COVID-19 and the public response: Knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

Zelalem Desalegn; Negussie Deyessa; Brhanu Teka; Welelta Shiferaw; Damen Hailemariam; Adamu Addissie; Abdulnasir Abagero; Mirgissa Kaba; Workeabeba Abebe; Berhanu Nega; Wondimu Ayele; Tewodros Haile; Yirgu Gebrehiwot; Wondwossen Amogne; Eva Johanna Kantelhardt; Tamrat Abebe

doi:10.1371/journal.pone.0244780

. 2021 Jan 7;16(1):e0244780. doi: 10.1371/journal.pone.0244780

COVID-19 and the public response: Knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

Zelalem Desalegn ^1,^*, Negussie Deyessa ², Brhanu Teka ¹, Welelta Shiferaw ³, Damen Hailemariam ², Adamu Addissie ², Abdulnasir Abagero ², Mirgissa Kaba ², Workeabeba Abebe ⁴, Berhanu Nega ⁵, Wondimu Ayele ², Tewodros Haile ⁶, Yirgu Gebrehiwot ⁷, Wondwossen Amogne ⁶, Eva Johanna Kantelhardt ⁸, Tamrat Abebe ¹

Editor: Khin Thet Wai⁹

¹Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

²School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

³Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

⁴Department of Pediatric and Child Health Department, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

⁵Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

⁶Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

⁷Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

⁸Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle, Germany

⁹Ministry of Health and Sports, Myanmar, MYANMAR

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: zelalem.desalegn@aau.edu.et, tzollove@gmail.com

Roles

Zelalem Desalegn: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Negussie Deyessa: Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Validation, Writing – review & editing

Brhanu Teka: Data curation, Formal analysis, Investigation, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Welelta Shiferaw: Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Damen Hailemariam: Conceptualization, Data curation, Investigation, Project administration, Validation, Visualization, Writing – review & editing

Adamu Addissie: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – review & editing

Abdulnasir Abagero: Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing

Mirgissa Kaba: Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – review & editing

Workeabeba Abebe: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing

Berhanu Nega: Data curation, Investigation, Methodology, Project administration, Validation, Visualization, Writing – review & editing

Wondimu Ayele: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing

Tewodros Haile: Data curation, Investigation, Supervision, Validation, Visualization, Writing – review & editing

Yirgu Gebrehiwot: Data curation, Investigation, Supervision, Validation, Visualization, Writing – review & editing

Wondwossen Amogne: Data curation, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – review & editing

Eva Johanna Kantelhardt: Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – review & editing

Tamrat Abebe: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Khin Thet Wai: Editor

PMCID: PMC7790293 PMID: 33411766

Abstract

Background

The COVID-19 pandemic is impacting the global community in many ways. Combating the COVID-19 pandemic requires a coordinated effort through engaging public and service providers in preventive measures. The government of Ethiopia had already announced prevention guidelines for the public. However, there is a scarcity of evidence-based data on the public knowledge, attitude, and practice (KAP) and response of the service providers regarding COVID-19.

Objective

This study aimed to assess the public KAP and service providers’ preparedness towards the pandemic in Addis Ababa, Ethiopia.

Methods

A community-based cross-sectional study was conducted in Addis Ababa, Ethiopia, from late March to the first week of April 2020. Participants were conveniently sampled from 10 different city sites. Data collection was performed using a self-administered questionnaire and observational assessment using a checklist. All statistical analysis was performed using SPSS version Descriptive statistics, correlation coefficient and chi-square tests were performed.

Result

A total of 839 public participants and 420 service providers enrolled in the study. The mean age was 30.30 (range = 18–72) years. The majority of the respondents (58.6%) had moderate knowledge about COVID-19, whereas 37.2% had good knowledge. Moreover, 60.7% and 59.8% of the participants had a positive attitude towards preventive measures and good practice to mitigate the pandemic, respectively. There was a moderate positive correlation between knowledge and attitude, whereas the correlations between knowledge and practice and attitude and practice were weak. With regard to service providers’ preparedness, 70% have made hand-washing facilities available. A large majority of the respondents (84.4%) were using government-owned media followed by social media (46.0%) as a main source of information.

Conclusion

The public in Addis Ababa had moderate knowledge, an optimistic attitude and descent practice. The information flow from government and social media seemed successful seeing the majority of the respondents identifying preventive measures, signs and symptoms and transmission route of SARS-CoV-2. Knowledge and attitude was not associated with practice, thus, additional innovative strategies for practice changes are needed. Two thirds of the service provider made available hand washing facilities which seems a first positive step. However, periodic evaluation of the public KAP and assessment of service providers’ preparedness is mandatory to combat the pandemic effectively.

Introduction

Infections with coronaviruses in humans and animals cause respiratory and intestinal diseases [1]. The diseases vary from mild, self-limiting forms to more severe manifestations depending on the type of viruses involved [2]. Coronaviruses belong to the subfamily Coronaviridae, which consists of four genera: Alphacoronavirus and Betacoronavirus members infect mammals, while Gammacoronavirus and Deltacoronavirus only infect birds and some mammals [3]. Among the coronaviruses that infect humans, severe acute respiratory syndrome coronavirus (SARS-CoV) and middle East respiratory syndrome-related Coronavirus (MERS-CoV) are highly pathogenic [4].

The current human coronavirus, named SARS-CoV-2, emerged as a public health problem from Wuhan, Hubei province, China, on 31 December 2019 as a cluster of pneumonia cases. On 7 January 2020, the a etiological agent of the pneumonia was officially announced as a novel coronavirus [5–7]. On 11^th January 2020, the first fatal case was reported. On the next day (12 January 2020), the whole genome sequence of the virus was shared with the World Health Organization (WHO) and the public. Confirmed cases outside Wuhan were reported from Thailand (13 January 2020), Japan (16 January 2020), Korea and in another province of China (19 January 2020), all from persons who had travelled to Wuhan [8]. On 30 January 2020, the Director-General of WHO declared the 2019-nCoV outbreaks a public health emergency of international concern [9]. The WHO announced that COVID-19 should be characterized as a pandemic on 11 March 2020 [9].

As of September 29, 2020, approximately 33,556,252 million cases, 1,006,450 deaths and 24,881,239 recovered cases have been reported globally [10]. Europe and America have been highly affected by the virus, as shown by overwhelmed health systems and high death tolls [11]. Although the virus arrived late in Africa, the number is increasing and it has been predicted that more than 1.2 billion people are at high risk [12]. In the context of Ethiopia, the first COVID-19 case was reported on 13 March 2020. Based on WHO recommendations, Ethiopia implemented thermal screening at various institutions, social distancing, providing hand washing facilities, stay-at-home orders, quarantining people assumed to be exposed and encouraging the community to use homemade masks when needed, including in areas where there are more people and traffic flow such transportation services and other service providers. As of 29 September 2020, there had been 73, 944 confirmed cases, 1,177 deaths and 30, 753 recovered cases in Ethiopia [13].

According to the WHO global strategy to respond to COVID-19, the overarching goal of all countries is to control the pandemic by slowing down the transmission to reduce the immediate burden on health systems and to reduce the mortality [14]. According to this strategy, everyone has a crucial role to play to stop COVID-19. Individuals must protect themselves and others by adopting behaviors like regular adequate hand washing or use alcohol-based hand sanitizers, avoid touching their faces, practice covering their mouths and noses anytime or while coughing and sneezing, maintain physical distancing, isolate themselves if they are sick, identify themselves as a contact of confirmed cases when appropriate and, most importantly, strictly follow measures announced by their government or health authorities [14]. The implementation of all the above depends on the background knowledge, skills and attitude of the public to COVID-19.

The knowledge, attitudes and, practices (KAP) that people hold towards the disease play an integral role in determining a society’s readiness to accept behavioral change measures from health authorities [15]. The KAP of people towards COVID-19 is critical to understand the epidemiological dynamics of the disease and the effectiveness, compliance and success of infection prevention control measures adopted in a country. Moreover, research has demonstrated that effective control and mitigation of COVID-19 in any country requires operational research and timely epidemiological data generated among different groups of the population. Such evidence-based data will inform health authorities so that they can design robust interventions and policies that are relevant and comprehendible to the community and beyond [16].

In a previous study, a plethora of evidence demonstrated that there is a disparity in the KAP level of the public about viral infection, including COVID-19 [15, 17–26]. The difference in the public KAP towards COVID-19 could be explained by geographical difference, methodological variability, health care system infrastructure, socio-economic status of the participants, the burden of the pandemic and residence of the participants, among many other factors.

