Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria

Osahon Enabulele; Somhi Ikhurionan; Doyle Etu

doi:10.4103/jnam.jnam_1_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 1 | Issue : 2 | Page : 72-82

Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria

Osahon Enabulele, Somhi Ikhurionan, Doyle Etu
Department of Family Medicine, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Submission	03-Jul-2021
Date of Acceptance	16-Aug-2022
Date of Web Publication	27-Dec-2022

Correspondence Address:
Osahon Enabulele
Department of Family Medicine, University of Benin Teaching Hospital, P.M.B. 1111, Ugbowo, Benin City, Edo State
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnam.jnam_1_21

Abstract

Background: Coronavirus disease 2019 (COVID-19) is a highly infectious disease that has affected peoples of all ages, gender, and income groups. Public health measures to limit the spread of the disease have not been well adhered to in Nigeria, due partly to poor public awareness and perception of the disease. Aim: This study assessed the knowledge of COVID-19, its perception, and practice of preventive measures, among patients attending the General Practice Clinic (GPC) of a tertiary hospital in Nigeria, with the hope of obtaining insights to guide strategic policy intervention to enhance adherence to prescribed public health measures. Subjects and Methods: This was a descriptive cross-sectional study conducted among patients attending the GPC of a tertiary hospital in Nigeria. A pretested semi-structured questionnaire was used to obtain data from study participants. Data analysis was done using the IBM SPSS statistics version 22.0 (Chicago, IL, USA) statistical software. Results: Virtually all the respondents (99.2%) were aware of COVID-19. Majority had a good knowledge of COVID-19 (55.1%), good perception of COVID-19 (51.6%), and good practice of preventive measures against COVID-19 (50.4%). Most respondents (57.0%) were of the view that government agencies are not sincere in the fight against COVID-19. Conclusion: A majority of the study participants had a good knowledge and perception of COVID-19 and a good practice of preventive measures. There was a positive correlation between knowledge and perception; knowledge and practice; and perception and practice. We recommend that information and educational messages should be timely and transparently delivered to the people, with public and political office holders showing exemplary leadership.

Keywords: COVID-19, General Practice Clinic, Knowledge, Patients, Precautionary Measure, Risk Perception

How to cite this article:
Enabulele O, Ikhurionan S, Etu D. Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria. J Niger Acad Med 2022;1:72-82

How to cite this URL:
Enabulele O, Ikhurionan S, Etu D. Assessment of the knowledge, practice, and perception of COVID-19 among patients attending the General Practice Clinic of a tertiary hospital in South-South, Nigeria. J Niger Acad Med [serial online] 2022 [cited 2023 Jun 9];1:72-82. Available from: http://www.jnam.com/text.asp?2022/1/2/72/365597

Introduction

The novel coronavirus that causes coronavirus disease 2019 (COVID-19) is a member of a large family of coronaviruses.^[1] It was formerly known as 2019-nCoV, but now officially known as SARS-CoV-2.^[1],[2] It was first identified following the report of an outbreak of an acute respiratory illness in Wuhan City, Hubei Province of China, to the authorities of the World Health Organization in December 2019.^[3],[4] Since the outbreak of the disease, it has spread to many different countries across the world, with the World Health Organization, respectively, declaring it a public health emergency of international concern on January 30, 2020, and a pandemic on March 11, 2020.^[5],[6]

