Knowledge and Practice Regarding Coronavirus Disease Prevention (COVID-19) Among Internally Displaced Persons in Camps in Central Darfur Region, Sudan

Background: The lacking healthcare system services in conflict areas and the emergence of infection with a pandemic of coronavirus disease may exacerbate the humanitarian crisis among the camp residents in the central Dafur region of Sudan. Adequate knowledge and practices are vital to prevent coronavirus disease 2019 (COVID-19). Therefore, this study aimed to investigate the knowledge and practice regarding COVID-19 among internally displaced persons in Sudan. How to cite this article: Mohammed Abdelkrim Adam Abdelmalik, Abdalbasit Adam Mariod, Mohamed Adam Beraima, Hammad Ali Fadlalmola, Eltagi Elsadeg Sulliman Rahama, Huda Khalafallah Masaad, Mohammed Ibrahim Osman Ahmed, Ibrahim Abbakr Ibrahim Abbakr, Eyas Gaffar Abdelraheem Osman, and Ibrahim Musa Ibrahim Hassan (2021) “Knowledge and Practice Regarding Coronavirus Disease Prevention (COVID-19) Among Internally Displaced Persons in Camps in Central Darfur Region, Sudan,” Sudan Journal of Medical Sciences, vol. 16, Issue no. 2, pages 178–195. DOI 10.18502/sjms.v16i2.9287 Page 178 Corresponding Author: Mohammed Abdelkrim Adam Abdelmalik, Assistant Professor of medical-surgical nursing; College of Applied Medical Sciences, Shaqra University, Saudi Arabia. Faculty of Nursing, University of ELImam EL Mhadai, Kosti city, Sudan. Phone number: +966504543043 email: mohammedabdelkrim9@gmail.com Received 11 April 2021 Accepted 3 May 2021 Published 30 June 2021 Production and Hosting by


Introduction
The coronavirus disease 2019 (COVID-19) is continuously introducing change in our lifestyle. Recently, it has had considerable effects on global health, economic, and social aspects [1]. The pandemic has led to the cause of morbidity and mortality worldwide [2]. Coronaviruses are a large family of viruses and exist in both animals and humans.
The viruses could cause illnesses ranging from the common cold to severe diseases such as severe acute respiratory syndrome (SARS) observed in November 2002 and the Middle East respiratory disorder (MERS) that emerged in September 2012 and transmitted from camels [3,4]. In December 2019, Wuhan city of China reported a new strain of coronavirus disease, recognized as the COVID-19 virus. On March 11, 2020, WHO confirmed it as a global pandemic [5].
To date, many coronaviruses have appeared from animal reservoirs. The symptoms of COVID-19 include fever, dry cough, tiredness, muscle pain, and difficulty in breathing. Some patients complain of aches, runny nose, sore throat, and diarrhea, usually gradually. However, some individuals could also be asymptomatic. Approximately 80% of cases recover from the illness without needing specific treatment [6][7][8]. People with diabetes, heart disease, respiratory disease, hypertension, or those aged >60 years are at greater risk of developing severe disease. The incubation period for the novel coronavirus is about 1-14 days, with an average of 5-6 days [4,9,10]. The  virus is mainly transmitted through respiratory droplets. An infected person can transmit the disease by coughing, sneezing, or talking closely (within a distance of six feet) to another. Also, individuals may become infected by touching contaminated surfaces or objects and then touching their eyes, nose, or mouth. However, there is no evidence that the COVID-19 virus is transmitted through houseflies.
The preventive measures from infection frequently include handwashing with soap and water for least 20 sec or using an alcohol-based handrub, staying home/indoors, avoiding crowded places, avoiding touching mouth, eyes, or nose with dirty hands, covering mouth and nose with a disposable tissue when coughing or sneezing or using elbow if no tissue is available [11,12]. Knowledge of the COVID-19 pathway and relevant precautions is essential in controlling the pandemic. Knowledge such as washing hands frequently or using alcohol-based handrub, wearing face masks, covering nose and mouth when coughing or sneezing, maintaining social distancing, and self-isolation when sick is crucial to reducing the widespread infection. Also, adequate knowledge motivates people to make quick decisions that may prevent and control epidemics [13].
Prompt preventive measures are necessary at the early stages of prevalence to protect against the disease spread. Knowledge and perceptions of people affect their behavior [14]. Determining public's opinion may prove crucial in determining the outcome of COVID-19 [15] Some pieces of evidence have shown a deficit of knowledge, attitudes, and a lack of community practices regarding COVID-19 [16,17]. In Sudan, authorities and health ministries are striving to reduce its widespread in all country borders. According to the Federal Ministry of Health of Sudan, the recent cases have continued to speed up in Sudan after the first COVID-19 case was confirmed on March 13, 2020, for a 50-year-old man who traveled from an Arabic country (18). Most people affected by the war live in the bare region; they have difficulty accessing health information. Also, there is little information about the new disease's knowledge and practical measures among internally displaced persons. Besides, it shows limited studies in Sudan to explore internally displaced persons' knowledge and practice (KP) regarding COVID- 19. Therefore, our current study aimed to first investigate the KP regarding COVID-19 prevention among internally displaced persons in Sudan. Second, to check the correlation between KPs of the study variable. And third, to find out any differences within demographic variables and KPs of the study population.

