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COVID-19 Knowledge, Attitudes, and Prevention Practices Among People with Hypertension and Diabetes Mellitus Attending Public Health Facilities in Ambo, Ethiopia

Background To confirm effective preventive practice and reduce the risk of COVID-19 data on knowledge, attitude, and preventive practices (KAP) are essential. Therefore, the current study was designed to evaluate the KAP of COVID-19 among people with hypertension (HTN) and/or diabetes mellitus (DM) attending public health facilities in Ambo town. Patients and Methods Institutional-based cross-sectional study design was done among patients with HTN and/or DM from June 2020 to September 2020 at Ambo University Referral Hospital (AURH) and Ambo General Hospital (AGH). To identify the associated factors with poor practice and knowledge, logistic regression analyses were used. Results The mean age of the study respondents was 44.6 years (± 9.84) of which the majority were male 235 (55.6%) and 159 (37.59%) of the participants had good knowledge. Concerning attitude, 335 (79.2%) have strongly believed that DM and HTN patients were more at risk of death because of COVID-19. Only 44 (10.4%) of them had a good level of COVID-19 prevention practice measures. Patients who use the source of information daily were 54.4% less likely to have poor knowledge about COVID-19 than those who use it weekly. Participants with no formal education were 3 times more likely to have poor COVID-19 prevention practice than those who were with formal education, and participants who have poor knowledge about COVID-19 were 2 times more likely to have poor COVID-19 prevention practice than those who have knowledge. Conclusion The prevalence of poor knowledge about COVID-19 was low, and only less than ¾ of the participants strongly believed COVID-19 as a serious disease. A small percentage of participants had a good level of COVID-19 prevention practice. Good knowledge had an association with a good level of prevention practice. So, health sectors should work to increase accessibility of COVID-19 information.


Introduction
spreading. As of August 27, 2020, 1236 new cases and a total of 40,407 cases as well as 745 deaths were reported. 3 The transmission of COVID-19 is thought to happen mostly through respiratory droplets. During individual coughs, sneezes, or talks the virus released within the respiratory secretions can infect another person if it makes direct contact with the mucous membranes. Another mode of viral transmission is when a person touches a contaminated surface with the virus and then touches her or his nose, mouth, and eyes. 4 The time between exposure to COVID-19 and onset of the symptom for COVID-19 is supposed to be in 14 days, with most cases happening approximately five to six days after exposure. 5 COVID-19 is one of the top reasons for cardiovascular disease, which can cause myocarditis, heart failure, pericarditis, and cardiac conduction defects. 6 Furthermore, in patients with a history of cardiovascular diseases, COVID-19 can cause a change in the progress of the underlying disease and rising mortality. 7 Increase in blood glucose levels can lead to the destruction of immune systems of individuals and results in a decrease in the abilities to fight different types of infections, such as COVID-19; accordingly, the virus can cause more abnormalities to the body. 8 The study conducted in China revealed that patients with cardiovascular disease have a high risk of severe COVID-19 infection. A large observational report, which was conducted on 1099 patients with COVID-19 showed that out of 173 patients with severe disease were with comorbidities of hypertension (23.7%) and DM (16.2%). 9 Another study which recruited 52 severe COVID-19 patients indicated that out of 32 non-survived patients, 7 (22%) were DM patients. 10 Thus, to minimize the risk of transmission, communities are required to follow accepted infection control practices such as frequent hand washing using soap, hand rubbing with an alcohol-based sanitizer, social distancing, awareness of the symptom frequently, wearing the mask in the community, and practicing respiratory hygiene. 11 To confirm effective protective practice and reduce the risk of COVID-19 data on knowledge, attitude, and preventive practices (KAP) are essential. This data would be important in providing the required approaches to be implemented to contain the spread of the virus. Additionally, the funding of the study would improve and assess the currently available programs to enhance attitudinal changes. Furthermore, behavioral changes and positive attitude mainly depend on the level of perceptions and knowledge towards preventive practices of COVID-19. Therefore, this study was designed to assess the knowledge, attitude, and prevention practices of COVID-19 among patients of HTN and DM attending Public health facilities in Ambo town, West Shoa zone, Oromia, Ethiopia.

Study Design, Setting, and Population
The multi-center institution-based cross-sectional study was conducted in Ambo town at AURH and AGH from June 2020 to September 2020. Ambo is 112 Km away to the west from the capital city Addis Ababa. All patients with HTN and/or DM who come consecutively to the chronic care clinics during the data collection period were enrolled in this study. All patients with HTN and/or DM greater than or equal to age 18 years on follow-up and newly diagnosed and gave consent to participate were included in the study and patients with a severe and uncorrectable cognitive, visual, or hearing impairment were excluded from the study.