The COVID-19 pandemic and the associated measures of confinement will have devastating consequences for micro and small business operations and will disrupt many existing value chains. This, in turn, will lead to loss of income and sharp increases in unemployment. The COVID 19 pandemic has and will continue to have a strong effect on labour markets worldwide, especially in developing economies, where more than 70% of the workforce is self-employed or works in micro and small enterprises [27, 28]. These effects will undeniably have many significant effects on a wide range of the population.

Engaging service providers and/or small and medium enterprises and exploring their preparedness to fight the COVID-19 pandemic is crucial. So far, government, health authorities, health institutions and the media have strived to help public and service providers be aware of the disease and apply preventive measures. Despite the public health measures, there is a huge research gap with regard to the public KAP and service providers’ preparedness towards COVID-19.

Therefore, the present study aimed to assess: (1) the public KAP and (2) the preparedness and response of service providers towards COVID-19 in Addis Ababa, Ethiopia.

Methods and materials

Study design and setting

A cross-sectional, community-based survey was conducted in selected sites in Addis Ababa, Ethiopia, among adults to assess their KAP and the preparedness of the service providers regarding COVID-19. The study was conducted during the last week of March through first week of April 2020. To achieve the intended study objectives, a self-administered questionnaire was used to assess the public KAP and a brief checklist was utilized to evaluate service providers’ preparedness and response towards COVID-19 in Addis Ababa, Ethiopia. Addis Ababa is the capital and largest city of Ethiopia. The study was carried out in 10 high traffic sites located in the respective sub-cities.

Study population and the target sample size

The study population was adults who were by chance walking in the 10 sites. Service providers in the selected sites were considered for assessing their practical readiness against COVID-19. Being adult (> 18 years of age) and consent to participate in the study taken were the inclusion criteria.

A single population proportion formula was used by considering 50% prevalence of public awareness of COVID-19, with a 5% margin of error at a 95% confidence level, with a design effect of 2.0, and adding 10% for non-response. A total of839(84/ per site) participants from major city sites were recruited. Again, given that there was no study among service providers related to a possible outbreak, we considered a 50% proportion of preparedness for COVID-19, with a 5% margin of error at a 95% confidence level, and adding 10% for non-response. Therefore, 420 service providers recruited from the 10 sites. A convenient sampling technique was employed and verbal consent obtained from all participants.

Participant recruitment procedure

The intended study was conducted during the early phase of the COVID-19 pandemic in Ethiopia at Piazza, Arat Kilo, Mexico, Bole Medhanealem, Bole Michael, Teklehaimanot, Megenagna, Jemo, Ayer Tena and Kera. The selection of specific streets from the high traffic enumeration site was done by spinning a bottle. The participants were approached and informed of the study objectives. Consecutive service providers on the same streets were included; their preparedness was assessed using a brief checklist along with a direct observational assessment.

Data collection tool

Data collection was done using a self-administered structured questionnaire and a brief checklist. The questionnaire consisted of 40 close-ended questions that aimed to collect the following information from the respondents: socio-demographic characteristics, travel history, risk factors and KAP related to COVID-19. The survey instrument took approximately 15–20 minutes to complete.

The data collection tool was initially prepared in English (S1 Appendix) version followed by translation to local Amharic language (S2 Appendix). Consistency of content, clarity and appropriate meaning between the two version was maintained through back translation of the questionnaire to the original version. Additionally, the practicability, validity and interpretability of answers for the respective questions was confirmed by performing pre-test in 10% of the targeted sample size. Based on this pre-test study, the format and wording of questions were corrected and refined.

A brief checklist and observational assessment were used to evaluate the preparedness and response of service providers (e.g. hotels, cafeterias and transportation enterprises). The brief checklist explored the availability of soap with water, alcohol and/or sanitizer for the any person entering. To facilitate the data collection, 10 data collection facilitators were enrolled to distribute and collect the completed questionnaire from the consented participants. Formal training on a brief introduction of the research objectives, data collection procedure and questionnaire content was delivered.

Knowledge related to COVID-19

The knowledge section of the questionnaire comprised40 questions. All the questions were developed by considering previous research done in same population with a similar research theme [29]. These questions were in the form of yes or no; if the answer was yes, the participants were asked to specify. The right answer to each question has a score of 1 and wrong answer 0. Modified Bloom’s cut-off points were used to judge knowledge as good (80%–100%),≥32), moderate (50%–79%, 20–31), or poor (≤ 50%,≤19) [30].

Attitude towards COVID-19

Eight questions were asked to evaluate the attitude of the general public towards the disease. A scoring system to attitude was used as follows: good (≥6), moderate (5) and poor (≤4).

Practice regarding COVID-19

There were four questions on practice towards COVID 19 (one point for each questions with correct answer). The cut-offs were similar to the knowledge and attitude scoring: good (4), moderate (3) and poor (≤2).

Statistical analysis

Before the analysis, completeness of the data was evaluated. Data entry and coding and were done using EpiData version 3.1. The data were analyzed with SPSS statistical software version 22. A descriptive analysis was performed. Specific knowledge, attitude and practice questions were used to establish scoring to assess the overall status of the participants. For each question, 1 point was given for answering correctly, whereas 0 points were assigned when the responders fail to respond correctly. Based on the total score relative to the maximum score, the public KAP level was categorized as good, moderate or poor, considering modified Bloom’s cut-off points. Inferential statistics between the socio-demographic factors and the public KAP regarding COVID-19 were investigated using a chi-square test. A statistically significant association was declared at < 0.05.

Research ethics approval

The study protocol was approved by the institutional review board (IRB) of the College of Health Sciences Addis Ababa University (Protocol number: 012/DMIP/2020) and verbal consent was obtained from each participant.

Results

Demographic characteristics

The study included 839 participants. The participants mean age was 30.3(standard deviation [SD] = 9.25, range = 18–72) years. The majority of the respondents were males (58.0%) and single (56.6%). With regard to occupational status, government employee and non-government employee occupied one third each (36.7% and 34.7%) followed by traders (8.3%), day workers (6.4%) and others (12.3%).

Travel history to COVID-19-affected areas

Only 7% of respondents had travel history in the last three months at the time of data collection. Of these, 17%, 11.8% and 10.0% had travelled to China, Europe and the Middle East, respectively, among COVID-19-affected areas at the time of data collection. With respect to contact history, 9.2% of the participants had had contact with individuals who had travelled to COVID affected areas (Table 1).

Table 1. Demographic characteristics of the study participants in Addis Ababa, Ethiopia.

Characteristics		Count (%)
Sex	Male	487 (58.0)
	Female	345 (41.1)
Age group (years)	≤19	48 (5.7)
	20–29	426 (50.8)
	30–39	233 (27.8)
	40–49	82 (9.8)
	50–59	31(2.7)
	≥60	10 (1.2)
	Unknown age	?
Marital status	Single	475(56.6)
	Married	322 (38.4)
	Divorced	31 (3.7)
	Widowed	7 (0.8)
	Unknown	?
Occupation	Governmental	308 (36.7)
	Non-governmental	291(34.7)
	Trader	70 (8.3)
	Day worker	54 (6.4)
	Others	103 (12.3)
	Unknown	?
Living condition	Alone	191 (22.8)
	With others	629 (75.0)
	Unknown	?
Travel history	Yes	59 (7.1)
	No	777(92.9)
Contact with a person who travelled to COVID-19 affected areas	Yes	69 (9.2)
	No	677(90.6)
	Unknown

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KAP towards the COVID-19 pandemic

Knowledge assessment

Knowledge was assessed using a total of 40 questions that focused on nature of the disease, prevention mechanisms, transmission mode, risk groups and signs and symptoms of COVID-19 (Table 2).

Table 2. The response of the participants to specific knowledge questions in Addis Ababa, Ethiopia.

