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 Table of Contents  
Year : 2021  |  Volume : 28  |  Issue : 1  |  Page : 14-21

Community mitigation strategies for coronavirus disease 2019: An assessment of knowledge and adherence amongst residents of Benin City, Edo State, Nigeria

1 Department of Community Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Medical Microbiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
3 Department of Anatomic Pathology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Submission26-Sep-2020
Date of Decision27-Nov-2020
Date of Acceptance29-Nov-2020
Date of Web Publication25-Feb-2021

Correspondence Address:
Dr. Esohe Olivia Ogboghodo
Department of Community Health, University of Benin Teaching Hospital, PMB 1111, Benin City, Edo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_321_20

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Background: In the absence of effective vaccines and definitive treatment, non-pharmaceutical interventions, also known as community mitigation strategies (CMS), are needed to reduce the transmission of respiratory virus infections such as coronavirus disease 2019 (COVID-19). However, the effectiveness of these strategies depends on a knowledgeable population cooperating and adhering strictly to recommended strategies. Objective: The objective of the study was to determine the knowledge and adherence to CMS against COVID-19 in Benin City, the capital of Edo State, Nigeria. Materials and Methods: A descriptive cross-sectional study was conducted amongst adult residents in Benin City using a self-administered questionnaire for data collection. Eighteen questions addressed knowledge of CMS, while adherence was assessed using 14 questions on a graded scale. Each correct answer was scored giving maximum and minimum scores of 18 and 0 for knowledge and 28 and 0 for adherence, respectively. Scores were converted to percentages with scores 70% and above adjudged as good knowledge of CMS and scores 50% and above adjudged as good adherence to CMS. Data were analysed with IBM SPSS version 25.0 software. The level of significance was set at P < 0.05. Results: The mean age (standard deviation) of 577 respondents who participated in the study was 32.5 ± 11.7 years. Overall, 532 (92.2%) respondents had good knowledge, while only 165 (28.6%) demonstrated good compliance with CMS against COVID-19. Christianity was a statistically significant predictor of knowledge of CMS. Income was found to be a significant predictor of adherence to CMS amongst respondents. Conclusion: Respondents demonstrated good knowledge but poor adherence with CMS against COVID-19 in Benin City, Edo State. Behaviour change communication is advocated to ensure that mitigation strategies are effective.

Keywords: Adherence, community mitigation strategies, coronavirus disease 2019, knowledge

How to cite this article:
Ogboghodo EO, Osaigbovo II, Obaseki DE, Nneka Okwara OH, Omo-Ikirodah OT, Adio F, Ehinze ES. Community mitigation strategies for coronavirus disease 2019: An assessment of knowledge and adherence amongst residents of Benin City, Edo State, Nigeria. Niger Postgrad Med J 2021;28:14-21

How to cite this URL:
Ogboghodo EO, Osaigbovo II, Obaseki DE, Nneka Okwara OH, Omo-Ikirodah OT, Adio F, Ehinze ES. Community mitigation strategies for coronavirus disease 2019: An assessment of knowledge and adherence amongst residents of Benin City, Edo State, Nigeria. Niger Postgrad Med J [serial online] 2021 [cited 2022 Jan 27];28:14-21. Available from: https://www.npmj.org/text.asp?2021/28/1/14/310162

  Introduction Top

The recent emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its subsequent spread around the world is responsible for the coronavirus disease 2019 (COVID-19) pandemic.[1] Person-to-person transmission rates of SARS-CoV-2 through respiratory droplets, contact and fomites have been unprecedented, exceeding previous experiences with other coronavirus strains which cause severe respiratory distress.[2],[3] Despite a lower case fatality rate than preceding strains, the high transmissibility of SARS-CoV-2 has resulted in far more cases and fatalities on a global scale.[4] Since the first reports from Wuhan, China, in December, 2019, over 30 million cases have been detected with close to a million deaths occurring globally.[5] These staggering figures have inundated health systems even in developed countries.

