PLOS ONE

RESEARCH ARTICLE

COVID-19 and the public response:

Knowledge, attitude and practice of the public
in mitigating the pandemic in Addis Ababa,
Ethiopia
Zelalem Desalegn ID1*, Negussie Deyessa2, Brhanu Teka1, Welelta Shiferaw3,
Damen Hailemariam2, Adamu Addissie2, Abdulnasir Abagero2, Mirgissa Kaba2,
Workeabeba Abebe4, Berhanu Nega5, Wondimu Ayele2, Tewodros Haile6,
a1111111111 Yirgu Gebrehiwot7, Wondwossen Amogne6, Eva Johanna Kantelhardt8, Tamrat Abebe1
a1111111111
1 Department of Microbiology, Immunology and Parasitology, School of Medicine, College of Health
a1111111111 Sciences, Addis Ababa University, Addis Ababa, Ethiopia, 2 School of Public Health, College of Health
a1111111111 Sciences, Addis Ababa University, Addis Ababa, Ethiopia, 3 Department of Psychiatry, School of Medicine,
a1111111111 College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, 4 Department of Pediatric and
Child Health Department, School of Medicine, College of Health Sciences, Addis Ababa University, Addis
Ababa, Ethiopia, 5 Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia, 6 Department of Internal Medicine, School of Medicine, College of Health
Sciences, Addis Ababa University, Addis Ababa, Ethiopia, 7 Department of Obstetrics and Gynecology,
School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, 8 Institute of
OPEN ACCESS Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle, Germany
Citation: Desalegn Z, Deyessa N, Teka B, Shiferaw
W, Hailemariam D, Addissie A, et al. (2021) COVID- * [email protected], [email protected]
19 and the public response: Knowledge, attitude
and practice of the public in mitigating the
pandemic in Addis Ababa, Ethiopia. PLoS ONE Abstract
16(1): e0244780. https://doi.org/10.1371/journal.
pone.0244780

Editor: Khin Thet Wai, Ministry of Health and Background

Sports, Myanmar, MYANMAR
The COVID-19 pandemic is impacting the global community in many ways. Combating the
Received: June 9, 2020 COVID-19 pandemic requires a coordinated effort through engaging public and service pro-
Accepted: December 16, 2020 viders in preventive measures. The government of Ethiopia had already announced preven-
Published: January 7, 2021
tion guidelines for the public. However, there is a scarcity of evidence-based data on the
public knowledge, attitude, and practice (KAP) and response of the service providers
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
regarding COVID-19.
process; therefore, we enable the publication of
all of the content of peer review and author Objective
responses alongside final, published articles. The
This study aimed to assess the public KAP and service providers’ preparedness towards
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0244780 the pandemic in Addis Ababa, Ethiopia.

Copyright: © 2021 Desalegn et al. This is an open

access article distributed under the terms of the
Methods
Creative Commons Attribution License, which A community-based cross-sectional study was conducted in Addis Ababa, Ethiopia, from
permits unrestricted use, distribution, and
late March to the first week of April 2020. Participants were conveniently sampled from 10
reproduction in any medium, provided the original
author and source are credited. different city sites. Data collection was performed using a self-administered questionnaire
and observational assessment using a checklist. All statistical analysis was performed using
Data Availability Statement: All relevant data are
within the manuscript and its Supporting SPSS version Descriptive statistics, correlation coefficient and chi-square tests were
information files. performed.

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

Funding: ZD Grant number: VPRTT/PY-403/2020 Result

Addis Ababa University www.aau.edu.et The
funders have no role in in the study design, data A total of 839 public participants and 420 service providers enrolled in the study. The mean
collection and analysis, decision to publish, or age was 30.30 (range = 18–72) years. The majority of the respondents (58.6%) had moder-
preparation of the manuscript. ate knowledge about COVID-19, whereas 37.2% had good knowledge. Moreover, 60.7%
Competing interests: The authors have declared and 59.8% of the participants had a positive attitude towards preventive measures and good
that no competing interests exist. practice to mitigate the pandemic, respectively. There was a moderate positive correlation
between knowledge and attitude, whereas the correlations between knowledge and practice
and attitude and practice were weak. With regard to service providers’ preparedness, 70%
have made hand-washing facilities available. A large majority of the respondents (84.4%)
were using government-owned media followed by social media (46.0%) as a main source of
information.

Conclusion
The public in Addis Ababa had moderate knowledge, an optimistic attitude and descent
practice. The information flow from government and social media seemed successful seeing
the majority of the respondents identifying preventive measures, signs and symptoms and
transmission route of SARS-CoV-2. Knowledge and attitude was not associated with prac-
tice, thus, additional innovative strategies for practice changes are needed. Two thirds of
the service provider made available hand washing facilities which seems a first positive
step. However, periodic evaluation of the public KAP and assessment of service providers’
preparedness is mandatory to combat the pandemic effectively.