Ser. No.	Knowledge questions	Responses	Correct response	Wrong response
1	Which of the following do you think are the major signs and symptoms of the disease caused by coronavirus?	1. Fever	721 (85.9)	118 (14.1)
		2. Diarrhea	68 (8.1)	771 (91.9)
		3. Bloody diarrhea	816 (97.3)	23 (2.7)
		4. Bloody sputum	786 (93.7)	53 (6.3)
		5. Swelling of legs	822 (96.0)	17 (2.0)
		6. Cough	412 (49.1)	427 (50.9)
		7. Swelling on mouth/nose	790 (94.2)	49 (5.8)
		8. Red and painful eyes	29 (3.5)	810 (96.5)
		9. Sneezing/runny nose	532 (63.4)	307 (36.6)
2	What are the current ways of prevention of COVID-19?	1. Vaccination	728 (86.8)	111 (13.2)
		2. Anti-viral therapy	775 (92.4)	64 (7.6)
		3. Using masks	387 (46.1)	452 (53.9)
		4. Frequent washing of hands	446 (53.2)	393 (46.8)
		5. Staying at home	622 (74.1)	217 (25.9)
		6. Frequent disinfectant	504 (60.1)	335 (39.9)
		7. Staying >meters from others	542 (64.6)	297 (35.4)
3	How could a person acquire the coronavirus disease?	1. Directly through breathing/ sneezing	698 (83.2)	141 (16.8)
		2. Through a mosquito bite	757 (90.2)	82 (9.8)
		3. Touching mouth and nose through contaminated hand	657 (78.3)	182 (21.7)
		4. Through unprotected sexual intercourse	121 (14.4)	121 (14.4)
		5. Through staying and playing near others	169 (20.1)	670 (79.9)
		6. Not frequently washing while at work	327 (39.0)	512 (61.0)
		7. Using public transport with closed windows	448 (53.4)	391 (46.6)
		8. Opening doors/windows in public places	477 (56.9)	362 (43.1)
		9. Frequent use of disinfectant while at work	774 (92.3)	65 (7.7)
4	Who is at risk of developing a severe form of the corona disease?	1. Diabetic patients	531 (63.3)	308 (36.7)
		2. Hypertensive patients	403 (48.0)	436 (52.00
		3. People with heart problem	449 (53.5)	390 (46.5)
		4. Pregnant women	555 (66.2)	284 (33.8)
		5. Cancer patients	379 (45.2)	460 (54.8)
		6. Khat chewers/smokers	432 (51.5)	407 (48.5)
		7. Asthmatic patients	440 (52.4)	399 (47.6)
		8. People with COPD	627 (74.7)	212 (25.3)
5	At what age group do you think the coronavirus disease occur?	1. Children	413 (49.2)	426 (50.8)
		2. Youth	485 (57.8)	354 (42.2)
		3. Elderly	760 (90.6)	79 (9.4)
6	Is the coronavirus transmittable by shaking/hugging anyone?		777 (92.6)	39 (4.6)
7	Is coronavirus transmittable by mosquito bite?		588 (70.1)	242 (28.8)
8	Is the coronavirus transmittable by direct breathing?		694 (82.7)	133 (15.9)
9	Is a person who has coronavirus detectable by looking at him/ her?		713 (85.0)	120 (14.3)

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The majority of respondents (58.6%) had moderate knowledge while37.2% had good knowledge (Table 3). Among the socio-demographic characteristics, only the age and occupation of the participants was associated with knowledge (Table 4).

Table 3. Number of questions, range, scores and levels of knowledge, attitude and practice of the study participants in Addis Ababa, Ethiopia.

Variables	Number of questions	Score range	Total score mean ± SD	Level (points)
Variables	Number of questions	Score range	Total score mean ± SD	Poor	Moderate	Good
Knowledge	40	16–40	28.92±5.4	35 (4.2)	492(58.6)	312 (37.2)
Attitude	8	0–8	5.73±2.1	247 (29.4)	82 (9.8)	509 (60.7)
Practice	4	0–4	2.49±0.7	94 (11.2)	242 (28.8)	502 (59.8)

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Note. SD, standard deviation.

Table 4. Association between respondent demographic characteristics and level of knowledge, attitude and practice scores in Addis Ababa, Ethiopia.

Characteristics		Knowledge scores			P	Attitude scores			p	Practice scores			p
		Poor	Mod.	Good		Poor	Mod.	Good		Poor	Mod.	Good
		Poor	Mod.	Good		Poor	Mod.	Good		N (%)	N (%)	N (%)
		N (%)	N (%)	N (%)		N (%)	N (%)	N (%)		N (%)	N (%)	N (%)
Sex	Male	24 (4.9)	292 (60.0)	171 (35.1)	0.09	145 (29.8)	49 (10.1)	293(60.2)	0.87	61 (12.5)	140 (28.7)	286 (58.7)	0.41
Sex	Female	9 (2.6)	196 (56.8)	140 (40.6)	0.09	98 (28.5)	33 (9.6)	213 (61.9)	0.87	33 (9.6)	100 (29.1)	211 (61.3)	0.41
Age group (years)	≤ 19	5 (10.4)	33 (68.8)	10 (20.8)	0.06	19 (39.6)	6 (12.5)	23 (47.9)	0.58	5 (10.4)	17 (35.4)	26 (54.2)	0.63
	20–29	18 (4.2)	250 (58.7)	158 (37.1)		125 (29.3)	36 (8.45)	265 (62.2)		47 (11.0)	124(29.1)	255 (59.9)
	30–39	4 (1.7)	131 (56.2)	98 (42.1)		69 (29.7)	22 (9.5)	141 (60.8)		25 (10.8)	63 (27.2)	144 (62.1)
	40–49	3 (3.7)	50 (61.0)	29 (35.4)		19 (23.2)	11 (13.4)	52 (63.4)		8 (9.8)	26 (31.7)	48 (58.5)
	50–59	3 (9.7)	17 (54.8)	11(35.5)		9 (29.0)	5 (16.1)	17 (54.8)		6 (19.3)	9 (29.0)	16 (51.6)
	≥ 60	1 (10.0)	6 (60.0)	3 (30.0)		2 (20.0)	1 (10.0)	7(70.0)		0 (0)	1 (10.0)	9 (90.0)
Marital Status	Un-married	18 (3.8)	277 (58.3)	180 (37.9)	0.16	131 (27.6)	48 (10.1)	295 (62.2)	0.40	46 (9.7)	147 (31.0)	281 (59.3)	<0.05
	Married	11 (3.4)	194 (60.2)	117(36.3)		98 (30.4)	28 (8.7)	196 (60.9)		42 (13.0)	82 (25.5)	198 (61.5)
	Divorced	4 (12.9)	15 (48.4)	12 (38.7)		14 (45.2)	4 (12.9)	13 (41.9)		2 (6.5)	11(35.5)	18 (58.1)
	Widowed	1 (14.3)	4 (57.1)	2 (28.6)		2 (28.6)	1(14.3)	4 (57.1)		3 (42.9)	2(28.6)	2 (28.6)
Occupation	Govern-mental	9 (2.9)	158 (51.3)	141 (45.8)	<0.05	82 (26.7)	18 (5.9)	207 (67.4)	<0.05	29 (9.4)	89 (29.0)	189 (61.6)	0.67
	Non-govern-mental	17 (5.8)	182 (62.5)	92 (31.6)		96 (33.0)	39 (13.4)	156 (53.6)		38 (13.1)	80 (27.5)	173 (59.5)
	Trader	2 (2.9)	42 (60.0)	26 (37.1)		20 (28.6)	6 (8.6)	44 (62.9)		8 (11.4)	18 (25.7)	4 (62.9)
	Day worker	2 (3.7)	41 (75.9)	11 (20.4)		17 (31.5)	7 (13.0)	30 (55.6)		8 (14.8)	20 (37.0)	26 (48.1)
	Others	3 (2.9)	59 (57.3)	41 (39.8)		25 (24.3)	10 (9.7)	68 (66.0)		10 (9.7)	30 (29.1)	63 (61.2)

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Attitude towards COVID-19 and association with demographic characteristics

A total of eight questions were used to assess the attitude of the participants to implement preventive measures against the COVID-19 pandemic. As shown in Table 3, the mean attitude score was 5.73, most of the public had positive attitude (60.7%) towards implementation of preventive measures against COVID-19. Among the respondents, 83.1% and 74.9% indicated they prefer frequent hand washing with soap and water and use alcohol-based sanitizer, respectively. Moreover, the majority (90.3%) had good attitude towards social distancing and its necessity to prevent COVID-19. With regard to lockdown, more than half of the participants agreed that it had to be in place to mitigate the pandemic in Ethiopia. Similar to knowledge, only occupational status was associated with a positive attitude (Table 4).

Practice towards COVID-19

In the study, there were four questions related to practice towards COVID-19, with a maximum total of four points. The mean practice score was 2.49 ± 0.7(range 0–4). The majority (59.8%) of the study participants had a good practice towards COVID-19. On the date of the data collection, the study participants’ experience of hand washing with soap and water for 20 seconds and utilization of sanitizer was 96.4% and 82.2%, respectively. Similarly, 88.0% of the participants had not practiced hand shaking. Good practice was only associated with marital status (Table 4).