Sample Size, Sampling Techniques, and Procedure
The sample size was calculated by a single population proportion formula Z α 2 2 � � � P 1À P ð Þ d 2 with the assumption, 95% confidence interval (Zα/2 = 1.96), 5% of marginal error (d), 10% non-response rate, 50% proportion (p) level since there is no published data during the initiation of this research that show the KAP toward COVID-19 among patients with HTN and/or DM in Ethiopia and then maximum sample size was considered for the current study.
The calculated sample size of this study was 423 respondents and this was allocated to each hospital proportionally. Finally, a consecutive sampling technique was used to collect the data from study participants.

Data Collection Tools
The initial draft of the study tool was developed by reviewing previously published similar studies, 12,13 and finalized in two steps. Accordingly, the developed tool was reviewed by senior researcher and professional through invitation by Ambo University's research and community service vice president and followed by a pilot submit your manuscript | www.dovepress.com

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Infection and Drug Resistance 2020:13 4204 study conducted at another health facility having similar having demographic features. Then the necessary modifications were done based on the findings and incorporated to finalize the questionnaire. The initial questionnaire was prepared in English and converted into Afaan Oromo language by a professional expert and the data were conducted in the Afaan Oromo language. The questionnaire contains socio-demographic characteristics of study participants, 26 questions assessing knowledge answered as yes, no or "I don't know" option. An incorrect or I do not know the answer was given 0 points and the correct answer was assigned 1 point. Respondents' overall knowledge was classified as good, moderate, and poor if the score was between 80% and 100% (20.8-26 points), 60% and 79% (15.6-20.5 points), and less than 60% (<15.6 points) respectively, using Bloom's cut-off point. In the attitudes part, 11 questions assessing attitude were used and the first negative questions were transformed into a positive question. Then, scores were scored based on the participants'' response to each statement as, 1 = certainly not, 2 = probably not, 3 = probably yes, and 4= Most certainly. Total scores ranged from 11 to 44, with high scores indicating positive attitudes. Likewise, 17 questions assessing preventive practice were responded as "yes or no"; 1 point for the correct answer and 0 points for the incorrect answer was given. Respondents' overall practice was classified as good, moderate, and poor if the score was between 80% and 100% (13.6-17 points), 60% and 79% (10.2-13.6 points), and less than 60% (<10.2 points) respectively, using Bloom's cut-off point. The training was provided for data collectors ahead of data collection. Eight BSc health professionals collected the data by using appropriate personal protective materials like a surgical face mask, glove, and washing their hands with alcoholbased hand sanitizer, and standing around 2 meters away from the participant.

Processing and Analysis of Data
Before entering into a statistical package for social sciences (SPSS) version 20 for analysis, data were cleaned and checked for completeness. Then, the data were analyzed descriptive statistics to summarize the knowledge, attitude, and prevention practice of the participants toward COVID-19 and presented by percentage (%) frequency and mean ± SD. Outlier and multi-collinearity were also checked. Logistic regression analyses were used to identify potential associated factors of poor knowledge and poor practice. The independent variables in bivariate analysis with p < 0.25 were considered and entered into multivariable logistic regression. The strength of the association of risk factors was established by calculating the crude odds ratio (COR) and the adjusted odds ratio (AOR) with a 95% confidence interval (CI). Lastly, the results were presented in the graphical and tabular form. The significance level with P-value less than 0.05 was considered as statistically significant for this study purpose.

Ethical Consideration
The study was planned and accompanied following the ethical principles established by Ambo University. A letter of ethical approval was obtained from the Ethical Review Board of Ambo University with Ref. No AU/937/2/18/12. Written informed consent was obtained from respondents who participated in the study. All the information was kept confidential and the study was done as per the ethical guidelines of the Declaration of Helsinki.

Socio-Demographic Characteristics of the Study Participants
In this study, a total of 423 people living with HTN and/or DM participated in a response rate of 100%. The mean (±SD) age of the study respondents was 44.6 years (± 9.84) of which the majority were male 235 (55.6%). The majority of the participant's religion was orthodox 199 (47.0%) followed by protestant 190 (44.9%) and most of them resided in urban. Among the total study respondents, around 338 (79.9%) were married. Concerning the educational level of the respondents, 112 (26.5%) was learned from grades 7-12. Regarding the types of disease of the study participants, 227 (53.7%) were hypertensive while 59 (13.9%) of the study participants were both diabetic and hypertensive. Additionally, chi-square test was used for each domain score of the study participants were categorized into 3 categories: good, fair and poor. The results of this categorization are shown (Table 1).

