	0.514	0.9 [0.6–1.2]	0.422
Muslim	90	22 (24.4%)	68 (75.6%)	0.5 [0.3–0.9]	0.016	0.6 [0.3–1.0]	0.052
Others	116	39 (33,6%)	77 (66,4%)	0.8 [0.5–1.2]	0.355	0.9 [0.6–1.4]	0.644
Having contracted COVID-19
Yes	98	41 (41.8%)	57 (58.2%)	1.4 [0.9–2.1]	0.202	1.5 [0.9–2.4]	0.116
No	647	224 (34.6%)	423 (65.4%)	1.0		1.0
Having a family member or close contact who has had COVID-19
Yes	195	74 (37.9%)	121 (62.1%)	1.1 [0.8–1.6]	0.471	1.1 [0.7–1.5]	0.748
No	550	191 (34.7%)	359 (65.3%)	1.0		1.0
Attending any conferences or discussions on COVID-19
Yes	244	115 (47.1%)	129 (52.9%)	2.1 [1.5–2.9]	<0.0001	2.0 [1.5–2.8]	<0.0001
No	501	150 (29.9%)	351 (70.1%)	1.0		1.0

Discussion

Our study is distinctive compared to other research on KAP concerning COVID-19 as it specifically targets IDPs in the aftermath of the Nyiragongo volcano eruption. Previous KAP investigations carried out in the North Kivu province or other regions of the DRC have focused on diverse groups, such as individuals displaced by insecurity (Claude et al., 2020), the general populace (Carsi Kuhangana et al., 2020), or healthcare workers (Michel-Kabamba et al., 2021), whose sociodemographic profiles vary considerably from our participants. Considering the particular hurdles faced in implementing COVID-19 preventive measures among IDPs, our study addresses a critical void by presenting insights into a marginalized and secluded population.

To our knowledge, this is the first survey to evaluate COVID-19 KAP among IDPs in the aftermath of the Nyiragongo volcanic eruption. The study was motivated by the fact that, in the months following this disaster, the North Kivu province became the main epicenter of the pandemic in the DRC. We administered a simple questionnaire to assess the KAP of IDPs affected by the volcanic crisis and insecurity in Goma, located in eastern DRC.

Our findings indicate generally good knowledge and positive attitudes towards COVID-19 among participants. However, adherence to preventive practices was suboptimal. This non-compliance appears to be associated with the context of the disaster, as respondents cited the lack of non-governmental organizations (NGOs) that could supply them with necessary resources like water, soap, or masks to adhere to preventive measures.

The IDPs identified international radio as their primary source of information on COVID-19, followed by radio, television, and social media. These results are consistent with other studies conducted in the DRC on KAP related to COVID-19 (Claude et al., 2020; Michel-Kabamba et al., 2021). It is worth noting that the Multi-Sectoral Committee for the Response to COVID-19 (CMR-COVID-19) continues to disseminate awareness messages through various media channels, including public and private radio and television stations, as well as online platforms. However, despite these efforts, misinformation and rumors persist, hampering public health interventions (Organization, 2020).

Therefore, the CMR-COVID-19 must strengthen its community outreach unit to better inform the population about the risks of COVID-19 and how to protect themselves. This includes managing rumors and misinformation through increased media surveillance and community discussions.

In our study, most participants demonstrated good knowledge of COVID-19, which appears higher than that reported in other studies conducted in the DRC (Claude et al., 2020; Carsi Kuhangana et al., 2020; Michel-Kabamba et al., 2021) and elsewhere in Africa (Alawa et al., 2020; Leye et al., 2020). This disparity could be attributed to the timing of the studies, as the others were carried out during the initial two waves of the pandemic, whereas ours occurred during the third wave. It is reasonable to infer that with the ongoing nature of the pandemic, there is an enhancement in people’s understanding of the disease.