Correlations among knowledge, attitude and practice

To visualize the correlation of participants knowledge, attitude and practice with one another, we performed a scatter plot analysis. There was a moderate positive correlation between participant’s knowledge and attitude (r = 0.624), whereas the correlations between knowledge and practice (r = 0.196) and attitude and practice (r = 0.172) were weak (Table 5).

Table 5. Correlation between knowledge, attitude and practice scores towards COVID-19.

	Variables	Correlation coefficient	P
A	Knowledge and attitude	0.624	<0.01
B	Knowledge and practice	0.196	<0.01
C	Attitude and practice	0.172	<0.01

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Source of information about COVID-19

For the majority of the respondents (84.4%), government-owned television was the primary source of information about COVID-19, followed by government-owned radio (49.7%), social media (46.0%) and private television (43.0%). Besides, the government health and social media were the information sources that the respondents highly believed. With regard to the adequacy of information, more than half (59.6%) of the respondents believed that the broadcasted information was adequate to act against COVID-19.

Response of service providers towards COVID-19 pandemic

The checklist used to assess the service providers contained questions on type of enterprise, method of preventive mechanism in place and the type of washing facility present (Table 6).

Table 6. Type of service providers included in the study in Addis Ababa, Ethiopia.

	Enterprise type	Number	Percent
1	Hotel/restaurant/cafeteria/juice house	114	27.1
2	Bus/taxi/train station	26	6.2
3	Banks	69	16.4
4	Local drinking houses	21	5.0
5	Mall/boutiques, cosmetic shops, business centre, stationary	85	20.2
6	Others	103	24.5

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Note. Others include electronics shops, butchers, pharmacies, bakeries, churches, mosques, etc.

Most (70%) of the enterprises provided hand washing facilities as a preventive mechanism towards COVID-19, followed by social distancing and sanitizer or alcohol use with 8.6% and 7.9%, respectively (Table 7).

Table 7. Preventive measures made available by service providers in Addis Ababa, Ethiopia.

	Preventive measure	Number	Percent
1	Hand washing facility (soap and water)	294	70
2	Sanitizer/alcohol	33	7.9
3	Social /physical distancing	36	8.6
4	None	97	23.1
5	Both hand washing facility and sanitizer/alcohol	13	3.1
6	Both hand washing facility and social/physical distancing	28	6.7
7	Both sanitizer/alcohol and social physical distancing	7	1.7

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Of the enterprises, 264 (62.9%) had hand washing facilities with soap and water, 32(7.6%) had water only, 11 (2.6%) had soap only and 34 (8.1%) had none of the hand washing facilities (Table 8).

Table 8. Type of washing facility available to prevent COVID-19 among service providers in Addis Ababa, Ethiopia.

Facility	Number	Percent
Water only	32	7.6
Soap only	11	2.6
Both (water and soap)	264	62.9
None	34	8.1

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Discussion

This study is the first survey in the capital of Ethiopia, Addis Ababa as far as our knowledge goes, that aimed to assess the public KAP towards the COVID-19 pandemic as well as to assess the preparedness and response of service providers in the city.

In the survey out of 839 respondents, almost two thirds had moderate knowledge and good attitude and practice. This level was far lower than a multinational survey in Africa (South Africa, Kenya and Nigeria), which reported that the level of awareness and concern about COVID-19 were very high (94%) [26]. A bi-national survey in Egypt and Nigeria also demonstrated that the mean knowledge score was higher, with a satisfactory knowledge of the disease [22]. A study from Nigeria also proved that the respondents had good knowledge (99.5%) of COVID-19 [16]. Since the current study in Addis Ababa was carried out during the early phase of the pandemic, the reported knowledge level is encouraging; however, periodic assessment should be in place considering the different scenario of COVID-19 pandemic in Ethiopian setting.

A study on Indian diabetes mellitus populations reported a high overall correct response rate on the knowledge questionnaire (83%) [31]. In another study, the majority of the participants were knowledgeable about COVID-19, with a mean COVID-19 knowledge score of 17.96 (SD = 2.24; Range = 3–22), indicating a high level of knowledge and the overall accuracy rate for the knowledge test was 81.64% (17.96/22 _ 100) [21]. A high knowledge level has also been reported in Malaysia, where the overall correct rate of the knowledge questionnaire was 80.5%and most participants held positive attitudes towards the successful control of COVID-19 (83.1%) [15].

The burden of COVID-19 was by far higher in some Asian countries than some African countries including Ethiopia, such difference in the spread would bring a disparity in the overall knowledge status of the population and preparedness towards the pandemic. Though the current knowledge and preparedness status is descent in our setting, the best practice from other countries employed to improving knowledge and preparedness should be adapted for best containment of the pandemic.

Knowledge assessment in this study included signs and symptoms, the disease transmission mode, the prevention mechanisms and risk groups. According to the assessment, a considerable number of the participants were aware of the disease signs and symptoms. However, a few participants incorrectly attributed signs and symptoms not shown in COVID-19 cases. This finding is similar to a study from the Philippines; those results showed that coughing and sneezing were identified as a transmission route by 89.5% of respondents [23]. In our study, knowledge of fever and cough as COVID-19 symptoms was high, and the participants knew that younger participants had a lower perceived risk and the elderly were identified as the high risk group [32]. One study from the United States among people with chronic conditions provided unexpected results: nearly one third could not correctly identify symptoms (28.3%) or ways to prevent infection (30.2%) [25].

Very interestingly, during early phase of COVID-19 pandemic, there has been an aggressive promotion of covid19 information through MOH and main government mass media. This lead to better knowledge and preparedness about the pandemic. Though still the promotion is present, adherence seems to become less. We believe that preventive attitude has to be re-enforced and appropriate prevention and control strategies should be promoted consistently.

With respect to identifying knowledge question related to COVID-19 prevention, nearly 50% of the participants identified using face mask, frequent hand washing and staying at home as the most important means of preventing the pandemic. The finding was by far lower than a study from Philippines which showed that hand washing was the most common preventive practice in response to COVID-19, adopted by 89.9% of respondents [23]. Another report from Ethiopia demonstrated that even 90% of the participants had a good prevention knowledge of maintaining social distance and frequent hand washing [24]. The moderate knowledge in our survey of participants living in the capital city of Ethiopia with consistent access to information.

Our study explored the association of socio-demographic characteristics with the public KAP. There was only an association between occupational status and good knowledge. In contrast with our findings, study from Tanzania and Iran showed that male sex, younger age (16 to 29 years), non-healthcare-related professions, being single and less education were significantly associated with lower knowledge scores [32, 33].

We also assessed the attitude of the participants towards practicing preventive measures, perceptions on lockdown and their stand on staying at home. Concerning attitudes, it was interesting that close to two thirds of the respondents showed a positive and optimistic attitude towards COVID-19 preventive measures. Similarly, a study from Saudi Arabia demonstrated that the mean score for attitude indicated optimistic attitudes and the mean score for practices was high, indicating good practices [21]. Findings from Egypt and Nigeria indicated that the attitude of most respondents (68.9%) towards instituted preventive measures was positive, with an average attitude score of 6.9 ± 1.2. In addition, the majority of the respondents (96%) practiced self-isolation and social distancing [22].

Another finding among the same population from Africa documented that the majority of the respondents (79.5%) had positive attitudes towards adherence to government infection prevention and control (IPC) measures, with 92.7%, 96.4% and 82.3% practicing social distancing/self-isolation, improved personal hygiene and using face masks, respectively [16].

In agreement with participants knowledge, the state of their attitude towards applying the preventive measures has been positive. Moreover, the findings proved that those with moderate knowledge and good knowledge turned out to have positive attitude which could ultimately impact the practice of the public and response towards for any possible outbreak.

The aforementioned optimistic attitude was consistent with participants’ practice of washing hands with soap and water and frequent use of hand sanitizer. It is an established fact that physical distancing is the most effective but also the most challenging measure. The respondents had a positive attitude towards physical distancing and implementation of lockdown in Ethiopia. This positive attitude will ultimately help in the prevention and control of COVID-19. However, periodic evaluation of this positive attitude towards preventive measures must be performed to determine whether it is sustained among the public.

In support of the present findings, a study from Ethiopia among several population revealed that frequent hand washing (77.3%) and avoiding shaking hands (53.8%) were the dominant practices [34]. Unlike our study, another investigation among health professionals from Oromia regional state, Ethiopia reportedly demonstrated that the practices of the participants towards COVID-19 prevention were relatively low: only 61% and 84% of the participants were practicing social distance and frequent hand washing, respectively [24]. Such a discrepancy might be due to the difference in the study population, study area and the pandemic phase.