Introduction
Infections with coronaviruses in humans and animals cause respiratory and intestinal diseases
[1]. The diseases vary from mild, self-limiting forms to more severe manifestations depending
on the type of viruses involved [2]. Coronaviruses belong to the subfamily Coronaviridae,
which consists of four genera: Alphacoronavirus and Betacoronavirus members infect mam-
mals, while Gammacoronavirus and Deltacoronavirus only infect birds and some mammals
[3]. Among the coronaviruses that infect humans, severe acute respiratory syndrome coronavi-
rus (SARS-CoV) and middle East respiratory syndrome-related Coronavirus (MERS-CoV) are
highly pathogenic [4].
The current human coronavirus, named SARS-CoV-2, emerged as a public health problem
from Wuhan, Hubei province, China, on 31 December 2019 as a cluster of pneumonia cases.
On 7 January 2020, the a etiological agent of the pneumonia was officially announced as a
novel coronavirus [5–7]. On 11th January 2020, the first fatal case was reported. On the next
day (12 January 2020), the whole genome sequence of the virus was shared with the World
Health Organization (WHO) and the public. Confirmed cases outside Wuhan were reported
from Thailand (13 January 2020), Japan (16 January 2020), Korea and in another province of
China (19 January 2020), all from persons who had travelled to Wuhan [8]. On 30 January
2020, the Director-General of WHO declared the 2019-nCoV outbreaks a public health emer-
gency of international concern [9]. The WHO announced that COVID-19 should be charac-
terized as a pandemic on 11 March 2020 [9].
As of September 29, 2020, approximately 33,556,252 million cases, 1,006,450 deaths and
24,881,239 recovered cases have been reported globally [10]. Europe and America have been
highly affected by the virus, as shown by overwhelmed health systems and high death tolls

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

[11]. Although the virus arrived late in Africa, the number is increasing and it has been pre-
dicted that more than 1.2 billion people are at high risk [12]. In the context of Ethiopia, the
first COVID-19 case was reported on 13 March 2020. Based on WHO recommendations, Ethi-
opia implemented thermal screening at various institutions, social distancing, providing hand
washing facilities, stay-at-home orders, quarantining people assumed to be exposed and
encouraging the community to use homemade masks when needed, including in areas where
there are more people and traffic flow such transportation services and other service providers.
As of 29 September 2020, there had been 73, 944 confirmed cases, 1,177 deaths and 30, 753
recovered cases in Ethiopia [13].
According to the WHO global strategy to respond to COVID-19, the overarching goal of
all countries is to control the pandemic by slowing down the transmission to reduce the imme-
diate burden on health systems and to reduce the mortality [14]. According to this strategy,
everyone has a crucial role to play to stop COVID-19. Individuals must protect themselves and
others by adopting behaviors like regular adequate hand washing or use alcohol-based hand
sanitizers, avoid touching their faces, practice covering their mouths and noses anytime or
while coughing and sneezing, maintain physical distancing, isolate themselves if they are sick,
identify themselves as a contact of confirmed cases when appropriate and, most importantly,
strictly follow measures announced by their government or health authorities [14]. The imple-
mentation of all the above depends on the background knowledge, skills and attitude of the
public to COVID-19.
The knowledge, attitudes and, practices (KAP) that people hold towards the disease play an
integral role in determining a society’s readiness to accept behavioral change measures from
health authorities [15]. The KAP of people towards COVID-19 is critical to understand the epi-
demiological dynamics of the disease and the effectiveness, compliance and success of infection
prevention control measures adopted in a country. Moreover, research has demonstrated that
effective control and mitigation of COVID-19 in any country requires operational research and
timely epidemiological data generated among different groups of the population. Such evi-
dence-based data will inform health authorities so that they can design robust interventions
and policies that are relevant and comprehendible to the community and beyond [16].
In a previous study, a plethora of evidence demonstrated that there is a disparity in the KAP
level of the public about viral infection, including COVID-19 [15, 17–26]. The difference in the
public KAP towards COVID-19 could be explained by geographical difference, methodological
variability, health care system infrastructure, socio-economic status of the participants, the bur-
den of the pandemic and residence of the participants, among many other factors.
The COVID-19 pandemic and the associated measures of confinement will have devastat-
ing consequences for micro and small business operations and will disrupt many existing
value chains. This, in turn, will lead to loss of income and sharp increases in unemployment.
The COVID 19 pandemic has and will continue to have a strong effect on labour markets
worldwide, especially in developing economies, where more than 70% of the workforce is self-
employed or works in micro and small enterprises [27, 28]. These effects will undeniably have
many significant effects on a wide range of the population.
Engaging service providers and/or small and medium enterprises and exploring their pre-
paredness to fight the COVID-19 pandemic is crucial. So far, government, health authorities,
health institutions and the media have strived to help public and service providers be aware of
the disease and apply preventive measures. Despite the public health measures, there is a huge
research gap with regard to the public KAP and service providers’ preparedness towards
COVID-19.
Therefore, the present study aimed to assess: (1) the public KAP and (2) the preparedness
and response of service providers towards COVID-19 in Addis Ababa, Ethiopia.

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

Methods and materials

Study design and setting
A cross-sectional, community-based survey was conducted in selected sites in Addis Ababa,
Ethiopia, among adults to assess their KAP and the preparedness of the service providers
regarding COVID-19. The study was conducted during the last week of March through first
week of April 2020. To achieve the intended study objectives, a self-administered question-
naire was used to assess the public KAP and a brief checklist was utilized to evaluate service
providers’ preparedness and response towards COVID-19 in Addis Ababa, Ethiopia. Addis
Ababa is the capital and largest city of Ethiopia. The study was carried out in 10 high traffic
sites located in the respective sub-cities.