Since the emergence of this disease, scientists have worked assiduously, exploring treatment options and developing vaccines; however, definitive treatments remain out of reach, while leading vaccine candidates are still undergoing clinical trials.[6],[7] In the absence of effective vaccines and definitive therapeutic agents, a range of non-pharmaceutical interventions, also known as community mitigation strategies (CMS), had to be adopted by various governments and public health agencies in different countries. The major goals of these CMS were to shift the epidemic curve to the right (thereby delaying the peak of the pandemic and preventing health systems from becoming overwhelmed while awaiting the availability of a vaccine) and lower its trajectory (thereby reducing the number of cases and thus decreasing morbidity and mortality within the community).[8],[9] CMS can be phased in, or layered, on the basis of pandemic severity and local transmission patterns over time. Categories of CMS include personal protective measures (e.g. voluntary home isolation of ill persons, respiratory etiquette, hand hygiene, voluntary home quarantine of exposed household members and use of face masks in community settings); community measures aimed at increasing physical distancing (e.g. school closures, physical distancing in workplaces and postponement or cancellation of mass gatherings); and environmental measures (e.g. routine cleaning and disinfection of frequently touched surfaces).[10],[11]

Historically, various combinations of CMS have been used under epidemic and pandemic circumstances to successfully control the spread and overall burden of influenza in affected communities.[12],[13] In the same vein, during the current COVID-19 pandemic, the lockdown instituted in China and early adoption of mass masking in Vietnam contributed significantly to bringing transmission rates under control in these countries.[14],[15] Although some of these strategies, especially lockdowns, business closures, prohibition of mass gatherings and movement restrictions, can significantly disrupt the social functioning of communities and cause negative economic impacts, mathematical modelling studies suggest that early implementation of multiple CMS may effectively reduce the transmission of the disease.[16],[17]

Nigeria recorded her first COVID-19 case on the 27th of February, 2020.[18] On 23rd March, 2020, Edo state became the fifth state to record a confirmed case of COVID-19 in Nigeria and by June had become the state with the fourth highest number of cases.[18],[19] Following the confirmation of the index case, the state government instituted CMS including the use of personal protective behaviours and equipment (hand hygiene using water and soap or hand sanitisers, the compulsory use of face mask and encouraging people to cover their cough or sneeze), physical distancing measures (restriction of social gatherings including closure of schools, religious gathering, non-essential services and limiting public transportation, mandatory stay at home order to civil service workers from Grade level 12 and below) and environmental provisions (disinfecting markets and public arenas). The federal government's ban on inter-state movement, air travel and dusk to dawn curfew were also domesticated in the state.

Local characteristics of disease transmission, demographics and health system capacity should guide selection and implementation of CMS.[9] However, public awareness, cooperation and adherence to the CMS determine how effective these strategies will be during a pandemic.[8] Perceptions regarding efficacy also impact on intentions to adopt these measures as well as their actual uptake.[20],[21] A study documented the reluctance of the populace in several African countries including Mali, Senegal, Burkina Fasso and Guinea, to comply with CMS, particularly physical distancing measures.[22] Few studies have assessed the uptake of CMS in Nigeria during the COVID-19 pandemic and none have been conducted in Edo state.[23],[24],[25] This survey was conducted amongst residents of the state capital to assess knowledge of and adherence to CMS implemented in Edo state during the COVID-19 pandemic.

  Materials and Methods Top

This descriptive cross-sectional study was carried out between 1st and 30th June 2020, amongst residents of Benin City, the capital of Edo State, Nigeria. Benin City is comprised of three Local Government Areas (LGAs), namely Egor, Oredo and Ikpoba-okha and has an estimated population of 1,402,107. Inhabitants of Benin City are mostly civil servants, traders and artisans.[26],[27]

Sample size and sampling technique

A minimum sample size of 493 was determined using the Cochran's formula for studying single proportions.[28] This was calculated considering a standard normal deviate of 1.96 at a significance level of 5%, degree of precision of 5%, a prevalence of 82.3% (the proportion of respondents practicing the use of facemask in an epidemiological survey in North Central Nigeria), and a 10% non-response rate.[23] Taking into consideration the complexity of the sampling technique utilised (two-stage cluster sampling technique), a design effect (Deff) of 2 was factored into the calculation.