In our study, only knowledge and attitude showed a moderate correlation. A previous study showed stronger relationship between knowledge, attitude and practice with infection prevention measures [35]. Finding from China revealed that COVID-19 knowledge score (odds ratio [OR] 0.75–0.90, p<0.001) was significantly associated with a lower likelihood of negative attitudes and preventive practices towards COVID-2019 [17]. This finding were also reported from Malaysia where most participants held positive attitudes towards the successful control of COVID-19 (83.1%) [15].

During an emergency, timely, adequate and appropriate information is important as the best intervention against rumors and misinformation [5]. Following the emergence of the pandemic, a large amount of information has been released in media based on internet information about COVID-19. Based on previous assessment, only 1.9% websites that provide health-related information had agreed to the Net Foundation Code of Conduct by the time of assessment [36].

The study explored the source of information regarding COVID-19. The majority of the study participants (84.4%) obtained information from government-owned television broadcast, followed by government-owned radio broadcast, social media and private television broadcast. In line with our finding, study from Iran indicated that government TV advertisements and short message service (SMS) were the most common sources of COVID-19 information and considered trustworthy (by >95% of participants) [32]. This was in support of a research finding from Philippines which demonstrated that traditional media sources such as television and radio were the main sources of information about the virus [23]. By contrast, another recent study in Ethiopia reported that social media were the main source of the information [24].

It was interesting that the public source of information was government outlets at the early phase of the pandemic; however, with time the public also tended to use social media as the primary source of information [24, 26]. Another study from Nigeria found that the participants mainly gained information about COVID-19 through the internet/social media (55.7%) and television (27.5%) [16]. However, the quality of information shared on the social media requires due attention and regulation to provide the public with reliable information so as to combat the pandemic effectively and in a sustainable approach.

TheCOVID-19 pandemic has been affecting enterprises of all sizes and types in unprecedented way [27, 37]. The majority of the assessed service providers in Addis Ababa in April 2020 had made available either washing facilities with soap and water or alcohol-based hand rub in an accessible spot. The availability of the washing facilities might explain the moderate state of knowledge, good attitude and best practice of public KAP. This is a very encouraging response; it shows that the government strategies were acceptable to the public, stake holders and clients of the service providers.

This survey had some limitations. First, the convenience sampling method did not avoid subjective selection bias. Second, selected localities may not reflect the whole picture of Addis Ababa at large because the ten sites were selected purposefully considering high traffic flow. In addition, we used a descriptive cross-sectional study design, which hinders determining a cause–effect relationship between an independent variable and the outcome variables. The comparability to other studies may be limited by use of different questionnaires. Although the study faced the above mentioned limitations, the strength of this study lies in its large sample size. To our knowledge, this is the first large scale study considering the public and service providers KAP and preparedness towards COVID-19 pandemic.

In terms of policy implication, the findings will the policy makers reconsider the engagement of the community as a key approach in combating any possible outbreak, including COVID 19. In general, data from the current study showed most probably a positive public health education effect leading to desired preventive measures as recommended by the government in the city.

Conclusion

In conclusion, the finding suggested that the public in Addis Ababa had moderate knowledge, optimistic attitudes and notable practice against the COVID-19 pandemic. Government and social media seem valuable sources of information and should further be utilized. COVID-19 knowledge correlated with an optimisticattitudetowardsCOVID-19; these finding indicate that effective awareness creation and health education have been delivered.

The service providers’ level of preparedness towards the pandemic was encouraging. Still, more practical support seems needed to assure full coverage with hand hygiene options in public enterprises. Periodic evaluation of service providers awareness and preparedness for any possible outbreak should be in place to assure sustainability of efforts.

Supporting information

S1 Appendix

(PDF)

Click here for additional data file.^{(31.1KB, pdf)}

S2 Appendix

(PDF)

Click here for additional data file.^{(85.3KB, pdf)}

Acknowledgments

We would like to express our gratitude to health professionals and researchers working to overcome COVID-19 throughout the world during this critical time.

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

ZD Grant number: VPRTT/PY-403/2020 Addis Ababa University www.aau.edu.et The funders have no role in in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0244780.r001

Decision Letter 0

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2 Jul 2020

PONE-D-20-17538

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

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Reviewer #1: PONE-D-20-17538

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

The manuscript addresses the important topic in timely presentation by describing the KAP of community in mitigating COVID-19 pandemic. While the manuscript is of some interest and paucity of COVID-19 related data, the manuscript could be strengthened by several modest changes as outlined below.

I suggest the authors to look for STROBE check list for cross-sectional studies to ensure reporting is complete and transparent.

https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_cross-sectional.pdf

GENERAL COMMENTS

-The manuscript is not well-written and needs to be edited by a native English speaker. Please check typo, grammar mistakes and format throughout the manuscript.

-Inserting line numbers may facilitate to give comments and feedbacks.

ABSTRACT

-The sentence “This would need knowledge, attitude and practice (KAP) of the population” is unclear.

-The authors concluded “The public service providers and enterprises were well prepared to contribute in the measures against the diseases”. But presented 62.9% made hand washing facilities available which is not satisfactory especially for COVID-19 prevention.

-Results presented here must be best support to the understanding of conclusions.

INTRODUCTION

-The sentence “The diseases vary from mild, self-limiting diseases to more severe manifestations depending on the type of viruses involved” is not clear. What types of virus involved? Subtypes or genotypes? Are you mentioning different types of viruses or COVID only?

-The sentence “The current human coronavirus named SARS-CoV-2 emerged as a public health problem from Wuhan City, Hubei Province of China on 31 December 2019 as a cluster of pneumonia cases” needs reference.

-In the sentence “As of June 7 , there were 2020 confirmed cases, twenty seven and 344 recovered cases in Ethiopia”, what do you mean by “twenty seven and 344 recovered cases”? typo error?

-The introduction section becomes like the history of COVID-19 but Why prevention plays vital role for COVID-19? Why do you need to assess KAP? are missing.

METHODS

-Did you calculate sample size for service providers?

-Is fever screening include in the observation checklist? If not, why?

-The authors mentioned a total of 35 closed questions including socio-demographic characteristics, travel history, risk factors, and KAP, and then later mentioned 40 Knowledge questions, 8 attitude questions and 4 practice questions.

-Add reference for Bloom’s cut off point

-Data analysis should be elaborated more

RESULTS

-The results section should avoid discussion words like interestingly, unlike, etc. and be written in academic way (E.g. “Next we looked at the association of knowledge…..”).

-Table 1 – check and correct frequency and percentage.

-Could you add travel and contact history to Table 1.

-I could not find contact history in the results. Do you ask question like “have contact with COVID-19 positive patient?”? as the authors titled travel and contact history.

-The description regarding variables included in the questionnaires should be moved to Methods.

-Did you calculate knowledge level by specific knowledge themes: prevention, transmission, sign and symptoms, etc. ?

-Any reason for using correlation coefficient (r) among KAP but not chi-square (as authors used before)?

-Table 7 – can the enterprise types combined into categories? (E.g. Hotel/restaurant and Cafeteria) as 35% occupied as others.

-I do not find the result in Table 8 for the sentence “Of the enterprises 264 (62.9%) had hand-washing facilities with soap and water, 32(7.6%) of them had water only, 11 (2.6%) of them had soap only and 34 (8.1%) had neither of the washing facilities (table 8)”. Meanwhile, hand washing facility of 294 (70%) from the Table 8 has discrepancy with the above mentioned sentence. Is hand washing facility 294 or 264 or 264+34 or 264+32+11? What is your operational definition for hand washing facility?

-The authors mentioned as small and medium enterprises but I found bank and mall in the list. Is bank and mall SME in Ethiopia?

DISCUSSION

-The discussion is weak in light of the findings and should be rewritten. The discussion needs to focus on the key implications of the data with a separate paragraph for each concept and discuss the potential reasons for it by comparing local and international literatures. Moreover, repeating the finding statements and analytical term (E.g. p value) should be avoided here.

-Some discussed points have not presented in the results (E.g. Nearly two thirds of the respondents could not properly identify symptoms or know how the disease is transmitted and could not identify preventive measures).