COVID-19 is a highly infectious disease that affects all ages, gender, and income groups, with main clinical symptoms such as fever, dry cough, dyspnea, and anosmia, among others. SARS-CoV-2 is known to also cause acute respiratory distress, septic shock, metabolic acidosis, bleeding, and coagulation dysfunction.^[7],[8],[9] These complications are more pronounced in the elderly, immunocompromised patients and patients with underlying health conditions such as diabetes mellitus, hypertension, and asthma.^[10] The disease has an average incubation period of 2–14 days and is mainly transmitted from person to person through respiratory droplets from coughing, sneezing, and aerosols, as well as touching surfaces and objects contaminated with the virus.^[11],[12] As at the time of conducting the study in the month of May 2020, there was no vaccine or drug to prevent infection with the novel coronavirus.^[13] Therefore, Infection Prevention and Control measures constituted the mainstay of prevention and containment efforts to reduce the spread of the disease. This is mainly through hand and respiratory hygiene such as regular hand washing with soap and water for at least 20 s, avoiding contact with contaminated surfaces and objects, avoiding touching the mouth, eyes, and nose with unwashed hands, avoiding contact with infected people by maintaining a physical distance of at least 2 m, using face masks and isolating suspected and confirmed cases, among other measures.^{[6],[12],[14]}

Since its emergence, COVID-19 has unfortunately affected millions of people across the world with thousands of deaths recorded. As at May 22, 2020, there were 4,993,470 confirmed cases of COVID-19 globally, with 327,738 deaths recorded.^[15] In Africa, the first case was confirmed in Egypt on February 14, 2020.^[16],[17] As at May 22, 2020, over 50 African countries had been affected by COVID-19, with 71,752 confirmed cases and 1,981 deaths.^[15] Nigeria recorded her first confirmed case of COVID-19 on February 27, 2020, and as at May 22, 2020, she had 7,261 confirmed cases, 2,007 recoveries, and 221 deaths.^[18]

The Nigerian government and various health authorities have instituted public health measures to limit the spread of the SARS-CoV-2, but their efforts have been faced with challenges such as poor public awareness and the inadequacies of the health system characterized by a poor health infrastructure, equipment, and technologies, among other challenges.^[19] With the reported rise in community transmission in some states of Nigeria,^[20],[21] the health system may likely be overwhelmed with a burgeoning increase in the number of confirmed cases, unless efforts are made to improve public awareness and compliance with prescribed preventive measures.^[6]

To facilitate the people’s adherence to the prescribed public health measures, it is important to assess the level of knowledge they have about COVID-19, their perception of the disease, as well as their practice of preventive measures. This is more so for individuals who visit the hospitals for medical care, as the hospital environment is a known source of nosocomial infections. This study assessed the knowledge of COVID-19, its perception, and practice of preventive measures against its spread, among adult patients attending the General Practice Clinic (GPC) of a tertiary hospital in Nigeria, with the hope of obtaining insights to guide strategic policy intervention to enhance adherence to prescribed public health measures and limit the spread of COVID-19. To the best of our knowledge, there has been no previous study on this in the study setting.

Subjects and Methods

This was a descriptive cross-sectional study conducted among patients attending the GPC of the University of Benin Teaching Hospital (UBTH), Benin City, Edo State, Nigeria. The study was conducted over a two-week period in the month of May 2020 during the enforcement of government guidelines on movement restriction in Nigeria. The UBTH is a federal tertiary hospital established on May 12, 1973.^[22] The hospital’s GPC is an outpatient clinic through which primary medical care is offered by family physicians and other primary care physicians to patients.

Adult patients (≥18 years of age) attending the GPC and who willingly consented to participate in the study were recruited as participants in the study, whereas adult patients who were too ill to participate in the study were excluded.

With an average of 610 adults seen over a previous two-week period in the month of April 2020, a minimum sample size of 235 was obtained using the formulas n = z2pq/d² (for a study population more than 10,000) and nf = n/1 + n/N (for a population less than 10,000).^[23] As at May 22, 2020, Nigeria had 7,261 confirmed cases of COVID-19.^[18] A total of 258 adults were therefore recruited as study participants through simple random sampling.

A pretested semi-structured questionnaire adapted from the template proposed by the World Health Organization was used to obtain data. The questionnaire assessed the relevant sociodemographic characteristics of respondents (such as age, gender, marital status), knowledge, practices of preventive measures against COVID-19, and perceptions of COVID-19. The questionnaire was made up of four sections.