Study population and the target sample size

The study population was adults who were by chance walking in the 10 sites. Service providers
in the selected sites were considered for assessing their practical readiness against COVID-19.
Being adult (> 18 years of age) and consent to participate in the study taken were the inclusion
criteria.
A single population proportion formula was used by considering 50% prevalence of public
awareness of COVID-19, with a 5% margin of error at a 95% confidence level, with a design
effect of 2.0, and adding 10% for non-response. A total of839(84/ per site) participants from
major city sites were recruited. Again, given that there was no study among service providers
related to a possible outbreak, we considered a 50% proportion of preparedness for COVID-
19, with a 5% margin of error at a 95% confidence level, and adding 10% for non-response.
Therefore, 420 service providers recruited from the 10 sites. A convenient sampling technique
was employed and verbal consent obtained from all participants.

Participant recruitment procedure

The intended study was conducted during the early phase of the COVID-19 pandemic in
Ethiopia at Piazza, Arat Kilo, Mexico, Bole Medhanealem, Bole Michael, Teklehaimanot,
Megenagna, Jemo, Ayer Tena and Kera. The selection of specific streets from the high traffic
enumeration site was done by spinning a bottle. The participants were approached and
informed of the study objectives. Consecutive service providers on the same streets were
included; their preparedness was assessed using a brief checklist along with a direct observa-
tional assessment.

Data collection tool

Data collection was done using a self-administered structured questionnaire and a brief check-
list. The questionnaire consisted of 40 close-ended questions that aimed to collect the follow-
ing information from the respondents: socio-demographic characteristics, travel history, risk
factors and KAP related to COVID-19. The survey instrument took approximately 15–20 min-
utes to complete.
The data collection tool was initially prepared in English (S1 Appendix) version followed
by translation to local Amharic language (S2 Appendix). Consistency of content, clarity and
appropriate meaning between the two version was maintained through back translation of the
questionnaire to the original version. Additionally, the practicability, validity and interpret-
ability of answers for the respective questions was confirmed by performing pre-test in 10%
of the targeted sample size. Based on this pre-test study, the format and wording of questions
were corrected and refined.

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

A brief checklist and observational assessment were used to evaluate the preparedness and
response of service providers (e.g. hotels, cafeterias and transportation enterprises). The brief
checklist explored the availability of soap with water, alcohol and/or sanitizer for the any per-
son entering. To facilitate the data collection, 10 data collection facilitators were enrolled to
distribute and collect the completed questionnaire from the consented participants. Formal
training on a brief introduction of the research objectives, data collection procedure and ques-
tionnaire content was delivered.

Knowledge related to COVID-19

The knowledge section of the questionnaire comprised40 questions. All the questions were
developed by considering previous research done in same population with a similar research
theme [29]. These questions were in the form of yes or no; if the answer was yes, the partici-
pants were asked to specify. The right answer to each question has a score of 1 and wrong
answer 0. Modified Bloom’s cut-off points were used to judge knowledge as good (80%–
100%),�32), moderate (50%–79%, 20–31), or poor (� 50%,�19) [30].

Attitude towards COVID-19

Eight questions were asked to evaluate the attitude of the general public towards the disease. A
scoring system to attitude was used as follows: good (�6), moderate (5) and poor (�4).

Practice regarding COVID-19

There were four questions on practice towards COVID 19 (one point for each questions with
correct answer). The cut-offs were similar to the knowledge and attitude scoring: good (4),
moderate (3) and poor (�2).

Statistical analysis
Before the analysis, completeness of the data was evaluated. Data entry and coding and were
done using EpiData version 3.1. The data were analyzed with SPSS statistical software version
22. A descriptive analysis was performed. Specific knowledge, attitude and practice questions
were used to establish scoring to assess the overall status of the participants. For each question,
1 point was given for answering correctly, whereas 0 points were assigned when the responders
fail to respond correctly. Based on the total score relative to the maximum score, the public
KAP level was categorized as good, moderate or poor, considering modified Bloom’s cut-off
points. Inferential statistics between the socio-demographic factors and the public KAP
regarding COVID-19 were investigated using a chi-square test. A statistically significant asso-
ciation was declared at < 0.05.

Research ethics approval

The study protocol was approved by the institutional review board (IRB) of the College of
Health Sciences Addis Ababa University (Protocol number: 012/DMIP/2020) and verbal con-
sent was obtained from each participant.

Results
Demographic characteristics
The study included 839 participants. The participants mean age was 30.3(standard deviation
[SD] = 9.25, range = 18–72) years. The majority of the respondents were males (58.0%) and

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

single (56.6%). With regard to occupational status, government employee and non-govern-
ment employee occupied one third each (36.7% and 34.7%) followed by traders (8.3%), day
workers (6.4%) and others (12.3%).

Travel history to COVID-19-affected areas

Only 7% of respondents had travel history in the last three months at the time of data collec-
tion. Of these, 17%, 11.8% and 10.0% had travelled to China, Europe and the Middle East,
respectively, among COVID-19-affected areas at the time of data collection. With respect to
contact history, 9.2% of the participants had had contact with individuals who had travelled to
COVID affected areas (Table 1).

KAP towards the COVID-19 pandemic

Knowledge assessment. Knowledge was assessed using a total of 40 questions that focused
on nature of the disease, prevention mechanisms, transmission mode, risk groups and signs
and symptoms of COVID-19 (Table 2).

Table 1. Demographic characteristics of the study participants in Addis Ababa, Ethiopia.