A two-stage cluster sampling technique was employed to select the respondents. All LGAs, in Benin City were included in the study. Stage 1 comprised selection of wards. Egor, Oredo and Ikpoba-Okha LGAs have 10, 12 and 8 wards, respectively. Two wards each were selected from the 3 LGAs using simple random sampling technique by balloting, giving a total of 6 wards. Stage 2 comprised selection of enumeration areas (EA) from the wards. EA maps of the six selected wards in the three LGAs were obtained from the National Population Commission. From a list of the EA maps of each ward, 2 EAs were selected from each ward by simple random technique by balloting. Thus, a total of 12 EA were selected. Each EA was taken as a cluster and all household heads or their representative in each cluster was invited to participate in the study.

Data collation and analysis

Data were collected using a self-administered questionnaire, adapted from a document on implementation of mitigation strategies for communities with local COVID-19 transmission.[6] The questionnaires were collated, screened for completeness, numbered serially and entered into IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY: IBM Corp. The questionnaire comprised four sections which sought to address the study objectives. Knowledge of CMS was assessed using 18 questions in two domains (meaning and categories of CMS). A correct response was scored 1 and incorrect 0 giving a maximum and minimum score of 18 and 0, respectively. Scores were converted to percentage and scores 70% and above were adjudged as having good knowledge of CMS while score <70% was adjudged to have poor knowledge. All the questions used in scoring knowledge were assessed for internal consistency and reliability using the Cronbach's alpha test. A Cronbach's alpha value of 0.702 was obtained, showing internal consistency and reliability. The level of adherence to CMS was assessed using 14 questions on a graded scale, scored from 0 to 2. The most correct adherence response was scored 2 and the least 0, giving a maximum score of 28 and a minimum score of 0. Scores were converted to percentage and scores 50% and above were adjudged to represent good adherence to CMS while scores <50% were adjudged to represent poor adherence to CMS.

Univariate analysis was done to assess the distribution of variables. Unadjusted and adjusted analysis using binary logistic regression was carried out using the 'enter approach' to determine significant predictors of the knowledge and adherence to the CMS. The statistical measure for the analysis was the adjusted odds ratio (OR) and 95% confidence interval (CI). The level of significance was set at P < 0.05 for all statistical associations. Frequency tables were used to present the results.

Ethical approval

Ethical approval was obtained on 22nd May 2020 from the Ethics and Research Committee of University of Benin Teaching Hospital (Study approval number ADM/E 22/A/VOL. VI/1483015). Permission to conduct the study was also obtained from Community heads in the selected EAs. Written informed consent was obtained from all respondents before questionnaire administration. They were assured of voluntary participation, confidentiality of their responses and the opportunity to withdraw at any time without prejudice. All data were kept secure and made available only to members of the research team.

  Results Top

Of 596 questionnaires administered, 577 were completed, giving a response rate of 96.8%. The mean age (standard deviation) of respondents was 32.5 ± 11.7 years. Sociodemographic characteristics of respondents are shown in [Table 1]. Almost all respondents, 555 (96.2%) had heard of CMS, and of these two-thirds, 532 (69.7%) got their information from television, 255 (45.9%) heard of CMS from social media sites, whereas 43 (7.7%) had other sources of information such as friends and family, health facility, seminars and workplace trainings. Majority 532 (92.2%) and 570 (90.5%) of the respondents correctly knew CMS to mean strategies and a set of actions to help reduce the spread of infections, respectively. However, over half, 310 (53.7%) perceived CMS as strategies deployed by the government to make money, whereas 324 (56.2%) thought that they were mechanisms that help to gain employment.
Table 1: Sociodemographic characteristics of respondents