Study design, setting, and population
This cross-sectional and community-based study was conducted to investigate the KP regarding COVID-19 prevention among internally displaced persons in two camps of the war conflict [19]. The internal conflicts affected the healthcare system's services reported by the United Nations, which left a vast humanitarian crisis around over one million internally displaced people in the Darfur region. In addition, there is a shortage of primary, secondary, and tertiary healthcare for pregnant women, children aged <5 years, those who lost their families, breastfeeding women, and elderly people [21].
Zalingei city is in the central Darfur region and is one of the urban areas surrounded by three camps of IDP: the Hesahesa, the Al Hamedia plus the Teyba, as a result of the war conflict [20]. The Hesahesa and the Al Hamedia camps are bigger than others and close to Zalingei city.

Sample size and technique
We used both manual and online google forms for data collection through convenience sampling and snowball sampling. We trained two data collectors who were nurses with a diploma. In the manual method of data collection, we maintained protective measures of COVID-19, such as social distancing and wearing a face mask during data collection. In the online method, we distributed google forms link through social networking platforms such as WhatsApp groups in the camps. Initially, data for 159 people were collected through nonprobability sampling, but only 143 eligible participants meeting the inclusion criteria were included in the survey.

Inclusion and exclusion criteria
Those participants who were willing to join the survey were included, while those who were unwilling to participate, were a non-resident of the camps, and those who pretested in the pilot test were excluded.

Data collection instrument
The researchers developed a questionnaire in the English language from a literature review based on guidelines [22][23][24]. We created an Arabic version of the original questionnaire and back-translated it into English for validity by three experts in the English language to match the original questionnaire. The researchers administered the final Arabic questionnaire to participants because the Arabic language is the primary language in Sudan. The researchers conducted a pilot study on 10 participants.
According to pretest findings, the researchers made corrections for the feasibility, content applicability, and duration before starting the actual data collection phase-the participants of the pilot study were excluded from the actual study. We conducted the reliability test for internal consistency, and it was good. The Cronbach's alpha coefficient of the tool assessing KPs regarding COVID-19 was 0.879 and 0.924, respectively. As a thumb rule, values <0.6 are considered poor, 0.6-0.7 are acceptable, and >0.7 are good.
The questionnaire comprised of three parts. Part one included seven demographic variables: gender, age, education level, previous disease, tobacco use, the camp res- While scores above the mean score indicated high KP, scores lower than mean scores indicated low KP. The total scores of KPs were converted into percentages by dividing the total obtained score of each part by the same part's maximum score and multiplied by a 100.
We used a five-point Likert scale with intervals created with the majority of the differences being constant (0.79) except for the last one that is wider and has a slighter difference of (0.1) among the rest [25]. The Likert scale is explained as follows:

Statistical analysis
We used a statistical package of social sciences (SPSS) version 25 to analyze this study, including descriptive statistics and inferential statistics. The non-parametric tests (Mann-Whitney U-test, Kruskal-Wallis, and Spearman correlation coefficient) were conducted to analyze the data because the Kolmogorov-Smirnov test abnormally distributed the data preliminarily. The significance level was at < 0.05.

Demographic characteristics
In this study, 143 participants responded to the survey. The majority, that is, 75 (52.4%) of them were female, while 68 (47.6%) were male; 49 (34.3%) of them were ages between 50 and 60 years; 78 (54.5%) were formally uneducated; 126 (88.1%) of them did not have a chronic disease; and 56 (39.2%) knew about COVID-19 from their relatives and friends, as shown in Table 1.

Assessment of knowledge toward COVID-19
The current results showed that more than half (51.7%) of the participants neutrally responded that coronaviruses are a large group of viruses and may cause disease in animals and humans. However, less than half of the participants answered correctly about the type and origin of the infection (43.4%) and its signs and symptoms (42.7%).
Also, nearly half of them responded neutrally about the transmission (42.7%), the incubation period of COVID-19 (47.6%), no definite treatment (49.0%). Besides, about half of the participants answered correctly about the effective ways to reduce the spread of

Assessment of practice toward prevention of COVID-19
Answers related to practice toward preventing COVID-19 showed that 52 (36.4%) participants did not practice frequent handwashing, 39 (27.3%) did not refrain from touching

Normality test
In this, we used the Kolmogorov-Smirnov test to examine the normality of the data for the knowledge, practice (KP) of participants in the study sample. The current results revealed not normally distributed data in mean scores of KPM (p< 0.000) in table 4.
Therefore, we adopted non-parametric tests to analyze the rest of the data.

