Attitude and Behavior of Emerging Novel COVID-19 Disease Khartoum, Sudan

Background

On December 8, 2019, the first identified case of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was officially reported in Wuhan, China [1]. However, the emerging disease has become a global health emergency, and was declared by World Health Organization (WHO) in January 2020 [2].

The whole world is now facing a catastrophic massive burden from the COVID-19 pandemic. Coronaviruses have varied symptoms ranged from mild to more per acute illnesses such as SARS and MERS [3]. These symptoms of the COVID19 infection include fever, headache, cough, sore throat, nausea and vomiting, diarrhea, dermatological lesions. The vulnerability of the COV increases with underlying chronic illnesses diabetes Millets and hypertension are more likely to be infected with COV and would experience worsen conditions [4] like heart, and respiratory failure, acute respiratory syndrome, or even death [5].

Many countries have taken extraordinary precautionary measures to curb the spread of the COVID19. However, these severe restrictions; locking down, hand washing, contact avoidance, wearing masks, keeping social distance, travel restrictions, and avoiding crowded places would minimize the risk of infection. The COVID19 has led to health crisis which has resulted in many countries to opt for social quarantine of their populations, communication systems have been characterized by disintermediation, the acceleration of digitization and an infodemic.

Since COVID19 is a behavioral disease many ministries of health should be displayed awareness of protective behaviors against COVID19 and develop health-protective attitudes during a health crisis. Further, behavior and attitude will definitely have direct impact on prevention measures. Thereby, these steps would help individuals to take meaningful steps to protect themselves. Healthy behavior and attitude are also crucial in keeping healthy during the coronavirus pandemic [6].

An attitude is a psychological state of mind. It is the way a person thinks about situations, and it ultimately determines a person’s behavior. It also refers to inclinations to react in a certain way to certain situations. Moreover, behavior is defined by the actions of a person based on specific stimuli. It refers to our opinions, beliefs, and feelings about aspects of our environment [7, 8]. Psychological factors are called internal factors, while social factors are called external factors. These factors interact together whether psychological factors with social factors, and this interaction results in the behavior of the individual, which is maybe positive or negative behavior [9].

In addition, the direct impact of behavior and attitude of COVID 19 on of those infected is also significant, and is often precipitated due to increased stigma, social isolation and quarantine. Thus the social isolation and movement restrictions due to COV also jeopardize health and access to basic needs, and point to the need for human rights, which resulted in many deaths whether by corona virus or other causes [10].

In Sudan on 13th March, the first reported case of coronavirus was confirmed in Khartoum, a man who was visiting United Arab Emirate in the first week of March, and by 27 of May, a surge of reported cases and death was reached with no of 4521 case and 233 deaths. Therefore, the Federal Ministry of Health Sudan (MoH) has made ongoing campaigns of awareness concerning mode of transmission and the importance of applying protective measures, quarantine and curfew. Although strict measures taken, the awareness of individuals towards infectious viruses remains the most important factor in controlling and containment of the COVID19 [11].

However, during the current outbreak misleading information for example; rumours and myth particularly on social media were shared widely, fear and anxiety were apparently manifested and stigmatization was appeared to be prevailed [12]. Furthermore, some individuals’ fear of being diagnosed and/or categorized as suspected case, thus this situation created psychosocial dilemma of accessing health care to know their status. Moreover, another mark of the fear is that Sudan MoH announced that more than 50% of those who returned to their home during the outbreak were pledged incorrect information at airport check to deceive the health workers of being investigated and screened [13].

The ongoing outbreak, propaganda, fear, stigma and discrimination, besides the fragility health system worsen the situation and created an appropriate pathway for triggering COVID19 distribution. Thus, this study attempted to highlight the importance of attitude and behavior of Sudanese participants in bridging gaps of controlling the COVID-19. This study will potentially help policy makers in implementing comprehensive interventional campaigns.

Methods

The aim of the current study is to determine behavior and attitude of participants towards COVID-19 in Khartoum. This is a cross sectional community based study. It was carried out in Khartoum the capital of Sudan, which encompasses three localities; Khartoum, Bahri and Omdurman. A multistage random sampling was applied. A number of 1200 participants were enrolled randomly. A total of 400 participants were recruited from each locality, whilst half of those were drawn from central and the remaining from peripheral sites. The sample size was calculated based on the assumption that the probability of having positive attitude towards preventive measures against COVID19 disease was 50.0%, at 95% confidence interval, limit of precision of 5%, with a design effect of 1.0, the calculated sample size was 384 participants and 5% were added as contingents [14]. Participants were answered a yes-no question to confirm their willingness to participate voluntarily. Participants were inquired about (i) Socio-demographic information, (ii) Attitude concerning COVID-19 (iii) protective measures (iv) behaviors to prevent COVID-19 (v) types of information. However, all participants were directed to complete the self-report survey.