Section 1: Obtained information regarding sociodemographic background of the respondents including gender, age, religion, marital status, level of education, and employment status.

Section 2: Information regarding knowledge on COVID-19 was elicited. Forty-six questions were used to score respondents’ knowledge of the disease. Each answer was graded as 0 (incorrect answers) and 1 (correct answers). The mean knowledge score was calculated (29.9), and respondents whose total score was below the mean score was classified as having a “poor” knowledge and scores above the mean were classified as a “good” knowledge.

Section 3: Questions were aimed at assessing the respondents’ practice of preventive measures against COVID-19. Eleven questions were used to calculate the practice score. Each answer was graded as 0 (incorrect answers) and 1 (correct answers). The mean practice score was calculated (6.2), and respondents whose total score was below the mean score were classified as having a “poor” practice and scores above the mean were classified as a “good” practice.

Section 4: Assessed the respondents’ perceptions and myths concerning the emerging disease. Twelve Likert-type questions were used to calculate the perception score. Scores for each answer ranged from 1 to 5, and the total score was 60. The mean perception score was calculated (45.6), and respondents whose total score was below the mean score were classified as having a “poor” perception and scores above the mean were classified as a “good” perception.

Data analysis

Data collected were extracted and analyzed using IBM SPSS version 22.0. Descriptive statistics was analyzed using frequency and proportions. Bivariate analysis (chi-square test) was done to determine the relationship between respondents’ characteristics and outcome variables (knowledge and practice). Binary logistic regression analysis was computed to determine factors associated with good knowledge and practices toward the disease. Pearson correlation analysis was used to determine the relationship between respondents’ knowledge, perception, and practice of COVID-19. The confidence level was 95%, and statistical significance was set at P < 0.05.

Ethical clearance was obtained from the Health Research Ethics Committee of the UBTH, while informed written consent was obtained before recruiting the study participants with the purpose, procedure, and benefits of the study, and their rights explained to the study participants. All the data obtained from the participants were kept strictly confidential and used solely for the purpose of the research study.

Results

Sociodemographic characteristics of respondents

There were 258 respondents that participated in this study, with a male to female ratio of 1:1.2. Majority were females (54.3%), aged 25–39 years (49.6%), married (48.4%), and Christian (96.5%). Most of the participants were employed (56.6%) and had tertiary education (58.9%) [Table 1].

Table 1: Sociodemographic characteristics of respondents

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Awareness of COVID-19

Nearly all the respondents were aware of COVID-19 (256, 99.2%), and they obtained information on the emerging disease from various sources, the commonest being television (57.0%) and the internet (55.4%), whereas the least common was seminars and workshops (4.3%) [Figure 1].

Figure 1: Respondents’ sources of information on COVID-19

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Knowledge of COVID-19

With regard to their self-assessment of their knowledge of COVID-19, most of the participants reported that they had a good knowledge (28.5%), whereas 25.8% stated that they had an excellent knowledge of the disease. Most respondents knew that COVID-19 is contagious (87.9%), that it is caused by a virus (77.7%) and has an average incubation period of 2–14 days (59.0), and that it can be transmitted asymptomatically (60.9%). Most respondents knew that the virus was transmitted via respiratory droplets (82.9%), that shortness of breath was a symptom of the disease (85.9%), and that the use of facemask was one of the ways to prevent contracting or spreading the virus (85.2%). Majority stated that there was no approved curative drug or vaccine for preventing the virus as at the time of this study (63.7%) [Table 2].

Table 2: Responses to questions that assessed respondents’ knowledge of COVID-19

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A majority of the respondents (141, 55.1%) had a good knowledge of COVID-19, whereas 115 (44.9%) had a poor knowledge of the disease [Figure 2]. The mean knowledge score was 29.9 ± 5.9 out of a total of 45. The scores ranged from 12 to 44.