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Almost all the respondents had good knowledge of the use of personal protective equipment such as face mask, 572 (99.1%); and behaviours such as hand washing, 570 (98.8%). Furthermore, majority had good knowledge on the physical distancing CMS such as maintaining at least 1 m distance from others 566 (98.1%); school closure 560 (97.1%) and interstate restriction of movement 559 (96.9%). [Table 2] shows the results of all aspects of awareness and knowledge of CMS assessed. Overall, 532 (92.2%) of the respondents had a good knowledge of CMS [Figure 1].
Table 2: Awareness and knowledge of community mitigation strategies

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Figure 1: Overall knowledge and implementation of community mitigation strategies

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Majority 465 (80.6%) of the respondents always obeyed the overnight curfew, two-thirds 386 (66.9%) always practiced proper hand hygiene and 348 (60.3%) wore masks when outside the home. More than half 302 (52.3%) of the respondents responded that they never attend ceremonies with more than twenty persons in attendance (as outlined by the State Government) and two-thirds 400 (69.3%) responded positively to abstaining from bars/clubs/hotels at night. [Table 3] shows the results of these and other aspects of adherence to CMS assessed. Overall, only 165 (28.6%) of the respondents had a good compliance with CMS against COVID-19.
Table 3: Levels of adherence to community mitigation strategies against coronavirus disease-19

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Age, sex, marital status and household size of respondents were not significantly predictive of knowledge of CMS or adherence to CMS against COVID-19 [Table 4]. However, the religion of respondents was a statistically significant predictor of knowledge of CMS. Christian respondents were more likely to have a good knowledge of CMS in both the unadjusted (P < 0.001) and the adjusted (P = 0.001) analyses. Income was found to be a significant predictor of adherence to CMS amongst respondents. Those earning <N100,000 monthly were approximately 80% less likely to have properly implemented CMS in the adjusted (OR: 0.213, CI: 0.106–0.431) analysis.
Table 4: Unadjusted and adjusted predictors of implementation of community mitigation strategies

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  Discussion Top

Collecting information on knowledge and behaviours in a community during disease outbreaks is crucial to understanding the epidemiological dynamics as well as the effectiveness of prevention and control measures.[23] A limited number of such community knowledge, attitude and practice (KAP) studies have been conducted in Nigeria during the COVID-19 pandemic; all have been conducted online.[23],[24],[25] This study amongst residents of Benin City, in the southern part of Nigeria, was conducted in June when the COVID-19 outbreak was already in the phase of widespread community transmission. The study specifically assessed the residents' knowledge of CMS and their adherence to the said strategies.

The generally satisfactory level of knowledge about CMS in this study is in keeping with the results of previous KAP surveys conducted within and outside Nigeria which equally show good knowledge of COVID-19.[20],[23],[24],[25],[29],[30],[31],[32] Although the index study specifically targeted CMS, previous surveys which assessed comprehensive knowledge of COVID-19 also encompassed knowledge of community mitigating strategies. The pandemic nature of the disease led governments in all parts of the world to engage in intensive media campaigns to educate their citizens. Accordingly, the high level of awareness and knowledge amongst respondents in the index study may be attributable to the intense awareness campaigns mounted by NCDC in the wake of the pandemic. While factors such as age, sex and marital status were not significantly associated with knowledge in this study, the relationship between the religion of respondents and knowledge of CMS was statistically significant; Christians were more likely to have good knowledge of CMS compared to their Muslim counterparts. This may be due in part to the high proportion of Christians versus Muslims in the South.