Statistical Analysis

Descriptive statistical methods were used to summarize data on socio-demographic profile and responses to questions concerning attitude and behavior towards COVID-19. Data were displayed as frequencies and percentages (%) for categorical variables. Data were analyzed using Statistical Package for the Social Sciences (SPSS, version 25; IBM, USA), and Smart PLS 3.3.2 version. A P value was considered statistically significant at level of P < 0.05. All baseline socio- demographics were described as categorical variables_._ Multivariable logistic analysis, with Odds Ratios (OR) reported, were used to determine factors associated with preventive behavior of COVID-19. Participants’ attitudes and behavior were categorized into two categories: poor and good. For attitudes, the median was of the scores was 33,

Results

Two constructs namely attitudes and behavior towards COVID 19 of the sampled members (n=1200) were tested for reliability. The domain of attitudes scored good reliability, since Cronbach Alpha coefficient was between 0.7 to 0.79 while the domain of behavior scored a very good reliability, since Cronbach Alpha coefficient was between 0.8 to 0.89 (source), and hence our instrument developed was valid and reliable.

Gender ratio in favor of females since (60.9%, n=731) were females. Majority of the participants (48.8%, n=585) were between 20 to 29 years at the time of data collection, However, 11.2% (N=134) of the participants were 50 years or above at the time of survey. While only 42 (3.5%) participants were uneducated, and (56.6%, n= 679) had bachelor/diploma certificate. With regard to marital status, majority of the surveyed persons were singles (55.5%, n= 666. Up to 668 participants (55.7%) reported that their families had between 4 to 6 members. Moreover, employed are (57.7%, n=693). Of the 693 participants who were employed closed to 40% of them work in private sector (39.4%, n= 273), regarding monthly income level greater than a half of the participants (51.2%, n=614) earned 3000 SDG or more a month.

Click to enlarge

When attitudes towards COVID 19 categorized, (median 33) greater than the half of the participants (52.7%, n= 632) had negative attitudes (95%Cl, 49.9% - 55.5%), while 47.3% of them had positive attitudes (95%Cl, 45.9% - 50.1%). Regarding behavior (median 36), greater than the half of the participants (55.3%, n= 663) had poor behavior (95%Cl, 52.5% - 58.1%), while 44.7% of them had good behavior (95%Cl, 41.9% - 47.5%).

Discussion

Currently, the widespread of propagating COVID19 outbreak is constituted a major public threat universal. Hitherto, no treatment or vaccine has been discovered. Therefore, prevention is an only solely solution. Effective prevention and control of COVID-19 is achieved through increasing the populations’ encourage positive attitude, and behavior towards COVID19. To our knowledge, this study is a pathfinder community based study to be carried out in Sudan, which demonstrates attitude and behavior during the COVID-19 outbreak.

According to the findings of our study, among the attitude being investigated, greater than half (56.7%) of the participants have negative attitudes, while 47.3% the remaining have positive attitudes. This result is higher than that of other studies conducted in Saudi Arabia [15], China [16] (81%) and (74%) respectively. where the majority of participants have optimistically positive attitude confident that the disease is curable and their country will contain the disease. In Saudi Arabia, approximately 81% of participants had high confidence that the virus can be successfully controlled, and 97% are convinced that the Saudi government will control the outbreak. This discrepancy might be attributed by selecting certain stratum from their communities, which did not reflect the actual situation. More, they thought that the capabilities and preparedness health system and rapid response for such outbreaks and also these affluence countries and they have capabilities for prompt interventions.

Our results indicate the behavior of participant regarding COVID 19 was categorized into two; poor was noted in 55% (995% CI, 52.5% - 58.1%), whilst the good behavior was found in 45%. Our result is incoherence with Ethiopian study done by Akalu Y, et al. [17] which was reported poor behavior in (47.3%). This result could be explained by the similarity of social context of the two populations regarding customs, traditions and lifestyle. However, other studies found poor behavior was less than we found. For example, other studies conducted in Nigeria [18] and Uganda [19] reported that poor behavior was seen in 17.7% and 14.7% correspondingly. These discrepancies could be ascribed to the difference sources of information channels, intensively awareness and panic of COVID 19 outbreak.

This study found three factors are negatively affected behavior regarding COVID 19 (61%) of the total variance clarified, which were reported in; isolation strategy anticipated stigma and enacted stigma. The overwhelming of pessimistically behavior was entirely focused on the isolation strategy, thus refusal to be put in quarantine facility, besides the most the imagined phantom image of the isolation environment, lack of confidence in health authorities’ competency. This may be due to the fact that the health authorities did not take into account the use of effective mechanisms to reflect the ideal image of isolation centers. However, many studies have been conducted among those who had been quarantined found that there is a high prevalence of psychological symptoms, emotional disturbance, depression , stress, low mood, anger, and emotional exhaustion [20, 21, 22, 23, 24, 25, 26].