Characteristics Count (%)
Sex Male 487 (58.0)
Female 345 (41.1)
Age group (years) �19 48 (5.7)
20–29 426 (50.8)
30–39 233 (27.8)
40–49 82 (9.8)
50–59 31(2.7)
�60 10 (1.2)
Unknown age ?
Marital status Single 475(56.6)
Married 322 (38.4)
Divorced 31 (3.7)
Widowed 7 (0.8)
Unknown ?
Occupation Governmental 308 (36.7)
Non-governmental 291(34.7)
Trader 70 (8.3)
Day worker 54 (6.4)
Others 103 (12.3)
Unknown ?
Living condition Alone 191 (22.8)
With others 629 (75.0)
Unknown ?
Travel history Yes 59 (7.1)
No 777(92.9)
Contact with a person who travelled to COVID-19 affected areas Yes 69 (9.2)
No 677(90.6)
Unknown
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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

Table 2. The response of the participants to specific knowledge questions in Addis Ababa, Ethiopia.
Ser. Knowledge questions Responses Correct Wrong
No. response response
1 Which of the following do you think are the major signs and symptoms of the 1. Fever 721 (85.9) 118 (14.1)
disease caused by coronavirus? 2. Diarrhea 68 (8.1) 771 (91.9)
3. Bloody diarrhea 816 (97.3) 23 (2.7)
4. Bloody sputum 786 (93.7) 53 (6.3)
5. Swelling of legs 822 (96.0) 17 (2.0)
6. Cough 412 (49.1) 427 (50.9)
7. Swelling on mouth/nose 790 (94.2) 49 (5.8)
8. Red and painful eyes 29 (3.5) 810 (96.5)
9. Sneezing/runny nose 532 (63.4) 307 (36.6)
2 What are the current ways of prevention of COVID-19? 1. Vaccination 728 (86.8) 111 (13.2)
2. Anti-viral therapy 775 (92.4) 64 (7.6)
3. Using masks 387 (46.1) 452 (53.9)
4. Frequent washing of hands 446 (53.2) 393 (46.8)
5. Staying at home 622 (74.1) 217 (25.9)
6. Frequent disinfectant 504 (60.1) 335 (39.9)
7. Staying >meters from others 542 (64.6) 297 (35.4)
3 How could a person acquire the coronavirus disease? 1. Directly through breathing/ sneezing 698 (83.2) 141 (16.8)
2. Through a mosquito bite 757 (90.2) 82 (9.8)
3. Touching mouth and nose through 657 (78.3) 182 (21.7)
contaminated hand
4. Through unprotected sexual intercourse 121 (14.4) 121 (14.4)
5. Through staying and playing near others 169 (20.1) 670 (79.9)
6. Not frequently washing while at work 327 (39.0) 512 (61.0)
7. Using public transport with closed 448 (53.4) 391 (46.6)
windows
8. Opening doors/windows in public places 477 (56.9) 362 (43.1)
9. Frequent use of disinfectant while at 774 (92.3) 65 (7.7)
work
4 Who is at risk of developing a severe form of the corona disease? 1. Diabetic patients 531 (63.3) 308 (36.7)
2. Hypertensive patients 403 (48.0) 436 (52.00
3. People with heart problem 449 (53.5) 390 (46.5)
4. Pregnant women 555 (66.2) 284 (33.8)
5. Cancer patients 379 (45.2) 460 (54.8)
6. Khat chewers/smokers 432 (51.5) 407 (48.5)
7. Asthmatic patients 440 (52.4) 399 (47.6)
8. People with COPD 627 (74.7) 212 (25.3)
5 At what age group do you think the coronavirus disease occur? 1. Children 413 (49.2) 426 (50.8)
2. Youth 485 (57.8) 354 (42.2)
3. Elderly 760 (90.6) 79 (9.4)
6 Is the coronavirus transmittable by shaking/hugging anyone? 777 (92.6) 39 (4.6)
7 Is coronavirus transmittable by mosquito bite? 588 (70.1) 242 (28.8)
8 Is the coronavirus transmittable by direct breathing? 694 (82.7) 133 (15.9)
9 Is a person who has coronavirus detectable by looking at him/ her? 713 (85.0) 120 (14.3)
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The majority of respondents (58.6%) had moderate knowledge while37.2% had good
knowledge (Table 3). Among the socio-demographic characteristics, only the age and occupa-
tion of the participants was associated with knowledge (Table 4).
Attitude towards COVID-19 and association with demographic characteristics. A total
of eight questions were used to assess the attitude of the participants to implement preventive
measures against the COVID-19 pandemic. As shown in Table 3, the mean attitude score was
5.73, most of the public had positive attitude (60.7%) towards implementation of preventive

Table 3. Number of questions, range, scores and levels of knowledge, attitude and practice of the study participants in Addis Ababa, Ethiopia.
Variables Number of questions Score range Total score mean ± SD Level (points)
Poor Moderate Good
Knowledge 40 16–40 28.92±5.4 35 (4.2) 492(58.6) 312 (37.2)
Attitude 8 0–8 5.73±2.1 247 (29.4) 82 (9.8) 509 (60.7)
Practice 4 0–4 2.49±0.7 94 (11.2) 242 (28.8) 502 (59.8)

Note. SD, standard deviation.