Regarding preventive measures, participants reported commonly practicing handwashing, avoiding handshakes, using the elbow to cough or sneeze, social distancing, wearing masks, and staying at home. While adherence to these practices is encouraging, it was slightly lower than reported in an Ethiopian study (Kebede et al., 2020). This variance could be attributed to the fact that the Ethiopian study involved individuals who frequented health facilities, making them more likely to be informed about COVID-19.

Education, age, sex, and participation in awareness activities were important determinants of COVID-19-related KAP among IDPs. Participants with higher/university education were more likely to possess good knowledge, likely because education enhances comprehension of complex health information, improves access to reliable sources, and facilitates the critical evaluation of misinformation, as observed in other COVID-19 KAP studies (Zhong et al., 2020; Gao et al., 2020). Similarly, sociodemographic factors such as age, gender, and education have been identified as frequent predictors of KAP levels in multi-country analyses, underscoring the influence of these characteristics on health behaviours (Rahman et al., 2022). In line with findings from Kenya, where education level was associated with better recognition of COVID-19 symptoms and preventive measures, differences in knowledge and practice by gender and age warrant careful interpretation (Mwai et al., 2023). Positive attitudes were associated with both older age and higher education in our multivariable analysis, suggesting that life experience and formal schooling may shape how individuals perceive risk and accept public health recommendations. In contrast, while older age was linked to differences in practice in unadjusted analyses, this did not remain significant after adjustment, pointing to potential confounding by other factors. Participation in COVID-19 awareness sessions emerged as a key factor positively influencing preventive practices, highlighting the role of targeted health education in translating knowledge and attitudes into protective behaviours.

Most respondents recognized the severity of the disease, indicating a general awareness of COVID-19 risk within our study population. This outcome is likely influenced by the proactive measures taken by health authorities, who have escalated awareness initiatives utilizing indigenous languages via television and radio broadcasts. Acknowledging the reality of the disease is crucial for fostering community involvement in combating the pandemic. The CMR-COVID-19 should persist in enhancing community participation through the education of credible local representatives and the dissemination of information in local dialects to counter misinformation.A majority of participants expressed fear of COVID-19, which may have contributed to reluctance to accept quarantine in case of suspected infection. Stigmatization, frequent reports from CMR-COVID-19 on the epidemic situation, and mandatory contact tracing may heighten this anxiety (Xiang et al., 2020). Lei et al. (Lei et al., 2020 Apr 26) also noted that individuals placed in quarantine may experience loneliness and anger, which complicates their care. The WHO recommends addressing fear related to COVID-19 through clear messaging on what to do and not to do (IFRC, 2020).

Finally, our study found that adherence to adequate preventive measures among IDPs was generally suboptimal. Key practices such as handwashing, mask-wearing, and social distancing were difficult to implement, likely due to limited access to resources and the challenging conditions of displacement. Similar barriers have been documented among internally displaced populations in conflict-affected settings, where lack of soap, crowded shelters, and frequent movements undermined implementation of recommended COVID-19 precautions (Claude et al., 2020). These difficulties reflect the lack of government and NGO support for IDPs after the Nyiragongo eruption, as well as the isolated and dangerous environment in which they live, consistent with broader observations of humanitarian contexts where limited sanitation and health services constrain preventive behaviors (Alawa et al., 2020). In addition to COVID-19 prevention, promoting systematic handwashing with soap and water remains essential for preventing other communicable diseases, including amoebic dysentery and cholera; evidence from LMIC settings shows that access to WASH infrastructure and hygiene programs is a key enabler of improved handwashing practices (Muchangi et al., 2024). Given these challenges, IDPs may have felt powerless to reduce physical contact during displacement. Our analyses suggest that participation in COVID-19 awareness conferences or sensitization sessions was a key factor positively influencing adherence to preventive practices, highlighting the importance of targeted health education interventions. Although age was not significantly associated with COVID-19 practice level in the multivariable analysis, participants aged ≥40 years tended to show lower adherence in the unadjusted analysis, which may reflect difficulties older individuals face in accessing preventive resources or differences in health-related behaviours (Musah et al., 2025).