A knowledgeable population is desirable as people who are better informed are more likely to practice safety measures which interrupt the transmission of the virus. However, good knowledge in this study did not translate to good adherence. Similarly, the first two rounds of a weekly online survey, the COVID-19 snapshot monitoring initiative, conducted at the early phase of the pandemic in Germany showed that, although knowledge was high, important protection behaviours were very low.[30] In contrast, a study conducted in the United States showed widespread adherence to recommended CMS including self-isolating, keeping ≥ six feet apart from others, avoiding groups of 10 or more and using face coverings when in public places.[31] A salient observation in the index survey is that while adherence to hand washing and the use of face masks was above average, most CMS related to physical distancing were poorly adhered to. A similar observation was described in an Australian survey which showed better adherence to 'hygiene strategies' than 'avoidance strategies.'[20]

Factors that can influence the ability to comply with CMS include people's perception of their susceptibility to infection, the perceived severity of the infection if acquired; whether they have the capacity, confidence and resources to comply with the strategies and sociodemographic status.[20],[33],[34] Demographic parameters such as age, sex and marital status had no association with the level of compliance in the index survey. However, lower income was a predictor of poor adherence to CMS. This is not surprising as CMS, particularly those related to movement restrictions are likely to interfere with livelihood and economic sustenance of households. Thus, the failure to adhere to some CMS may stem from lack of capacity and resources to comply with the said strategies. As this study did not assess the risk perception of the disease amongst respondents, it is not possible to say how this might have affected adherence to CMS; it has been identified that the perception of risk posed by a pandemic is an important motivator for continued compliance with preventive measures.[34] Therefore, this variable needs to be assessed to guide risk communication efforts.

Another important finding in this study was that, despite the good level of knowledge, more than half of respondents perceived CMS as avenues for government to make money and/or a means of employment. These misperceptions are worrisome and may stem from a lack of public trust in the government which in turn might be a contributory factor to the poor adherence to prescribed CMS. On the other hand, the poor adherence in this study may have represented a deterioration in previously better compliance at the start of the pandemic, so called pandemic fatigue. To support this notion, data for Edo state obtained from Google mobility reports showed increments of 26%, 14% and 11% in the mobility at workplaces; retail and recreation areas and groceries, respectively, between the first and last days of June, the month when the study was conducted.[35] However, the mobility data need to be interpreted with caution since they were not specific for Benin City. Nevertheless, periodic assessments of adherence at various time points of the outbreak provide a better perspective and may better guide risk communication efforts.

The probabilistic sampling technique employed was the major strength of this study. This was possible because there was no lockdown instituted in Edo state, and so it was possible to conduct a physical, paper-based questionnaire survey that did not limit respondents to people with internet access. In contrast, many similar studies conducted during the COVID-19 pandemic have relied on convenience sampling due to their online nature. A limitation of the study is its cross-sectional design which means that the findings are only a snapshot and not predictive of the entire duration of the pandemic. Despite this limitation, it can be inferred that poor adherence to CMS may have been the root cause of the sustained increase in the number of COVID-19 cases which was evident at the time of conducting the study. However, at the time of writing, the number of cases has begun declining. This might imply that a sufficient level of herd immunity has been reached. Seroprevalence studies would be required to determine how widely the virus spread in the face of poor adherence to CMS.

As various facets of the economy continue to reopen and educational institutions prepare to resume activities, a second wave or exponential rise in cases remains a distinct possibility. If this happens, some CMS may need to be re-instituted. The findings from this study can guide the future selection of CMS as well as risk communication efforts for a better response. CMS such as hand washing and use of face masks to which adherence was relatively good represent low hanging fruits and should be further encouraged. A more coercive approach – through fines and/or jail time – may be required to enforce compliance with CMS related to physical distancing while improving on provision of palliatives to low-income earners to enable them comply. Risk communication should focus on building trust in government and public health authorities because willingness to comply with CMS is greater when people trust these entities. Finally, risk perception should be evaluated on a regular basis to further improve upon and tailor risk communication.

  Conclusion Top

Although residents of Benin City displayed good knowledge of CMS against COVID-19, this did not translate to good adherence to these strategies at the time of conducting this study. Frequent monitoring of knowledge, risk perception, adherence levels and appropriately tailored risk communication are necessary to successfully curb transmission using CMS.

Financial support and sponsorship

This research was self-funded.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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