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Table 4. Association between respondent demographic characteristics and level of knowledge, attitude and practice scores in Addis Ababa, Ethiopia.
Characteristics Knowledge scores P Attitude scores p Practice scores p
Poor Mod. Good Poor Mod. Good Poor Mod. Good
N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%)
Sex Male 24 292 171 0.09 145 49 293(60.2) 0.87 61 140 286 0.41
(4.9) (60.0) (35.1) (29.8) (10.1) (12.5) (28.7) (58.7)
Female 9 (2.6) 196 140 98 (28.5) 33 (9.6) 213 33 (9.6) 100 211
(56.8) (40.6) (61.9) (29.1) (61.3)
Age group � 19 5 33 (68.8) 10 (20.8) 0.06 19 (39.6) 6 (12.5) 23 (47.9) 0.58 5 (10.4) 17 (35.4) 26 (54.2) 0.63
(years) (10.4)
20–29 18 250 158 125 36 265 47 124(29.1) 255
(4.2) (58.7) (37.1) (29.3) (8.45) (62.2) (11.0) (59.9)
30–39 4 (1.7) 131 98 (42.1) 69 (29.7) 22 (9.5) 141 25 63 (27.2) 144
(56.2) (60.8) (10.8) (62.1)
40–49 3 (3.7) 50 (61.0) 29 (35.4) 19 (23.2) 11 52 (63.4) 8 (9.8) 26 (31.7) 48 (58.5)
(13.4)
50–59 3 (9.7) 17 (54.8) 11(35.5) 9 (29.0) 5 (16.1) 17 (54.8) 6 (19.3) 9 (29.0) 16 (51.6)
� 60 1 6 (60.0) 3 (30.0) 2 (20.0) 1 (10.0) 7(70.0) 0 (0) 1 (10.0) 9 (90.0)
(10.0)
Marital Status Un-married 18 277 180 0.16 131 48 295 0.40 46 (9.7) 147 281 <0.05
(3.8) (58.3) (37.9) (27.6) (10.1) (62.2) (31.0) (59.3)
Married 11 194 117(36.3) 98 (30.4) 28 (8.7) 196 42 82 (25.5) 198
(3.4) (60.2) (60.9) (13.0) (61.5)
Divorced 4 15 (48.4) 12 (38.7) 14 (45.2) 4 (12.9) 13 (41.9) 2 (6.5) 11(35.5) 18 (58.1)
(12.9)
Widowed 1 4 (57.1) 2 (28.6) 2 (28.6) 1(14.3) 4 (57.1) 3 (42.9) 2(28.6) 2 (28.6)
(14.3)
Occupation Govern-mental 9 (2.9) 158 141 <0.05 82 (26.7) 18 (5.9) 207 <0.05 29 (9.4) 89 (29.0) 189 0.67
(51.3) (45.8) (67.4) (61.6)
Non-govern- 17 182 92 (31.6) 96 (33.0) 39 156 38 80 (27.5) 173
mental (5.8) (62.5) (13.4) (53.6) (13.1) (59.5)
Trader 2 (2.9) 42 (60.0) 26 (37.1) 20 (28.6) 6 (8.6) 44 (62.9) 8 (11.4) 18 (25.7) 4 (62.9)
Day worker 2 (3.7) 41 (75.9) 11 (20.4) 17 (31.5) 7 (13.0) 30 (55.6) 8 (14.8) 20 (37.0) 26 (48.1)
Others 3 (2.9) 59 (57.3) 41 (39.8) 25 (24.3) 10 (9.7) 68 (66.0) 10 (9.7) 30 (29.1) 63 (61.2)
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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

measures against COVID-19. Among the respondents, 83.1% and 74.9% indicated they prefer
frequent hand washing with soap and water and use alcohol-based sanitizer, respectively.
Moreover, the majority (90.3%) had good attitude towards social distancing and its necessity
to prevent COVID-19. With regard to lockdown, more than half of the participants agreed
that it had to be in place to mitigate the pandemic in Ethiopia. Similar to knowledge, only
occupational status was associated with a positive attitude (Table 4).
Practice towards COVID-19. In the study, there were four questions related to practice
towards COVID-19, with a maximum total of four points. The mean practice score was
2.49 ± 0.7(range 0–4). The majority (59.8%) of the study participants had a good practice
towards COVID-19. On the date of the data collection, the study participants’ experience of
hand washing with soap and water for 20 seconds and utilization of sanitizer was 96.4% and
82.2%, respectively. Similarly, 88.0% of the participants had not practiced hand shaking. Good
practice was only associated with marital status (Table 4).
Correlations among knowledge, attitude and practice. To visualize the correlation of
participants knowledge, attitude and practice with one another, we performed a scatter plot
analysis. There was a moderate positive correlation between participant’s knowledge and atti-
tude (r = 0.624), whereas the correlations between knowledge and practice (r = 0.196) and atti-
tude and practice (r = 0.172) were weak (Table 5).

Source of information about COVID-19

For the majority of the respondents (84.4%), government-owned television was the primary
source of information about COVID-19, followed by government-owned radio (49.7%), social
media (46.0%) and private television (43.0%). Besides, the government health and social media
were the information sources that the respondents highly believed. With regard to the ade-
quacy of information, more than half (59.6%) of the respondents believed that the broadcasted
information was adequate to act against COVID-19.

Response of service providers towards COVID-19 pandemic

The checklist used to assess the service providers contained questions on type of enterprise,
method of preventive mechanism in place and the type of washing facility present (Table 6).
Most (70%) of the enterprises provided hand washing facilities as a preventive mechanism
towards COVID-19, followed by social distancing and sanitizer or alcohol use with 8.6% and
7.9%, respectively (Table 7).
Of the enterprises, 264 (62.9%) had hand washing facilities with soap and water, 32(7.6%)
had water only, 11 (2.6%) had soap only and 34 (8.1%) had none of the hand washing facilities
(Table 8).