Correlation between knowledge and practice (KP) of study variables 3.5.1. Testing correlation hypothesis
H0: There is no significant correlation between knowledge and practice of study variables.
H1: There is a significant correlation between knowledge and practice of study variables.
We tested the hypothesis of a correlation between knowledge and practice by Spearman's rho non-parametric test. We observed a strong correlation between knowledge and practice (r = 0.70**, p < 0.000). Therefore, the test that supported the alternative hypothesis is mentioned in Table 5. Note: *Statically significant at -p-values < 0.05. We used non-parametric tests, Mann-Whitney U-test, Kruskal-Wallis test. K-Average: knowledge mean score; P-Average: practice mean score.

Testing differences hypothesis
H0: There are no significant differences between the knowledge and practice of IDPs with demographic characteristics.
H1: There are significant differences between the knowledge and practice of IDPs with demographic characteristics.
We compared the mean scores of knowledge and practice with each demographic characteristic to determine any differences within them. We used inferential statistics tests such as Mann-Whitney U-test for two independent groups and the Kruskal-Wallis test for more than two independent groups to compare mean scores of knowledge and practice variables with their demographic characteristics. We found significant differences between the mean scores of knowledge, practice, and all age groups. The participants that were aged <20 years (117.83) showed higher knowledge and practice than other age groups. Also, we observed a significant difference in educational level. There was a significant difference between the mean score of knowledge with people who did not have medical disease and smokers and information source. Respondents who received their information from social media, Facebook, WhatsApp (112.95) showed higher knowledge than others, while respondents who received their information from television (116.41) showed significantly higher practice. However, we did not notice any statistically significant difference in the mean scores of the knowledge and practice with gender (p > 0.05) ( Table 6).

Discussion
This study aimed to investigate the knowledge and practice of COVID-19 among IDPs  19. In contrast, a previously community-based study in Addis Ababa, Ethiopia revealed a weak correlation between knowledge and practice, but only a moderate positive correlation between respondents' knowledge and attitude [28].
We tested the hypothesis to compare overall mean scores of knowledge and practice variables with demographic characteristics to determine the differences. We found that the participants aged <20 years revealed significantly higher knowledge than other age groups. The graduates showed a statistically significantly higher average score of knowledge than other educational levels. However, uneducated people exhibited significantly less knowledge and practice. There is no formal education program campaign to increase their awareness and adherence to practical measures against COVID-19.
Besides, there is limited access to online social-medical services in rural areas like the Darfur region. The studies are in line with those conducted in Pakistan and India that reported that older people had poor knowledge compared to students and graduates [22,23]. However, a study conducted in Malaysia reported that knowledge scores were higher among females, higher income group, and those aged >50 [29]. Thus, we suggest focusing on continuous educational intervention and awareness programs for illiterates, less educated, and older people in future.
In the current study, the respondents' overall mean score was 2.65+1.08 with a rate of 53%, denoting moderate practice toward preventive measures against COVID-19.
Respondents belonging to the younger ages and secondary education level showed significantly higher practice. However, those aged >60 years, uneducated respondents, and those who received their source of information from relatives and friends showed significantly low practice. There is no formal education program among older people to increase their adherence to practicing preventive measures against COVID-19.
In contrast, young people and graduates gained the information of COVID-19 from social media, Facebook, and WhatsApp. The result of our study is similar to a study conducted in Pakistan that reported that preventive practices toward COVID-19 were far from satisfactory. The study attributed poor behavior of practice because the study participants were older, formally uneducated, lived in the countryside, and had limited access to online health information resources [30]. Therefore, we suggest an urgent focus on the campaign to increase awareness of practical measures by demonstrating correct handwashing, wearing a mask, maintaining social distances, and avoiding crowded areas. Since primary preventive measures from infection were frequently handwashing with soap and water for least 20 sec or using an alcohol-based handrub, staying at home, avoiding crowded places, avoiding touching eyes, nose, or mouth with unwashed hands, covering the mouth and the nose with a disposable tissue when coughing or sneezing or using elbow if no tissue is available. It is also essential to avoid close contact with anyone who has had a respiratory infection and maintaining at least a 1 m distance socially (11,12).

Conclusion
Most respondents had adequate knowledge and moderate practice toward COVID-19.
Participants with a high level of education, namely secondary education and graduates, showed higher knowledge and practice toward COVID-19 than others. Our findings suggest an urgent need for educational intervention and awareness programs to focus on uneducated and older people.

Limitations
This current study has some limitations. First, the study was conducted among Sudanese IDP population in the central Darfur region, namely in Zalingei city. Second, we used a convenience sampling technique of a non-probability sampling method. We used both manual and online google forms for data collection through convenience sampling and snowball sampling. Thus, the results do not represent the entire IDP population of Sudan.

Implications
Our findings from this study may contribute to the existing literature. It may help the health policymakers plan awareness programs to raise consciousness and improve practical infection control measures against COVID-19 among the IDP population that may thereby reduce the spreading of the new coronavirus disease pandemic in the Darfur region.