Demographic characteristics showcase that males have less likely poor behavior as compared to their females counterparts( 0.48 β = − , p <0.05, AOR=0.62, 95% C.I.; 0.43 -0.89). This finding is inconsistence with other authors’ findings [27, 28]. Further, also corresponding to other epidemiological studies which declared that females prone to poor behavior compared to males [29], this disparity might be attributed to those males had had exposed to extensive awareness.

This study found that an attitude was the best predictor of behavior towards COVID19. While for negative attitudes category, the next best predictor is locality. However Omdurman locality was found greater than three-quarters of the inhabitants had had negative attitudes and poor behavior (75.9%) compared to other localities. This variance might be

attributed to that Omdurman is more populated compared

to others. Further, in one study was conducted in China [30]

found that the variability of spatial has a role in behavioral

variation. Our study reported that, the monthly income

played major role in determining the individuals behaviors,

participants earned between 2000-2999 SDG a month

were 2.83 times more likely to have poor behavior towards

COVID19 compared with those who earned 3000 SDG and

$$ \mathrm {a b o v e} (\beta = 1. 0 4, $$

, p <0.001, AOR=2.83, 95% C.I.; 1.77 -4.52).

Furthermore, this result is supported enormous studies

carried out in Ethiopia [17], Malaysia [31] and United States

[32] which reported that participants with low income have

tendency of poor behavior of COVID-19.

This study found that participants aged between 40 - 49

years were 2.55 more likely to have poor behavior compared

with those who were in the upper class of age (

$$ (\beta = 0. 9 4, p $$

<0.05, AOR=2.43, 95% C.I.; 1.23 -5.28). This point could be

explained by the virulence of the disease that because of

those who elder are more vulnerable to the infection. This

finding agreed with Saudi study [33] that revealed good

practicing behavior among old age people and young was

considered that it is the disease of the old and young people;

therefore, to avoid getting this infection, their practicing

behavior was better.

Previous studies have shown different source of obtaining knowledge. Our study was conducted on first months of outbreak. The main source of information in this study was reported in TV (81.7%) followed by social media (68.9) in addition to at least each participant receive information from three different channels. This finding is supported by previous studies performed in Ethiopia [34], and Egypt [35] have shown social media platforms, and the internet represented the most important sources of information. This difference might be due to a difference in study populations’ socioeconomic and educational status, and can be explained by the time of data collection was early day strict lockdown were people exposure to TV could be more infodemic and multiple nonofficial source of information give chance to Rumors and spread of inaccurate information. In this study, infodemic and misconception was the main contributor in formulation negative attitude. Now, there has been increase in the internet access and usage to receive information about infection control [36]. Moreover, now a day’s internet is widely available and utilized to gain knowledge on evolving disease by many people. This has been proven from multiple studies published about the disease in China [37]. Again this reflects the effectiveness of the message provided by the different media platforms, which was confirmed by the negative assumptions that that media is exaggerating the risk (16.8% only thought that media outlets exaggerate the danger of the disease).

Misconceptions about COVID19 of statistically describe

person’s attitudes positively (

$$ (\beta = 0. 9 2 6, p - v a l u e < 0. 0 0 1) $$

; therefore, misconception was the main contributor in

forming negative attitude.

Participants perceptions was varied, 28% believed the disease is life-threatening danger and potentially fatal and the prognosis recorded in 31%. Up to 19% of our participants convinced the outbreak is a political lie, 42.5 % agree with it is God’s punishment and about (18.5%) of participants thought; the infection is associated with stigma. Many previous studies have been conducted are in agreement with our finding [38, 39, 40, 41].

Stigma (anticipated and enacted) was also extracted as factor changing behavior because of stigma hurts everyone by creating more fear or anger toward ordinary people instead of focusing on the disease that is causing the problem. Stigma can also make people more likely to hide symptoms or illness, keep them from seeking health care immediately, and prevent individuals from adopting healthy behaviors it also makes them practice some negative behaviors, such as distancing everyone who has been exposed to illness, even if he is cured, impeding ambulances and rejecting them in their areas. Our finding is in line with enormous authors’ results conducted elsewhere [42, 43, 44, 45]. This result in agreement with our finding, thus can be resolved through proper education

Conclusion

Majority of participants had had negative attitude. More than half of participants had a poor behavior. The spectrum of behavior was noted in; response to isolation strategy, anticipated stigma, and enacted stigma. Factors had occurred changing attitude were misconceptions about covid19, infodemics of COVID19, and negative stereotyping. Monthly income and education status were significantly associated with negative attitude.

Acknowledgment

This study was fully supported by Arab Open University in Sudan. The Authors (Arab Open Research Group Members) thank all the involved participants for their cooperation and support. Special thank for the research assistants for data collection and management.