Discussion
This study is the first survey in the capital of Ethiopia, Addis Ababa as far as our knowledge
goes, that aimed to assess the public KAP towards the COVID-19 pandemic as well as to assess
the preparedness and response of service providers in the city.

Table 5. Correlation between knowledge, attitude and practice scores towards COVID-19.
Variables Correlation coefficient P
A Knowledge and attitude 0.624 <0.01
B Knowledge and practice 0.196 <0.01
C Attitude and practice 0.172 <0.01
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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

Table 6. Type of service providers included in the study in Addis Ababa, Ethiopia.
Enterprise type Number Percent
1 Hotel/restaurant/cafeteria/juice house 114 27.1
2 Bus/taxi/train station 26 6.2
3 Banks 69 16.4
4 Local drinking houses 21 5.0
5 Mall/boutiques, cosmetic shops, business centre, stationary 85 20.2
6 Others 103 24.5

Note. Others include electronics shops, butchers, pharmacies, bakeries, churches, mosques, etc.

https://doi.org/10.1371/journal.pone.0244780.t006

Table 7. Preventive measures made available by service providers in Addis Ababa, Ethiopia.
Preventive measure Number Percent
1 Hand washing facility (soap and water) 294 70
2 Sanitizer/alcohol 33 7.9
3 Social /physical distancing 36 8.6
4 None 97 23.1
5 Both hand washing facility and sanitizer/alcohol 13 3.1
6 Both hand washing facility and social/physical distancing 28 6.7
7 Both sanitizer/alcohol and social physical distancing 7 1.7
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Table 8. Type of washing facility available to prevent COVID-19 among service providers in Addis Ababa,
Ethiopia.
Facility Number Percent
Water only 32 7.6
Soap only 11 2.6
Both (water and soap) 264 62.9
None 34 8.1
https://doi.org/10.1371/journal.pone.0244780.t008

In the survey out of 839 respondents, almost two thirds had moderate knowledge and good
attitude and practice. This level was far lower than a multinational survey in Africa (South
Africa, Kenya and Nigeria), which reported that the level of awareness and concern about
COVID-19 were very high (94%) [26]. A bi-national survey in Egypt and Nigeria also demon-
strated that the mean knowledge score was higher, with a satisfactory knowledge of the disease
[22]. A study from Nigeria also proved that the respondents had good knowledge (99.5%)
of COVID-19 [16]. Since the current study in Addis Ababa was carried out during the early
phase of the pandemic, the reported knowledge level is encouraging; however, periodic assess-
ment should be in place considering the different scenario of COVID-19 pandemic in Ethio-
pian setting.
A study on Indian diabetes mellitus populations reported a high overall correct response
rate on the knowledge questionnaire (83%) [31]. In another study, the majority of the partici-
pants were knowledgeable about COVID-19, with a mean COVID-19 knowledge score of
17.96 (SD = 2.24; Range = 3–22), indicating a high level of knowledge and the overall accuracy
rate for the knowledge test was 81.64% (17.96/22 _ 100) [21]. A high knowledge level has also
been reported in Malaysia, where the overall correct rate of the knowledge questionnaire was
80.5%and most participants held positive attitudes towards the successful control of COVID-
19 (83.1%) [15].

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

The burden of COVID-19 was by far higher in some Asian countries than some African
countries including Ethiopia, such difference in the spread would bring a disparity in the over-
all knowledge status of the population and preparedness towards the pandemic. Though the
current knowledge and preparedness status is descent in our setting, the best practice from
other countries employed to improving knowledge and preparedness should be adapted for
best containment of the pandemic.
Knowledge assessment in this study included signs and symptoms, the disease transmission
mode, the prevention mechanisms and risk groups. According to the assessment, a consider-
able number of the participants were aware of the disease signs and symptoms. However, a few
participants incorrectly attributed signs and symptoms not shown in COVID-19 cases. This
finding is similar to a study from the Philippines; those results showed that coughing and
sneezing were identified as a transmission route by 89.5% of respondents [23]. In our study,
knowledge of fever and cough as COVID-19 symptoms was high, and the participants knew
that younger participants had a lower perceived risk and the elderly were identified as the high
risk group [32]. One study from the United States among people with chronic conditions pro-
vided unexpected results: nearly one third could not correctly identify symptoms (28.3%) or
ways to prevent infection (30.2%) [25].
Very interestingly, during early phase of COVID-19 pandemic, there has been an aggressive
promotion of covid19 information through MOH and main government mass media. This
lead to better knowledge and preparedness about the pandemic. Though still the promotion
is present, adherence seems to become less. We believe that preventive attitude has to be re-
enforced and appropriate prevention and control strategies should be promoted consistently.
With respect to identifying knowledge question related to COVID-19 prevention, nearly
50% of the participants identified using face mask, frequent hand washing and staying at home
as the most important means of preventing the pandemic. The finding was by far lower than a
study from Philippines which showed that hand washing was the most common preventive
practice in response to COVID-19, adopted by 89.9% of respondents [23]. Another report
from Ethiopia demonstrated that even 90% of the participants had a good prevention knowl-
edge of maintaining social distance and frequent hand washing [24]. The moderate knowledge
in our survey of participants living in the capital city of Ethiopia with consistent access to
information.
Our study explored the association of socio-demographic characteristics with the public
KAP. There was only an association between occupational status and good knowledge. In con-
trast with our findings, study from Tanzania and Iran showed that male sex, younger age (16
to 29 years), non-healthcare-related professions, being single and less education were signifi-
cantly associated with lower knowledge scores [32, 33].
We also assessed the attitude of the participants towards practicing preventive measures,
perceptions on lockdown and their stand on staying at home. Concerning attitudes, it was
interesting that close to two thirds of the respondents showed a positive and optimistic attitude
towards COVID-19 preventive measures. Similarly, a study from Saudi Arabia demonstrated
that the mean score for attitude indicated optimistic attitudes and the mean score for practices
was high, indicating good practices [21]. Findings from Egypt and Nigeria indicated that the
attitude of most respondents (68.9%) towards instituted preventive measures was positive,
with an average attitude score of 6.9 ± 1.2. In addition, the majority of the respondents (96%)
practiced self-isolation and social distancing [22].
Another finding among the same population from Africa documented that the majority of
the respondents (79.5%) had positive attitudes towards adherence to government infection
prevention and control (IPC) measures, with 92.7%, 96.4% and 82.3% practicing social dis-
tancing/self-isolation, improved personal hygiene and using face masks, respectively [16].

