Knowledge and Adherence to COVID-19 Preventive Measures: A Continental Review

Abstract Background: The burden of the novel coronavirus disease (COVID-19) has been on the rise since it was first reported in December 2019. COVID-19 has devastated global economy, public health, social interaction, and has claimed millions of lives globally within a few months. Due to the severe effect of some of the instituted guidelines on citizens and the economy, some of the policies in place to curtail the spread were receded. Hence, the present review aims to assess existing literature on the knowledge and adherence of Africans toward the COVID-19 preventive measures. Methods: Studies focused on Africans’ knowledge and adherence to COVID-19 preventive measures were selected using Google Scholar, Scopus, and PubMed databases. Preprints that have not been peer-reviewed, reviews, and non-COVID-19 studies were excluded. Results: All selected studies showed a satisfactory knowledge of respondents about COVID-19 but poor level of adherence to the preventive measures. Good knowledge and satisfactory level of adherence was common mostly among the clinical health workers, highly educated, and those with higher professional qualification, while poor knowledge and poor practice was observed mostly among rural dwellers, people of poor educational background, and those unable to read and write. Conclusion: This review identified a relatively good knowledge about COVID-19 from all the studies, however, the level of adherence to preventive measures was poor. We recommend that the populace adhere to the laid guidelines to ensure the spread of the virus is curbed while also enhancing the eradication of the pandemic.


Introduction
The rampaging novel coronavirus disease  has become prevalent. The highly pathogenic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, has spread globally, claiming over a million lives within a few COVID-19 was significantly associated with their different job cadre with F value = 3.691; P = 0.001. Furthermore, 79.9% of the 318 Libyan healthcare workers studied had satisfactory knowledge about COVID-19 [15]. Their major sources of information about COVID-19 were health practitioners (33.3%), social media platforms (30.2%), and journal articles (29.2%).
In Kenya, among 353 respondents sampled, most (83.97%) had very good knowledge about COVID-19 [16]. Social media platforms serve as a major source of information for 55% of the respondents. Despite this, only half (50%) of the respondents have trust in the news and information on social media about the pandemic. Among the 404 chronic disease patients (mean age 56.5 ± 13.5 years) in northwest Ethiopia, only few (33.9%) had a good knowledge of COVID-19 [17]. Respondents' age, illiteracy (unable to read and write), rural dwellers, and low monthly income were factors associated with poor knowledge of COVID-19. This calls for concern as most severe COVID-19 cases are seen in infected patients with comorbidities. Hence, more drastic measures are needed to sensitize the high-risk individuals about the novel COVID-19.
In a study of 3712 Egyptians, most (70.2%) had high satisfactory knowledge of COVID-19 [18]. High educational level was associated with good knowledge. This corroborates with another study in Nigeria where there was a significantly higher knowledge level among 141 correctional officers sampled with higher educational qualifications [19]. In a binational study, Egyptians were reported to be 1.8 times (95% CI: 0.43-0.74; P < 0.001) more likely to have more satisfactory knowledge about COVID-19 than Nigerians [20].
This disparity might be a result of public health literacy and the specific and peculiar measures implemented in both countries in curbing the spread of the pandemic. Of the 362 respondents (mean age 33.5 ± 10.4 years) sampled in Uganda [21], 264 (93.9%) had good knowledge about COVID-19. Television (77.4%) and social media (73.2%) were the major sources of information and there was no difference in respondents' sociodemographic with respect to their knowledge about COVID-19.
Among the 545 respondents (mean age 30.03 ± 11.2 years) sampled in conflictaffected areas in southwest Cameroon [22], only 21.9% had very good knowledge about COVID-19, while others had intermediate (43.8%), poor (34.4%), and no knowledge (11.92%). The respondents live in an anglophone crisis-affected area; hence, the knowledge gap observed might be a result of poor health literacy and adjustment to normal communal living. Those with no knowledge of COVID-19 (11.92%) were not included in the analysis. In line with earlier reports [21,23], television (64.2%) and social media (38.8%) were also respondents' major sources of information about the pandemic and there was no association between respondents' sociodemographic and their knowledge about COVID-19.
Out of the 2336 respondents in Sudan, the majority (84.7%) had a good level of knowledge. Age (≤17 years), education (primary or lower school), low-income earner, and those who reside outside Khartoum were related to lower COVID-19 knowledge score [24]. A good knowledge level was also reported among 1253 respondents in Sierra Leone [25], 589 respondents from north-central Nigeria [23] and a study of 1006 respondents from Cameroon [13] with most (84.19%) having a high knowledge score.
In all, a high proportion of the targeted populace in Nigeria, Kenya, Ethiopia, Uganda, Sudan, south-west Cameroon, Sierra-Leone, Libya, and Egypt had a good and satisfactory knowledge of COVID-19. The knowledge of COVID-19 is mainly acquired through health practitioners, social media and Internet, which have proven to be a chosen tool to adapt to the physical constraint measure of prevention during the pandemic outbreak as especially among the young adults where social media is the source of disseminating information and communication. In contrast to this, the level of trust in social media is low amongst the respondents in Kenya [16]. In a similar study on Indian citizens, Roy et al. [27] noted that the citizens considered social media as a threat to their state of mind, often causing them to worry about receiving updates on COVID-19.
The level of education, literacy, gender, educational background, and age of the respondents are major contributory factors to increased knowledge about COVID-19 [20]. However, in the south-west Cameroon, no association has been noted between respondent's sociodemographic factors and knowledge about COVID-19. The different studies reviewed have also shown a low level of knowledge in Sudan and south Cameroon which is partly associated with the age difference, illiteracy, low income, and respondent's residence [17,28]. Poor knowledge, health illiteracy, poverty, poor health infrastructure, as well as distrust in Government's intervention can serve as major obstacles to the global effort against COVID-19.