Knowledge About COVID-19 Among HTN and DM Patients
In this study, 266 (62.9) study respondents stated that COVID-19 have no specific effective treatment and vaccine. The majority of 416 (98.3) of the study respondents reported that Covid-19 is a contiguous disease. About 338 (79.9%) of the respondents indicated that they were conscious of the incubation period of the diseases as 2 to 14 days to observe the sign and symptoms of the person infected with the virus. About 268 (63.4%) of study respondents distinguished that as COVID-19 is caused by a virus and also having information of symptoms including cough, fever, headache, and sore throat by 380 (89.8%), 371 (87.7%), 247 (58.4%), 194 (45.9%) respondents, respectively. Moreover, the majority of participants 355 (83.9%) knew COVID-19 can be spread directly through cough from infected people, and reported potentially the disease is more dangerous in HTN and DM patients by 385 (91%) and 370 (87.5%), respectively. Besides, 268 (63.4%) of respondents knew that people with age group >50 years old are at a higher risk of severe disease and death as shown in ( Table 2).

The Overall Level of Knowledge About COVID-19 Among HTN and DM Patients
Analysis of the data collected showed that the prevalence of poor knowledge about COVID-19 among the study participants was 31.44% whereas the prevalence of good and moderate knowledge were 37.59% and 30.97%, respectively, together consisting about 68.66% of good knowledge of COVID-when compared to those with poor knowledge (Figure 1).

An Attitude About COVID-19 Among HTN and DM Patients
The majority of participants 288 (68.1%) strongly agreed that COVID-19 is a cause for serious illness, while 87 (20.6%) agree that COVID-19 is a curable disease. Two hundred twenty-seven (53.7%) participants reported that the probability of getting COVID-19 is high. The majority of 306 (72.3%) of the study participants highly agreed early detection of COVID-19 can improve treatment outcomes. COVID-19 disease results in death in cases and COVID-19 disease can be transmitted through household pets to humans were considered not agreed by 201 (47.5%) and 195 (46.1%) respondents, respectively (Table 3).

Overall COVID-19 Preventive Practice
Analysis of the data collected showed that the prevalence of poor COVID-19 preventive practice among the study participants was 45.39% whereas the prevalence of good practice was 10.40% ( Figure 1).