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

In agreement with participants knowledge, the state of their attitude towards applying the
preventive measures has been positive. Moreover, the findings proved that those with moder-
ate knowledge and good knowledge turned out to have positive attitude which could ultimately
impact the practice of the public and response towards for any possible outbreak.
The aforementioned optimistic attitude was consistent with participants’ practice of wash-
ing hands with soap and water and frequent use of hand sanitizer. It is an established fact that
physical distancing is the most effective but also the most challenging measure. The respon-
dents had a positive attitude towards physical distancing and implementation of lockdown in
Ethiopia. This positive attitude will ultimately help in the prevention and control of COVID-
19. However, periodic evaluation of this positive attitude towards preventive measures must be
performed to determine whether it is sustained among the public.
In support of the present findings, a study from Ethiopia among several population
revealed that frequent hand washing (77.3%) and avoiding shaking hands (53.8%) were the
dominant practices [34]. Unlike our study, another investigation among health professionals
from Oromia regional state, Ethiopia reportedly demonstrated that the practices of the par-
ticipants towards COVID-19 prevention were relatively low: only 61% and 84% of the partic-
ipants were practicing social distance and frequent hand washing, respectively [24]. Such a
discrepancy might be due to the difference in the study population, study area and the pan-
demic phase.
In our study, only knowledge and attitude showed a moderate correlation. A previous study
showed stronger relationship between knowledge, attitude and practice with infection preven-
tion measures [35]. Finding from China revealed that COVID-19 knowledge score (odds ratio
[OR] 0.75–0.90, p<0.001) was significantly associated with a lower likelihood of negative atti-
tudes and preventive practices towards COVID-2019 [17]. This finding were also reported
from Malaysia where most participants held positive attitudes towards the successful control
of COVID-19 (83.1%) [15].
During an emergency, timely, adequate and appropriate information is important as the
best intervention against rumors and misinformation [5]. Following the emergence of the pan-
demic, a large amount of information has been released in media based on internet informa-
tion about COVID-19. Based on previous assessment, only 1.9% websites that provide health-
related information had agreed to the Net Foundation Code of Conduct by the time of assess-
ment [36].
The study explored the source of information regarding COVID-19. The majority of the
study participants (84.4%) obtained information from government-owned television broad-
cast, followed by government-owned radio broadcast, social media and private television
broadcast. In line with our finding, study from Iran indicated that government TV advertise-
ments and short message service (SMS) were the most common sources of COVID-19 infor-
mation and considered trustworthy (by >95% of participants) [32]. This was in support of a
research finding from Philippines which demonstrated that traditional media sources such as
television and radio were the main sources of information about the virus [23]. By contrast,
another recent study in Ethiopia reported that social media were the main source of the infor-
mation [24].
It was interesting that the public source of information was government outlets at the early
phase of the pandemic; however, with time the public also tended to use social media as the
primary source of information [24, 26]. Another study from Nigeria found that the partici-
pants mainly gained information about COVID-19 through the internet/social media (55.7%)
and television (27.5%) [16]. However, the quality of information shared on the social media
requires due attention and regulation to provide the public with reliable information so as to
combat the pandemic effectively and in a sustainable approach.

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

TheCOVID-19 pandemic has been affecting enterprises of all sizes and types in unprece-
dented way [27, 37]. The majority of the assessed service providers in Addis Ababa in April
2020 had made available either washing facilities with soap and water or alcohol-based hand
rub in an accessible spot. The availability of the washing facilities might explain the moderate
state of knowledge, good attitude and best practice of public KAP. This is a very encouraging
response; it shows that the government strategies were acceptable to the public, stake holders
and clients of the service providers.
This survey had some limitations. First, the convenience sampling method did not avoid
subjective selection bias. Second, selected localities may not reflect the whole picture of Addis
Ababa at large because the ten sites were selected purposefully considering high traffic flow.
In addition, we used a descriptive cross-sectional study design, which hinders determining a
cause–effect relationship between an independent variable and the outcome variables. The
comparability to other studies may be limited by use of different questionnaires. Although the
study faced the above mentioned limitations, the strength of this study lies in its large sample
size. To our knowledge, this is the first large scale study considering the public and service pro-
viders KAP and preparedness towards COVID-19 pandemic.
In terms of policy implication, the findings will the policy makers reconsider the engage-
ment of the community as a key approach in combating any possible outbreak, including
COVID 19. In general, data from the current study showed most probably a positive public
health education effect leading to desired preventive measures as recommended by the govern-
ment in the city.