Figure 2: Respondents’ knowledge of COVID-19

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Perception of COVID-19

The mean perception score was 45.6 ± 5.0, and the scores ranged from 31 to 58. A little above half of the respondents had a good perception of COVID-19 (132, 51.6%), whereas 124 (48.4%) had a poor perception of the disease. Most respondents strongly disagreed that coronavirus does not exist (38.4%) and disagreed that the virus is not as harmful as the authorities say it is (32.4%) and that the disease results in death in all cases (40.6%). Most respondents (57.0%) were of the view that government agencies are not sincere in the fight against COVID-19, with 29.1% and 27.9% strongly agreeing and agreeing with this view, respectively. More responses to perception questions are reported in [Table 3].

Table 3: Responses to questions that assessed respondents’ perception of COVID-19

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Respondents’ practice behaviors

Concerning respondents’ practice behaviors, majority stated that they always follow recommendations from health authorities to prevent the spread of the disease (35.5%). The most commonly practiced preventive measure was hand washing with soap and water (76.4%) followed by avoiding touching the face with unwashed hands (75.8%). Other measures taken by respondents outside the recommended measures included taking vitamin supplements (30.5%), using antibiotic hand sanitizers (29.3%), and eating garlic, ginger, and lemon (22.3%) among others [Table 4].

Table 4: Responses to practice questions

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The average practice score was 6.2 ± 2.9, and the scores ranged from 0 to 11. A hundred and twenty-nine (50.4%) respondents had a good practice of preventive measures against the spread of COVID-19, whereas 127 (49.6%) did not [Figure 3].

Figure 3: Respondents’ practice of preventive measures against the spread of COVID-19

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Relationship between respondents’ sociodemographic characteristics and their knowledge of COVID-19 and practice behaviors

[Table 5] shows the relationship between respondents’ sociodemographic characteristics and their knowledge of COVID-19. The difference in knowledge was significant across the different levels of education using bivariate analysis (P = 0.006). Respondents with a tertiary level of education had the highest proportion of a good knowledge (63.6%) compared with the rest. On binomial regression analysis, respondents with primary and secondary level of education had -1.44 (0.07–0.77) and -0.75 (0.27–0.83) odds of having a good knowledge, respectively, when compared with respondents that had tertiary education.

Table 5: Relationship between respondents’ sociodemographic characteristics and their knowledge of COVID-19

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[Table 6] shows the relationship between respondents’ sociodemographic characteristics and their perception of COVID-19. On bivariate analysis, gender, marital status, and level of education had significant relationships with the respondents’ perception of COVID-19 (P = 0.015, 0.040, and 0.026, respectively). A higher proportion of males (59.8%), married respondents (54.8%), and those with a tertiary level of education (58.3%) had a good perception of COVID-19. On regression analysis, no significant association was found between perception of COVID-19 and the respondents’ sociodemographic characteristics.

Table 6: Relationship between respondents’ sociodemographic characteristics and their perception of COVID-19

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[Table 7] shows the relationship between respondents’ sociodemographic characteristics and their practices of preventive measures against COVID-19. On bivariate analysis and regression analysis, no significant association was found between practice and the respondents’ sociodemographic characteristics.

Table 7: Relationship between respondents’ sociodemographic characteristics and their practices of preventive measures against COVID-19

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Pearson correlation was used to assess the association between respondents’ knowledge, perception, and practices toward COVID-19. There was a positive but weak relationship between knowledge and perception (r = 0.288, P = 0.00), knowledge and practice (r = 0.455, P = 0.000), and perception and practice (r = 0.211, P = 0.001) [Table 8].

Table 8: Association between respondents’ knowledge, perception, and practice scores toward COVID-19

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Myths concerning COVID-19

The respondents were also assessed on their beliefs concerning myths about the coronavirus and COVID-19. Majority strongly disagreed that the disease was a conspiracy theory (34.5%) and that it can be cured by drinking alcohol (40.1%). Most disagreed that the virus is caused by 5G technology (30.9%) and can be cured by staying under hot African sun (36.3%) and by eating hot African food (39.5%). However, most were undecided when asked if the virus was prepared in a laboratory in Wuhan and if it is a weapon for biological warfare [Table 9].