Reviewer #2: This manuscript describes the results of a community based KAP survey in Ethiopia

Some comments

1- The abbreviations, SARS CoV, MERS needs to be defined

2- In the abstract, its described that the Questionnaire was self administered ; in the M&M, it was administered by data collectors. Authors should clarify on this

3. In the introduction, the number of cases, recoveries and deaths needs to be clarified

4. The questionnaire needs to be provided as a supplementary material for the readers

5. Discussion, some sentences missing citations

Reviewer #3: The authors attempt to describe the knowledge, attitude and practices about COVID-19 prevention and mitigation practices among members of the community, service providers and enterprises in Addis Ababa, Ethiopia.

The study requires a major overhaul of the language for better comprehension

Abstract

The line in conclusion “The public service providers and enterprises were well prepared to contribute in the measures against the diseases.” Does not stem from the study findings which are only about hand washing facilities’ availability.

Main text

The penultimate para in introduction mentions twenty seven….but does not qualify what it is referring to

The introduction does not establish the rationale for studying the preparedness of the service providers

There is no sample size calculation described for the enterprises and service providers

Why a design effect of 2 was chosen is not described

The authors have calculated the sample size for descriptive analysis / proportion..but the analysis plans included comparison of two proportions..

They have written “The modified Bloom’s cutoff points were used to judge knowledge as good, moderate or poor if the total mark is :sufficient knowledge ≥80%, positive attitude :80-100% (≥32) good;50-79% (20- 31) moderate ;o r ≤ 50% (≤19) poor knowledge respectively.” It is not clear if it is for knowledge or attitude

It says data was validated, but not elaborated how? Was double data entry done for validation?

The nature of consent obtained isn’t clear

From the data presented in tables, the questionnaire seems to be very arbitrarily designed.

Table 3,4,5 can be compressed into one

The larger picture of the relevance of the findings and their addition to existing knowledge to inform current prevention and control measures for COVID

**********

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Reviewer #1: Yes: Kyaw Lwin Show

Reviewer #2: No

Reviewer #3: No

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PLoS One. 2021 Jan 7;16(1):e0244780. doi: 10.1371/journal.pone.0244780.r002

Author response to Decision Letter 0

29 Sep 2020

Point by point response for Editor and reviewers comment

Manuscript number: PONE-D-20-17538

Manuscript title: "COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia"

Dear editor and the reviewer,

First of all, we would like to thank the journal team members, the journal editor and the respective reviewers for taking their time and sending valuable suggestions for our manuscript.

As per the request, we incorporated all the relevant changes to the revised manuscript with track change. Additionally, a detail point by point response for each editors and reviewers comment enclosed with this letter.

With kind regards,

Zelalem Desalegn Woldesonbet

PI and corresponding/submitting author

Assistant professor, Department of Microbiology, Immunology and Parasitology

School of Medicine, College of Health Sciences

Addis Ababa University

Reviewer 1 comments:

Reviewer 1-General comments

1. Comments: Consider STROBE check list for cross-sectional studies to ensure reporting is complete and transparent

Dear reviewers, we appreciate your suggestion and direction. We have gone through the STROBE for cross-sectional studies, and forwarded thoughtful consideration into the method section.

2. Comments: Please check typo, grammar mistakes and format throughout the manuscript

The authors and a professional proof-reading service thoroughly checked and corrected the manuscript.

3. Comments: Inserting line numbers may facilitate to give comments and feedbacks.

We accept the raised suggestion. The line numbers are included in the revised version of the manuscript.

4. Comments: the manuscript is not well-written and needs to be edited by a native English speaker

We considered the comment. To manage the language issue, professional proof-reading was implemented.

Reviewer 1-Specific comments: Abstract

1. Comments: The sentence “This would need knowledge, attitude and practice (KAP) of the population” is unclear.

Yes, we accept your thoughtful comment. Accordingly, we have presented the unclear aforementioned sentence in a very meaningful way in the revised version of the manuscript (“However, there is a scarcity of evidence-based data on the public knowledge, attitude and practice ( KAP) and response of the service providers regarding COVID-19. Therefore, the study was conducted to generate key findings attributable to combating the recent pandemic ”)(Please refer line number 40 to 43)

2. Comments: The authors concluded “The public service providers and enterprises were well prepared to contribute in the measures against the diseases”. But presented 62.9% made hand washing facilities available which is not satisfactory especially for COVID-19 prevention.

We agree with your argument. Definitely, only making available the hand washing facility in 62.9% may be too little to have significant impact on COVID 19 prevention, but we consider this as a good starting point. Therefore, the phrase presented is now: “Two thirds of public service providers made hand washing facilities available is a first positive step”(please refer line number 69 to 70).

3. Comments: Results presented here must be best support to the understanding of conclusions.

Based on the suggestion made, the result section has been re-constructed taking into account additional relevant findings and the conclusion was drawn out of it. In addition to the previously presented data, we made additions of the major findings which was missed due to the word limit of the abstract.

Reviewer 1-Specific comments: Introduction

1. Comments: The sentence “The diseases vary from mild, self-limiting diseases to more severe manifestations depending on the type of viruses involved” is not clear. What types of virus involved? Subtypes or genotypes? Are you mentioning different types of viruses or COVID only?

The sentence "“The diseases vary from mild, self-limiting diseases to more severe manifestations depending on the type of viruses involved” in the first paragraph is a continuation of the first sentence referring " Infections with Coronaviruses in humans and animals cause respiratory and intestinal diseases " describing about infection caused by any type of Coronavirus not specifically with the SARS-cov-2.

2. Comments: The sentence “The current human coronavirus named SARS-CoV-2 emerged as a public health problem from Wuhan City, Hubei Province of China on 31 December 2019 as a cluster of pneumonia cases” needs reference

Thank you. The indicated research finding along with other related information was extracted from a references 5 through 7 which has been also indicated in the submitted manuscript and in the reference section( please refer line number 92).

3. Comments: In the sentence “As of June 7, there were 2020 confirmed cases, twenty seven and 344recovered cases in Ethiopia”, what do you mean by “twenty seven and 344recovered cases”? typo error?

Well taken. As you have noted it well, in the description we missed to link the figure" twenty seven" with the health parameter which is "deaths" during the submission. We have made changes of the numbers taking into account the latest data( Please refer line number 101 to 102).

4. Comments: The introduction section becomes like the history of COVID-19 but Why prevention plays vital role for COVID-19? Why do you need to assess KAP? are missing.

Well taken. Evidence based data showing the relevance of the study and the reason for the finding on KAP are presented well and the role of prevention to fight against the pandemic well narrated concisely with latest data released on COVID-19. “The KAP of people towards COVID-19 is critical to understand the epidemiological dynamics of the disease and the effectiveness, compliance and success of infection prevention control measures adopted in a country. Moreover, research has demonstrated that effective control and mitigation of COVID-19 in any country requires operational research and timely epidemiological data generated among different groups of the population ( Please refer line number 125 to 153).

Reviewer 1-Specific comments: Methods

1.Comments: Did you calculate sample size for service providers?

Well taken. originally, we calculated the sample size but missed in the previously submitted manuscript. Considering your comments, the sample size calculation assumptions with the final sample size presented under the method section in the revised version of the manuscript ( please refer line number 176 to 179).

2. Comments : Is fever screening include in the observation checklist? If not, why?

We did not include fever screening in the checklist because at that time point the government and health authorities only advised the service providers to make available washing facilities or alternatives including sanitizer. Additionally, the enterprises were enforced to manage the sitting pattern of the customer. In case of for example transportation service, the users were well spaced while standing in line. In case of restaurants and Bank, security officers directed the customers to wash their hands before entry for the respective services. We did not include it into the checklist because thermal screening was not in place during the early phase of the pandemic in out context.

3. Comments :The authors mentioned a total of 35 closed questions including socio-demographic characteristics, travel history, risk factors, and KAP, and then later mentioned 40 Knowledge questions, 8 attitude questions and 4 practice questions.

Yes, you are right and well taken. We changed to 40 knowledge questions( please refer line number 193).

4. Comments :Add reference for Bloom’s cut off point

Well taken. Reference incorporated in the revised version of the method section( line number 202).

5. Comments :Data analysis should be elaborated more

We did the elaboration on data analysis and incorporated into the revised version of the manuscript. (second last paragraph of method section)( please refer 224 to 233)

Reviewer 1-Specific comments: Results

1. Comments: The results section should avoid discussion words like interestingly, unlike, etc. and be written in academic way(E.g. “Next we looked at the association of knowledge…..”).

Thank you for the forwarded comments. Based on your comments, we omit of using words highlighting description of matter.