Discussion
For a disease like COVID-19, protecting self and others rely on obeying with the recommended protocols. However, study assessing KAP regarding COVID-19 in selective disease populations (risk groups), like the current  The knowledge, attitude, and prevention practice toward COVID-19 is an important issue because studies reported as they have to have health impact on COVID-19. 14- 16 We had intentionally excluded children and adolescents less   17 The similarity could be due to the uniformity of the study population as both types of research focused on the patient with chronic diseases. The high proportion of correct answer to knowledge-related questions among the respondents may be due to the characteristics like they gained awareness and knowledge about the disease and its transmission, via social media, radios and television news, and educational level as more than 50% had got a formal education in different levels. The positive association found between knowledge, and educational background, and access to a source of information supports our claim. However, the funding was lower than the study conducted in China among health care workers in which the knowledge of HCW towards COVID-19 prevention was high (89%). 18 And in Pakistan in which the knowledge towards COVID-19 prevention was 92.3%. 19 This discrepancy could be due to the difference in the study population. These previous studies were conducted among health professionals to assess their knowledge level, but the current study is conducted among the general population with different educational levels. This is because health professional has more exposure to the information regarding the disease. Being a public servant, hearing COVID-19 information through social media, using the source of information (media) daily was reported to have a smaller risk of poor COVID-19 knowledge when compared with their counterparts. This might be because of getting information through different meetings and media for the former and DovePress widespread airing of COVID-19 information through media for the latter two factors. In contrast to this, the Web-based study done in India among DM patients has shown that being urban residence had a statistically significant association with better knowledge. 20 The present study has also shown indifference with the studies done in Vietnam and of the Kingdom of Saudi Arabia which have shown being male to have an association with lesser knowledge. 21,22 This study has shown similarity as it has shown a significant decrease of knowledge with a 1-year increase in age as reported with the very similar study conducted among chronic patients in Addis Zeman hospital, North West part of Ethiopia, which has revealed age, illiteracy, rural resident and lower to have a significant association with poor knowledge too. 23 A study conducted in Pakistan among 242 patients with DM found that only 78.5% of the participants were aware of the modes of transmission of COVID-19. 24 In this study, it was found that 83.9% and 77.5% of the participants state that COVID-19 spreads via cough and sneeze, respectively. However, many participants (54.1%) were not aware of the fact that sore throat is a symptom of COVID-19. Similarly, as many as 68.3% of the respondents were not aware of the fact that body pain a symptom of COVID-19, even though, they are at an increased risk of severe disease and mortality from COVID-19. It is thus necessary that health education programs for people with HTN and DM need more emphasis on these aspects while imparting awareness about COVID-19.
Concerning attitude, 79.2% of the participants strongly believed that DM and hypertensive patients were more at risk of death because of COVID-19, and 68.1% of the participants have strongly agreed with the idea, COVID-19 can cause serious illness and health education could help to prevent the disease as well. About 335 (79.2%) of the respondent believes that a patient with a chronic disease like HTN, DM, and others are more vulnerable to the effect of COVID-19 than other people. Approximately 306 (72.3%) mostly agree that that early diagnosis of COVID-19 can enhance treatment outcomes and 288 (68.1%) believed that health education can help in the prevention of COVID-19 spreading. Furthermore, 280 (66.2%) are agreed Ethiopian government should quarantine patients with COVID-19 in a special quarantine center. These Positive attitudes help control and COVID-19 spread, to safeguard citizens and ensure their well-being. Very few numbers of the participants strongly agreed with the statement, which says COVID-19 will result in death and being able to carry out prevention measures set by the authority with 2.1% and 0.2%, respectively. Similarly, only 10.4%, of participants had a good level of COVID-19 prevention practice measures.
The number of participants with good knowledge, favorable attitude, and good COVID-19 prevention practices in this study is lower when compared with the results of the study done in Jeddah, Nigeria, Malaysia, and Saudi Arabia, the main reasons of which were; those done in Jeddah and China was among medical students, 25,26 and the one in Nigeria was among trained correctional officers, 27 who would have gotten better opportunity to access information's from both formal and informal sources and the first outbreak of the disease in Asian countries. 21,27,28 Similarly, the percentage of participants with good knowledge in the present study is lower when compared with even the study done in Ethiopia within which data were collected over Facebook with the probable reason for getting better access to online disseminated pieces of information for the participants. Unfortunately practicing prevention measures was very low as in this study too. 29 The problem might be negligence among our society, which might have developed because of the lesser report in the number of COVID-19 positive patients during the first four months.
The prevalence of poor practice to prevent COVID-19 spread in this study was high. This finding is relatively consistent with that of the cross-sectional study conducted among patients with chronic medical conditions in Addis Ababa. 17 However, this finding is not consistent with that of the studies in Iran. 30 The possible reason for this difference might be due to a difference in sources of information, frequency of media exposure, knowledge, and concern related to the outbreak of the disease by study participants which lead to the variation in the implementation of recommended actions and behaviors to prevent COVID-19. In the present study, there is a direct relationship between the knowledge and preventive practice of the study participants. Similar to this finding, a study in Ethiopia showed that a higher level of education was associated with high practice scores. 17 This may be because as an individual gets more educated, it will create an opportunity to acquire more information about COVID-19 prevention methods in many ways and will practice accordingly. Additionally, when someone gets more educated there will be a better understanding of control measures and preventive strategies related to COVID-19, and the ability to implement practice methods to protect COVID-19 spread will increase. Furthermore, submit your manuscript | www.dovepress.com

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Infection and Drug Resistance 2020:13 education results in better information collection habit and lead to efficient use of health inputs for prevention of COVID-19. 17 Our study multivariate logistic regression analysis showed that those patients with no formal education, who have poor knowledge about COVID-19, who used sources of information less frequently (weekly) were more likely to have poor COVID-19 prevention practice. This portrayed a positive correlation between knowledge and practice as shown with the other study done in Ethiopia. 23 The present study used face to face data collection methods rather than online Google form questionnaires. This could help to address part of the population who do not use the internet and were excluded from previous studies mentioned in this paper. Besides, the current study was conducted in the two hospitals in Ambo town and it could show the real picture of HTN and DM patients in the town. The limitation of this study was the study did not include admitted patients with these diseases and other risky patients with a chronic illness like other cardiac disease and respiratory disease.
Generally, in the present study, the individuals' knowledge on COVID-19 prevention was positively and significantly correlated with their practice. The findings showed that the improvement of people's knowledge on COVID-19 can increase their prevention for the disease and poor practices in this study might be primarily attributed to the lack of strict prevention and control measures implemented by government, such as enforcing peoples to wear a mask and prohibition public gatherings.

Conclusion
The prevalence of poor knowledge about COVID-19 among the study participants was very low. Daily usage of information sources had a positive impact to have good knowledge. Only less than three fourth of the participants believe COVID-19 as a serious disease. A very little number of participants had a good level of COVID-19 prevention practice. Good knowledge had an association with a good level of prevention practice. Those patients with no formal education; who had poor knowledge about COVID-19; who used sources of information less frequently (weekly) had a greater risk for the poor level of prevention practice. So the government, university, and hospitals should work to make intensive accessibility of COVID-19 information I with a special focus for patients with no formal education and have a greater risk for COVID-19 mortality like DM and Hypertensive patients.