Table 9: Myths concerning COVID-19

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Discussion

This study aimed to assess the knowledge, perception, and practice behaviors toward COVID-19 among patients attending the GPC of the UBTH. The study had more female respondents, and most of the respondents were mostly educated up to a tertiary level of education with an overall COVID-19 awareness level of 99.2%, similar to findings in Northern Nigeria.^[24]

It was seen that over half of the respondents had a satisfactory level of knowledge of COVID-19 (55.1%), a good perception of COVID-19 (51.6%), and good practice behaviors toward COVID-19 (50.4%). This may be because the study population is well educated, and the significant association between knowledge scores and respondents’ level of education supports this assertion. Another possible explanation is that the seriousness of the global pandemic in addition to daily updates from public health agencies would have prompted the need to learn and made it easier to acquire knowledge on COVID-19, even though it is an emerging disease. These findings were similar to those of previous studies among healthcare workers in the same facility, where 51.1% of the respondents had a good knowledge of COVID-19,^[25] and 57.1% had good practices of precautionary measures against COVID-19.^[26] These are, however, lower than the previous KAP studies on COVID-19 in China, Nigeria, and Egypt.^[9],[27]

The commonly used sources of information on COVID-19 were television and the internet. This is consistent with other findings that reported either the use of the internet/social media or television as the commonest sources of information.^{[9],[24],[28]} In contrast, studies among rural dwellers found that family members/friends were the most common sources of information on the virus.^[29] Less than one in 10 people in this study used seminars, scientific journals, or medical institutions’ press release as sources of information on the emerging disease. A previous study among health workers found a higher engagement of these sources of information; however, the usage was still low compared with other sources.^[25] The methods of information dissemination to targeted audiences are therefore very important, especially when planning an educational intervention as one method does not fit all. Although respondents who are more educated and exposed may use modern technology and mass media to source for information on health-related issues as seen in this study, individuals in rural areas may prefer person-to-person spread of information, and seminars/workshops and scientific articles are used by a more professional population such as medical professionals and those in academia.^[30]

The mean knowledge score in this study was 29.9/45, giving an average score of 66.4%. This shows that the respondents were knowledgeable on the causative agent, mode of transmission, symptoms, and treatment options at the time the study was being carried out. It should be noted that as at the time data were being collected for this study, there was no approved curative drug or vaccine against COVID-19. Studies in Jordan, China, and the United States of America that were carried out during the high-rise period of the disease in these regions showed average knowledge scores of over 80%.^{[9],[30],[31]} On the other hand, Bhagavathula et al.^[32] reported that a significant proportion of healthcare workers displayed a poor knowledge about COVID-19 infection, particularly its transmission and incubation period in the early days of the pandemic. Although the respondents’ knowledge of COVID-19 did not differ significantly across the different age groups, gender, marital status, and employment status, educational level was seen to be a significant predictor of knowledge of COVID-19. Those with primary and secondary levels of education were 1.44 and 0.75 times less likely to have a good knowledge of COVID-19 compared with those with a tertiary level of education. This agrees with findings in similar studies.^[33]

Perception, which is the way a health event is regarded, understood, or interpreted, is a product of a person’s knowledge of the said health event, and this was observed in this study that detected a positive albeit weak correlation between knowledge and perception (r = 0.288). Iorfa et al.,^[34] however, had a conflicting finding, where knowledge was not a significant predictor of respondents’ risk perception of COVID-19. Male sex, marriage, and a tertiary level of education were significantly associated with a good perception of COVID-19. Hager et al.^[27] found a significant relationship between perception and level of education, but not with gender. Another notable finding in this study is the distrust of government agencies concerning the fight against the disease. Over half of the respondents either agreed or strongly agreed that the government was not being sincere, whereas another fifth of the respondents were undecided about this. This perception may be responsible for the outright defiance of some government directives such as the prohibition of gathering for religious purposes. The pandemic has been said to be a money-making scheme for the government of Nigeria and hence blown out of proportion.^[35] This distrust is not only present in Nigeria, but in many African countries as well.^[36]