Conclusion
In conclusion, the finding suggested that the public in Addis Ababa had moderate knowledge,
optimistic attitudes and notable practice against the COVID-19 pandemic. Government and
social media seem valuable sources of information and should further be utilized. COVID-19
knowledge correlated with an optimisticattitudetowardsCOVID-19; these finding indicate that
effective awareness creation and health education have been delivered.
The service providers’ level of preparedness towards the pandemic was encouraging. Still,
more practical support seems needed to assure full coverage with hand hygiene options in pub-
lic enterprises. Periodic evaluation of service providers awareness and preparedness for any
possible outbreak should be in place to assure sustainability of efforts.

Supporting information
S1 Appendix.
(PDF)
S2 Appendix.
(PDF)

Acknowledgments
We would like to express our gratitude to health professionals and researchers working to
overcome COVID-19 throughout the world during this critical time.

Author Contributions
Conceptualization: Zelalem Desalegn, Negussie Deyessa, Damen Hailemariam, Adamu
Addissie, Tamrat Abebe.

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PLOS ONE The response of the public towards COVID-19 in Addis Ababa Ethiopia

Data curation: Zelalem Desalegn, Negussie Deyessa, Brhanu Teka, Welelta Shiferaw, Damen
Hailemariam, Adamu Addissie, Abdulnasir Abagero, Mirgissa Kaba, Workeabeba Abebe,
Berhanu Nega, Wondimu Ayele, Tewodros Haile, Yirgu Gebrehiwot, Wondwossen
Amogne, Eva Johanna Kantelhardt, Tamrat Abebe.
Formal analysis: Zelalem Desalegn, Brhanu Teka, Welelta Shiferaw, Adamu Addissie, Abdul-
nasir Abagero, Mirgissa Kaba, Workeabeba Abebe, Wondimu Ayele, Eva Johanna Kantel-
hardt, Tamrat Abebe.
Funding acquisition: Zelalem Desalegn, Negussie Deyessa, Tamrat Abebe.
Investigation: Zelalem Desalegn, Negussie Deyessa, Brhanu Teka, Welelta Shiferaw, Damen
Hailemariam, Adamu Addissie, Abdulnasir Abagero, Mirgissa Kaba, Workeabeba Abebe,
Berhanu Nega, Wondimu Ayele, Tewodros Haile, Yirgu Gebrehiwot, Wondwossen
Amogne, Eva Johanna Kantelhardt, Tamrat Abebe.
Methodology: Zelalem Desalegn, Negussie Deyessa, Welelta Shiferaw, Adamu Addissie,
Abdulnasir Abagero, Mirgissa Kaba, Workeabeba Abebe, Berhanu Nega, Wondimu Ayele,
Wondwossen Amogne, Eva Johanna Kantelhardt, Tamrat Abebe.
Project administration: Zelalem Desalegn, Brhanu Teka, Welelta Shiferaw, Damen Hailemar-
iam, Abdulnasir Abagero, Mirgissa Kaba, Berhanu Nega, Wondwossen Amogne, Eva
Johanna Kantelhardt, Tamrat Abebe.
Resources: Zelalem Desalegn.
Supervision: Zelalem Desalegn, Brhanu Teka, Welelta Shiferaw, Adamu Addissie, Tewodros
Haile, Yirgu Gebrehiwot, Wondwossen Amogne, Eva Johanna Kantelhardt, Tamrat Abebe.
Validation: Zelalem Desalegn, Negussie Deyessa, Brhanu Teka, Welelta Shiferaw, Damen Hai-
lemariam, Adamu Addissie, Abdulnasir Abagero, Mirgissa Kaba, Workeabeba Abebe, Ber-
hanu Nega, Wondimu Ayele, Tewodros Haile, Yirgu Gebrehiwot, Wondwossen Amogne,
Eva Johanna Kantelhardt, Tamrat Abebe.
Visualization: Zelalem Desalegn, Brhanu Teka, Welelta Shiferaw, Damen Hailemariam,
Adamu Addissie, Abdulnasir Abagero, Mirgissa Kaba, Workeabeba Abebe, Berhanu Nega,
Wondimu Ayele, Tewodros Haile, Yirgu Gebrehiwot, Wondwossen Amogne, Eva Johanna
Kantelhardt, Tamrat Abebe.
Writing – original draft: Zelalem Desalegn, Brhanu Teka, Welelta Shiferaw, Abdulnasir Aba-
gero, Wondimu Ayele, Tamrat Abebe.
Writing – review & editing: Zelalem Desalegn, Negussie Deyessa, Brhanu Teka, Welelta Shi-
feraw, Damen Hailemariam, Adamu Addissie, Abdulnasir Abagero, Mirgissa Kaba, Work-
eabeba Abebe, Berhanu Nega, Wondimu Ayele, Tewodros Haile, Yirgu Gebrehiwot,
Wondwossen Amogne, Eva Johanna Kantelhardt, Tamrat Abebe.

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