2. Comments : Table 1 – check and correct frequency and percentage.

Thank you. In table 1, there were few variables to which the participants did not respond for example in case of age and others. The proportion of unknown information was added.

3. Comments :Could you add travel and contact history to Table 1.

Well taken. As per the suggestion, the travel and contact history is added to Table 1.

4. Comments I could not find contact history in the results. Do you ask question like “have contact with COVID-19 positive patient?”?as the authors titled travel and contact history.

Well taken. We did not include whether the participants had contact with COVID-19 patients instead we asked the history of contact with a person who travelled to COVID affected areas. This is changed.

5. Comments: The description regarding variables included in the questionnaires should be moved to Methods.

We have considered your comments and moved to method section

6. Comments: Did you calculate knowledge level by specific knowledge themes: prevention, transmission, sign and symptoms, etc. ?

Well taken. We have created a new descriptive table summarizing presented knowledge questions focusing on prevention, sign and symptoms, transmission. Additionally, there are too few questions to further sub-classify the knowledge and a further study on this could be interesting.

7. Comments :Any reason for using correlation coefficient (r) among KAP but not chi-square (as authors used before)?

We have used correlation coefficient because it shows the direction of the relation between Knowledge-attitude, Knowledge-practice, Attitude-practice in addition to Chi-square which shows only presence of association across/characteristics.

In addition, we have seen that other research findings similar study population applied correlation coefficient and thus comparison is possible.

Comments: 7 – can the enterprise types combined into categories? (E.g. Hotel/restaurant and Cafeteria) as 35% occupied as others.

Yes, you are perfectly correct. During the analysis we summarized the enterprise by putting them into in same package However, the table number was re-organized the required table was labeled as table 6 in the revised version(Please refer line number starting from 321)

8. Comments : I do not find the result in Table 8 for the sentence “Of the enterprises 264 (62.9%) had hand-washing facilities with soap and water, 32(7.6%) of them had water only, 11 (2.6%) of them had soap only and 34 (8.1%) had neither of the washing facilities (table 8)”. Meanwhile, hand washing facility of 294 (70%) from the Table 8 has discrepancy with the above mentioned sentence.

Just to be clear, 264 (62.9%) had hand-washing facilities with soap and water is referring to the detail of the facility, whereas the hand washing facility of 294 (70%) was referring hand washing facility regardless of the type of the hand washing facilities made available by the service providers.

For the better understanding of these part, we have added additional table describing the type of facilities in each service providers (Please refer table 7 and 8).

9. Comments : Is hand washing facility 294 or 264 or 264+34 or 264+32+11? What is your operational definition for hand washing facility?

Well taken and we appreciate your perspectives. When we are saying hand washing facility, a facility packaged with water with soap. To make the figure more clear, we have created additional table( please refer table 8)

10. The authors mentioned as small and medium enterprises but I found bank and mall in the list. Is bank and mall SME in Ethiopia?

Thank you for your observation. We have considered your suggestion into the revised version of the manuscript. “A total of 420 service providers were included in the survey.”

Reviewer 1- Specific comments: Discussion

1. Comments The discussion is weak in light of the findings and should be rewritten. The discussion needs to focus on the key implications of the data with a separate paragraph for each concept and discuss the potential reasons for it by comparing local and international literatures. Moreover, repeating the finding statements and analytical term (E.g. p value) should be avoided here.

We have considered your comments and the discussion was re-written considering the major findings of the study. We attempted to provide strong evidence-based information conducted elsewhere and tried to explain our finding, appreciate the discrepancy and strengthen our studies importance with respect to showing the gaps in the fight against the pandemic.

Additionally, Considering your suggestions, we avoided using the detailed findings in the discussion section.

2. Comments: Some discussed points have not presented in the results (E.g. Nearly two thirds of the respondents could not properly identify symptoms or know how the disease is transmitted and could not identify preventive measures).

Based on your scientific comments, all the discussed points have been incorporated into the result section. Your comments were valuable and accommodated accordingly.

Reviewer 2 comments

Reviewer #2: This manuscript describes the results of a community based KAP survey in Ethiopia

1. Comments: The abbreviations, SARS CoV, MERS needs to be defined

This has been addressed in the revised manuscript (please refer line numbers 86 and 87).

2. Comments: In the abstract, its described that the Questionnaire was self administered ; in the M&M, it was administered by data collectors. Authors should clarify on this

Well noted. Yes, as you have mentioned the questionnaire was self administered; however, the data collectors were responsible for facilitating, briefing the objectives of the study, distributing the tool, checking the completeness and collecting the questionnaire from each consented participants ( please refer line number 192 and 207).

See Methods: “To facilitate the data collection, 10 data collection facilitators were enrolled to distribute and collect the completed questionnaire from the consented participants. Formal training included a brief introduction of the research objectives, data collection procedure and questionnaire content was delivered.”( please refer line number 207 to 210)

3. Comments : In the introduction, the number of cases, recoveries and deaths needs to be clarified

We highly appreciate your comments. Accordingly, we presented the local and global latest update of SARS cov-2 number of cases, recoveries and death figure with the respective reference. Please see introduction.

Global perspectives: "As of September 29 2020, approximately 33,556,252 million cases, 1,006,450 deaths and 24,881,239 recovered cases have been reported globally" ( please refer line number 101 and 102)

Ethiopian context: "As of 29 September 2020, there had been 73, 944 confirmed cases, 1,177 deaths and 30, 753 recovered cases in Ethiopia" ( line number 112 and 113)

4. Comments: The questionnaire needs to be provided as a supplementary material for the readers

Well taken comments. The questionnaire provided as a supplementary material in the revised version of the manuscript. The detail description of the questionnaire presented under the method section( please refer line number 192 to 210).

5. Comments : Discussion, some sentences missing citations

We thoroughly looked at the manuscript to make sure that there are sentences missing citations. However, the citations are sometimes mentioned few sentences later in the text.

Reviewer #3:

The authors attempt to describe the knowledge, attitude and practices about COVID-19 prevention and mitigation practices among members of the community, service providers and enterprises in Addis Ababa, Ethiopia.

1. Comments :The study requires a major overhaul of the language for better comprehension

Well taken. A major language editing was done throughout the manuscript. The revised version has also been sent out for professional language editing service.

2. Comments : The line in conclusion “The public service providers and enterprises were well prepared to contribute in the measures against

the diseases.” Does not stem from the study findings which are only about hand washing facilities’ availability.

Well taken. As you have clearly described, we have modified the sentences in the conclusion part of the abstract section. (“Two thirds of public service providers made hand washing facilities available is a first positive step.”)( Please refer line number 69 and 70)

3. Comments : The penultimate para in introduction mentions twenty seven….but does not qualify what it is referring to

Well noted.

In the introduction section, twenty seven was referring death related with COVID 19 in Ethiopian context. In the revised manuscript, latest data related with COVID 19 has been presented in the local context(please refer line number 112 and 113).

4. Comments : The introduction does not establish the rationale for studying the preparedness of the service providers

Well taken.

Considering your comments, we have presented research based information and established facts describing how service providers preparedness could affect the prevention and control of any possible outbreak including COVID 19( please refer line number 141 to 153)

5. Comments :There is no sample size calculation described for the enterprises and service providers. Why a design effect of 2 was chosen is not described

Sample size calculation was done for the service providers and shown in the revised version of the manuscript ( please refer line number 176 to 179). The design effect was used to maximize the sample size and enhance the generalization of the finding.

6. Comments : The authors have calculated the sample size for descriptive analysis / proportion..but the analysis plans included comparison of two proportions.

Well taken. We carried out both descriptive analysis and association of the independent variables with the outcome variables computed using Chi-square – this was rather exploratory analysis.

7. Comments: They have written “The modified Bloom’s cutoff points were used to judge knowledge as good, moderate or poor if the total

mark is :sufficient knowledge ≥80%, positive attitude :80-100% (≥32) good;50-79% (20- 31) moderate ;o r ≤ 50% (≤19)poor knowledge respectively.” It is not clear if it is for knowledge or attitude .

Thank you for your insightful comments. The description was meant for knowledge not for attitude. The clarification presented very well in the revised version of the manuscript. The above description ws replaced with " The right answer to each question has a score of 1 and wrong answer 0. Modified Bloom’s cut-off points were used to judge knowledge as good (80%–100%), ≥32), moderate (50%–79%, 20–31),or poor (≤ 50%, ≤19) "( please refer line number 216 to 218) . Moreover, the modified bloom's cut-off point was referenced in the method section of the revised version of the manuscript.