Adherence to COVID-19 preventive measures
An increased adherence to the health regulations laid down by the WHO would drastically reduce the COVID-19 burden. Table 2 represents articles on adherence and practice of COVID-19 preventive measures conducted in Africa. The study on 446 healthcare workers in Jos, Nigeria [14] showed that clinical healthcare workers had higher satisfactory practice scores (9.01 out of 12) compared to nonclinical healthcare workers (with an average score of 6.59). This gap could be attributed to their need for more precaution due to their relative closeness to patients and knowledge discrepancies when compared to nonclinical healthcare workers. In another study of 318 Libyan healthcare workers [15], 39.6% took vitamins and supplements and majority (69.5%) ate healthy food to avoid infection. Although most participants wash their hands with soap, use alcohol-based hand rub, maintain social distancing, and avoid touching the face with unwashed hands, their practice of wearing masks was poor. As frontline workers and with a very low availability of COVID-19 vaccines in Africa, it is pertinent for healthcare workers to strictly adhere to the precautionary measures.
Among the 353 Kenyans [16], the level of adherence is poor as about half (50%) had visited a crowded place. Although most (91%) wear face masks, 83% apply hand sanitizers and 67% maintain social distancing in public places. Majority (60%) indicated that other people do not adhere to the preventive measures. This could be deleterious due to the observed high human-human transmission of the virus. Among the 141 correctional officers in Nigeria [19], 87.9% regularly washed their hands with soap and water, 84.4% wore face masks when outside, 83% maintained a safe distance from others, and 58.9% distanced from crowded places. Knowledge and practice showed a statistically significant, moderate, positive correlation (r = 0.375, P < 0.001).
Among the studied Ugandans, less than half (48.3%) of the 362 respondents adhered to practicing the instituted preventive guidelines [21]. The respondents who had the highest level of adherence had up to secondary school education (71.4%), were >45 years of age (61.2%), self-employed (57.3%), female (56%), and are Anglicans (53%). Poor adherence observed was also found among Cameroonians living in a conflict-affected area [22], where although most participants identified the importance of face mask (93.5%) and hand sanitizers (88.8%), only 21.7% and 32.9% of them had purchased them for use, respectively. This is in contrast with another report on Cameroonians, where all 1006 respondents used face masks, 94.5% washed hands and/or used hand sanitizers, and 83.8% observed social distancing [13]. This disparity can be a result of the direct consequences of conflict on inhabitant's health and social lifestyle.
In a study of 404 chronic disease patients in Ethiopia [17], the adherence level was also not satisfactory as only 105 (25.9%) had a good practice of the preventive measures.
To adhere to the lockdown policy and social distancing rule, most of the studies utilized web-based surveys, which serve as a major limitation to the studies due to the low Internet penetration rate in most African countries. This likewise skewed the respondents toward young people and highly educated individuals or professionals who are the major Internet users. The present review shows that a good number of the population although having a good knowledge of the disease outbreak failed to adhere strictly to the COVID-19 preventive measures. A high number of healthcare providers have a good practice of the measure of prevention while others do not. This is the case with Libyan healthcare workers where only very few (<30 %) wear face masks and/or gloves as part of preventive measures against COVID-19 infection [15]. This calls for concern as healthcare workers are at the forefront of combatting the pandemic. This is in contrast to 353 Kenyans [16], who also had low level of adherence but a good practice of wearing facemask. The associated myths, misinformation circulated on social media, health illiteracy, distrust in government's policies, and low mortality due to COVID-19 in most African countries could have contributed to the poor adherence to the preventive measures.

Results
The ongoing COVID-19 pandemic comes with excruciating psychological, financial, social and public health challenges. The selected 13 studies on knowledge and practice reviewed showed a satisfactory knowledge, a positive attitude, and a relatively poor adherence to the COVID-19 preventive measures. Good knowledge and satisfactory level of adherence was common mostly among the clinical healthcare workers, highly educated, and those with higher professional qualification, while poor knowledge, negative attitude, and poor practice was observed mostly among the rural dwellers, people of poor educational background, and those unable to read and write. This poor practice and negative attitude occurs due to ignorance, negligence, and the inability to read and write.

Conclusion
There is a need for improvement in maintaining a good practice of the preventive measures. A better and simplified way of passing the information to the rural dwellers and those in war-torn communities needs to be encouraged which will in turn create more awareness alongside reducing the spread of the virus.