With regard to respondents’ practice behaviors, knowledge and perception were significantly correlated with practice of preventive measures. It is logical to expect that when individuals know about threats, they adopt reasonable practices in order to avert the threat from causing harm. This is, however, not always the case as other factors may mediate the relationship between knowledge and behavior change such as perceived risks, perceived benefits, obstacles to overcome in achieving behavior change and self-efficacy.^[37] Over two-thirds of the participants in this study reported that they often or always followed recommendations from health authorities regarding COVID-19; however, the mean practice score was 6.2/11, giving an average of 56.4%. Although the vast majority of participants practiced regular hand washing, avoiding touching of the face with unwashed hands, and the use of facemask in public, only a small proportion avoided public transportation or carried out regular disinfection of surfaces. Maintaining the recommended social distancing is very difficult to do with the public transportation system in Nigeria where passengers sit as close to each other as possible. Nevertheless, public transportation is probably the most popular means of transportation for the common man and may not be easily avoided even in the face of a pandemic.^[38] This is an example of an environmental factor that can mediate the relationship between health knowledge and behavior change.

From the onset of the outbreak of the virus in the world, many unverified information and beliefs have been going around probably because of insufficient information about the behavior and characteristics of the virus. These misconceptions could lead to poor practices in terms of health beliefs and health seeking behaviors. This study assessed respondents’ stance concerning some of the myths about COVID-19. The most commonly believed of these were that the virus was prepared in a laboratory in Wuhan and that it is a weapon for biological warfare. These claims, though widely spread, have not been proven^[39] and hence should be discarded.

This study has several limitations. The cross-sectional design of the study mitigates the ability to infer causal relationships, and thus, the possibility of reverse directions in the model cannot be ruled out. Studies involving data collection at multiple time points of the pandemic could yield different results. In addition, the data presented in this study are self-reported and partly dependent on the participants’ honesty and recall ability; hence, they may be subject to recall bias. Furthermore, this study was carried out among patients in only one hospital; therefore, the results obtained may not be generalizable to the entire population. Despite these limitations, our findings provide valuable information about the knowledge, perceptions, and practices of individuals during the peak period of the COVID-19 pandemic in Nigeria.

Conclusion

We found that a little over half of the patients who visited the GPC as at the time of this study had a good knowledge of the transmission, diagnosis, and prevention of COVID-19. They also had a good perception and a good practice of precautionary measures. Respondents with a tertiary level of education had a higher proportion of a good knowledge and perception compared with others. Gender and marital status were also significantly associated with a good perception of COVID-19. Positive correlation was seen between knowledge and perception, knowledge and practice, and perception and practice. We recommend a continued dissemination of targeted educational messages about the virus through specific channels (depending on the audience). Information should also be timely and transparently delivered to the people, with public and political office holders showing exemplary conduct and leadership. This will help build trust in the government and its agencies. Also, policies that would make it easier to adhere to COVID-19 public health measures should be emplaced, such as limiting the number of passengers in public transport vehicles and provision of wash hand basins and running water at strategic public places to further enhance hand hygiene.

Acknowledgments

The authors acknowledge the study participants for their cooperation, which made the study possible, especially at a time of great uncertainty during the first wave of COVID-19 in Nigeria.

Authors’ contributions

OE did the conception, intellectual content, design, literature search, article drafting, review, and editing. SI did literature search and data collection. DE did literature search, data collection, and editing. All the authors have read and agreed to the final article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Data availability

Data used for the study will be made available upon reasonable request made to the corresponding author.

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