This study has several limitations. First, data were collected using self-reported questionnaires, which may be subject to recall and social desirability bias, particularly in a context where preventive behaviours are strongly promoted by authorities and humanitarian actors. Second, the cross-sectional design precludes causal inference between socio-demographic factors and COVID-19-related knowledge, attitudes, and practices. Third, although participants were recruited across multiple displacement sites, the findings may not be fully representative of all IDPs in Goma or other conflict-affected settings. Insecurity, population mobility, and access constraints may have led to the underrepresentation of certain subgroups. In addition, despite a relatively high response rate (87.6%) given the humanitarian context, non-response bias cannot be excluded, as non-participants may have differed systematically from respondents. Finally, data on COVID-19 vaccination status were not collected due to the timing of data collection, which preceded large-scale vaccine availability in the study setting. This limits our ability to assess the potential interaction between vaccination status and COVID-19-related knowledge, attitudes, and practices.

Notwithstanding these limitations, the study provides important insights into COVID-19-related knowledge, attitudes, and practices among IDPs living in a complex humanitarian setting. By situating these findings within the realities of displacement, insecurity, and constrained health service delivery, the results offer actionable evidence to inform context-appropriate public health responses. Our findings underscore the need for targeted, context-sensitive public health interventions among IDPs living in polycrisis environments. Risk communication strategies should prioritize low-literacy, multilingual messaging delivered through trusted community leaders and humanitarian actors. Mobile health teams and community health workers may play a critical role in bridging information gaps, particularly among younger individuals and those with lower educational attainment. Integrating COVID-19 prevention with broader humanitarian services, including shelter, food distribution, and protection activities, may enhance uptake of preventive practices. These findings may inform preparedness and response strategies for future epidemics in conflict-affected and disaster-prone settings.

Conclusion

This study provides essential insights into the KAP related to COVID-19 among IDPs within the context of a polycrisis, marked by the combination of a persistent armed conflict, the COVID-19 pandemic, and the Nyiragongo volcanic eruption. The findings reveal that, despite a relatively high level of knowledge and positive attitudes towards COVID-19, the adoption of preventive measures remains largely insufficient. This lack of adherence is exacerbated by the scarcity of resources, such as clean water, masks, and soap, along with the absence of humanitarian support for IDPs.

The polycrisis context in which these populations live, characterized by violence, socio-economic instability, and mass displacement, further complicates the management of the pandemic and the implementation of public health measures. COVID-19 has compounded an existing series of crises, deepened vulnerabilities and compromising access to healthcare, information, and the resources needed to protect IDPs.

To tackle these challenges, it is crucial to enhance specific education campaigns on COVID-19 prevention, customized to the circumstances of these displaced populations, and guarantee the provision of necessary supplies during comparable displacement situations. Additionally, it is vital to harmonize actions among local authorities, NGOs, and the international community to enhance awareness, offer assistance, and mobilize resources appropriate for addressing this polycrisis.

In the future, additional research should delve into the specific barriers these populations encounter in this multidimensional crisis context, to gain a better understanding of how to enhance their resilience. It is crucial to formulate a comprehensive and sustainable response that considers the cumulative impacts of armed conflict, the COVID-19 pandemic, and natural disasters, while strengthening health infrastructure to safeguard vulnerable populations in the DRC.

CRediT authorship contribution statement

Olivier Mukuku: Writing – original draft, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Kaymarlin Govender: Writing – review & editing, Visualization, Validation, Supervision, Methodology, Conceptualization. Hervé Nawej Mutumba: Writing – original draft, Software, Resources, Investigation, Data curation. Joseph Lopema Kiloka: Writing – original draft, Software, Methodology, Formal analysis, Data curation. Stanislas Okitotsho Wembonyama: Writing – review & editing, Visualization, Validation, Supervision, Resources, Project administration, Conceptualization.

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.