8. Comments : It says data was validated, but not elaborated how? Was double data entry done for validation?

Well taken. No double entry was done was not done and thus not described due to lack of resources.

9. Comments: The nature of consent obtained isn’t clear

Verbal consent was obtained from each participants which has been indicated under participant recruitment procedure and ethical approval section( please refer line number 239) .

10. Comments : From the data presented in tables, the questionnaire seems to be very arbitrarily designed.

We appreciate your comments. What we did was, we explored research works conducted in related topic and same population. Following that, we referred also WHO and CDC guidelines, to select major themes and outline the content which have to be considered while assessing KAP of the public towards COVID 19. Finally, we have built the questions taking into account the local social, cultural and educational context.

11. Comments : Table 3,4,5 can be compressed into one

The larger picture of the relevance of the findings and their addition to existing knowledge to inform current prevention and control measures for COVID

Well taken, and table 3, 4 and 5 merged and a new table was created ( table 4)

Additional Editor Comments:

1. Extensive English language editing is deemed necessary.

Professional English language editing was done.

2. Authors need to discuss the limitations of the study and policy implications.

Well taken. We have considered the need of discussing the limitation and anticipated policy implication of the finding. Accordingly, the comment incorporated into the revised version of the manuscript (discussion section)( please refer line number 517 to 530).

3. Authors need to add one descriptive table analyzing 40 knowledge items.

Well noted. Accordingly, we have presented a descriptive table composed of knowledge questions on prevention, sign and symptom and transmission mechanisms of SARS-cov-2( Please refer table 2).

Attachment

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PLoS One. doi: 10.1371/journal.pone.0244780.r003

Decision Letter 1

Khin Thet Wai

15 Oct 2020

PONE-D-20-17538R1

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. Desalegn,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please submit your revised manuscript by Nov 29 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Still needs to do English language editing by the native speaker or the recognized English language editing service and also needs to improve the discussion part up to standard.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Reviewer #1: PONE-D-20-17538-R1

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

The authors have made their efforts and the manuscript becomes far better than before. However, the manuscript still could be strengthened especially in the discussion.

-LINE 166 – I think it is a typo. “839 84 per site)”.

-LINE 232 – 36.7 % is not the large majority. You can simply say” government employee and non-government employee occupied one third each (36.7% and 34.7%) followed by …”.

-Table 1 - Remove the unknown row if it does not exit (0%) or remain if occupied some %

-Some parts of table 4 are missing. I think it is a formatting error.

-Table 5 - I accept author explanation. It is better to present as a correlation matrix table.

-Table 8 - does not make 100% in cumulative. Please check.

-Discussion – still have lots of room for improvement for better, concise and comprehensive. Repeating the finding statements and sentences from the methods (e.g. LINE 341, 369, 377, etc.) should be avoided here. Information is repeated in many places (e.g. LINE 329 vs 360 vs 402). There are ways to discuss better without repeating findings and methods. The discussion part includes mostly comparison while missing potential reasons why the current results were found.

Reviewer #2: I would like to thank the authors for sufficiently addressing all the comments raised by the reviewer. Well done.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Kyaw Lwin Show

Reviewer #2: Yes: Felix Bongomin, MD

Attachment

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PLoS One. 2021 Jan 7;16(1):e0244780. doi: 10.1371/journal.pone.0244780.r004

Author response to Decision Letter 1

15 Dec 2020

Response to reviewers and editor comments:

Reviewer #1:

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

The authors have made their efforts and the manuscript becomes far better than before. However, the manuscript still could be strengthened especially in the discussion.

1. LINE 166 – I think it is a typo. “839 84 per site)”.

Thank you for your thoughtful comment. We appreciate the comment and corrected in the revised version ( Please refer line number 166 of the revised version)

2. LINE 232 – 36.7 % is not the large majority. You can simply say” government employee and non-government employee occupied one third each (36.7% and 34.7%) followed by …”.

Well taken. We accept the comment and we presented the data in the way you have recommended ( Please refer line number 232-236 of the revised manuscript)

2. Table 1 - Remove the unknown row if it does not exit (0%) or remain if occupied some %

Well taken. We have removed the unknown row ( Please refer table 1)

3. Some parts of table 4 are missing. I think it is a formatting error.

Well taken. We included the missed p-value ( Please refer table 4)

4. Table 5 - I accept author explanation. It is better to present as a correlation matrix table.

We appreciate your positive feedback.

5. Table 8 - does not make 100% in cumulative. Please check.

Well taken. Yes, as you have sated it has to give 100%; however, the reason for not making 100% is due to no response for some of specific questions in the checklist ( please refer table 8)

6. Discussion – still have lots of room for improvement for better, concise and comprehensive. Repeating the finding statements and sentences from the methods (e.g. LINE 341, 369, 377, etc.) should be avoided here. Information is repeated in many places (e.g. LINE 329 vs 360 vs 402). There are ways to discuss better without repeating findings and methods. The discussion part includes mostly comparison while missing potential reasons why the current results were found.

We appreciate your comments. Accordingly, we removed the finding statements and sentence directly taken from result section. We also removed information repeated and tried to discuss better without repeating findings and methods (Please refer the whole discussion part for better clarification).

Reviewer #2:

I would like to thank the authors for sufficiently addressing all the comments raised by the reviewer. Well done.

Additional Editor Comments (if provided):

1. Still needs to do English language editing by the native speaker or the recognized English language editing service and also needs to improve the discussion part up to standard.

Well take. We appreciate the comment forwarded by editor for the betterment of the revised manuscript. We have gone through the manuscript thoroughly to improve the language and present the research data fulfilling the journal requirements.

Additionally, the manuscript has been sent out for recognized language editing service.

The authors strived to their best to make the discussion part very comprehensive, concise and clear to improve it up to the standard.

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PLoS One. doi: 10.1371/journal.pone.0244780.r005

Decision Letter 2

Khin Thet Wai

17 Dec 2020

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

PONE-D-20-17538R2

Dear Dr. Desalegn,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Res.)

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0244780.r006

Acceptance letter

Khin Thet Wai

28 Dec 2020

PONE-D-20-17538R2

COVID-19 and the public response: knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

Dear Dr. Desalegn:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Khin Thet Wai

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

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Data Availability Statement

All relevant data are within the manuscript and its Supporting information files.

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COVID-19 and the public response: Knowledge, attitude and practice of the public in mitigating the pandemic in Addis Ababa, Ethiopia

Zelalem Desalegn

Negussie Deyessa

Brhanu Teka

Welelta Shiferaw

Damen Hailemariam

Adamu Addissie

Abdulnasir Abagero

Mirgissa Kaba

Workeabeba Abebe

Berhanu Nega

Wondimu Ayele

Tewodros Haile

Yirgu Gebrehiwot

Wondwossen Amogne

Eva Johanna Kantelhardt

Tamrat Abebe

Roles

Abstract

Background

Objective

Methods

Result

Conclusion

Introduction

Methods and materials

Study design and setting

Study population and the target sample size

Participant recruitment procedure

Data collection tool

Knowledge related to COVID-19

Attitude towards COVID-19

Practice regarding COVID-19

Statistical analysis

Research ethics approval

Results

Demographic characteristics

Travel history to COVID-19-affected areas

Table 1. Demographic characteristics of the study participants in Addis Ababa, Ethiopia.

KAP towards the COVID-19 pandemic

Knowledge assessment

Table 2. The response of the participants to specific knowledge questions in Addis Ababa, Ethiopia.

Table 3. Number of questions, range, scores and levels of knowledge, attitude and practice of the study participants in Addis Ababa, Ethiopia.

Table 4. Association between respondent demographic characteristics and level of knowledge, attitude and practice scores in Addis Ababa, Ethiopia.

Attitude towards COVID-19 and association with demographic characteristics

Practice towards COVID-19

Correlations among knowledge, attitude and practice

Table 5. Correlation between knowledge, attitude and practice scores towards COVID-19.

Source of information about COVID-19

Response of service providers towards COVID-19 pandemic

Table 6. Type of service providers included in the study in Addis Ababa, Ethiopia.

Table 7. Preventive measures made available by service providers in Addis Ababa, Ethiopia.

Table 8. Type of washing facility available to prevent COVID-19 among service providers in Addis Ababa, Ethiopia.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Khin Thet Wai

Roles

Author response to Decision Letter 0

Decision Letter 1

Khin Thet Wai

Roles

Author response to Decision Letter 1

Decision Letter 2

Khin Thet Wai

Roles

Acceptance letter

Khin Thet Wai

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

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