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Knowledge, Attitude and Perceptions of Socio-ecological and Socio-anthropological Determinants of COVID-19 in Lusaka District of Zambia

Fri A. Fonchin*, Linda Basikolo, Simegnew A. Kallu, Henson Kainga, Jezreel Mwiinde, Vistorina Benhard

University of Zambia, Lusaka 10101, Zambia

Abstract: Background: The Corona Virus Disease of 2019 (COVID-19) was declared a disease of public health concern by the WHO in January 2020, one month after its emergent. Efforts have been made to raise and improve public awareness of COVID-19. Zambia has reported repeated waves of the COVID-19 pandemic with highest transmissions in Lusaka, the Copperbelt, and Ndola districts. Populations’ knowledge, attitude, and perceptions (KAPs) towards COVID-19 have impacts on control and prevention measures. Despite the collection of research on KAPs towards COVID-19, the KAP of socio-ecological and socio-anthropological determinants regarding the disease remains speculative. Hence, this study investigates KAPs of socio-ecological and socio-anthropological determinants of COVID-19 among the inhabitants of Lusaka district of Zambia. Methodology: A total of 301 inhabitants from four Lusaka District Compounds were sampled by a simple random method using a cross-sectional study design and interview-based questionnaires data collection method to investigate the KAPs of ecological and anthropological determinants of COVID-19. The analysis included descriptive statistics, chi-square analysis for associations between participants KAPs towards COVID-19, and finally, a multivariate logistic regression to determine KAP predictors. Findings/conclusion: Majority of study participants were females (54.5%). 53.2% of the respondents were in the age group of 18–28 years, and mostly (53.5%) single. 46.5% participants had tertiary level of education and (57.8%) had a monthly income of 0-K1000. The overall KAP knowledge was moderate (67.1%), and only 51.5% of participants demonstrated a positive attitude towards preventing COVID-19 infections. Socio-demographic factors had a weak bearing on KAP and attitude scores, with levels of education and gender being the only significant variables, respectively. This study indicates a poor understanding of COVID-19 with respect to ecological and anthropological determinants. Governments need to ensure more awareness campaigns to improve the populations’ KAPs towards future infectious diseases that may occur.

Keywords: anthropological, COVID-19, ecological, Lusaka

Received May 17, 2022; Revised June 21, 2022; Accepted June 30, 2022

Citation: Fri A. Fonchin, Linda Basikolo, Simegnew A. Kallu, Henson Kainga, Jezreel Mwiinde, Vistorina Benhard, Knowledge, Attitude and Perceptions of Socio-ecological and Socio-anthropological Determinants of COVID-19 in Lusaka District of Zambia. American Journal of Epidemiology and Infectious Disease, 10 (2). 40-49. January 2022. doi:10.12691/ajeid-10-2-1

1. Introduction

The Coronavirus disease of 2019 (COVID-19) is a global health threat which has caused a universal psychosocial impact on the general public [1] and has disrupted human lives globally. The disease which is of viral origin is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) [2]. COVID-19 has led to high morbidity and mortality, resulting to over 220,000,000 confirmed cases and 4,000,000 deaths globally as of September, 2021 [3]. Further, the pandemic affected the global economy with predicted revenue losses of about 810.7 billion United States Dollars in 2020 [4,5]. The pandemic generated immense spikes, with major uncertainties surrounding almost every aspect of the disease spread [6].

Evidently, COVID-19 has spread much faster in Africa, which only accounts for about 1.13% of the global COVID-19 cases than in other regions of the world [7]. Like other sub-Saharan African countries, Zambia has faced repeated waves of the disease, with an exceptional increase in cases [8], registering 80,687 positive cases and 1,109 deaths, as of March, 2021, representing one of the highest in Africa [3]. As COVID-19 spreads globally and around the nation of Zambia, several factors including environmental [9] and cultural factors [10] are responsible for the spread of the disease. Unfortunately, the association between infectious diseases and environmental factors, particularly in the case of communicable diseases, has not been clearly understood [11], and they have been less interest in the areas of anthropological dynamics and their effect on infectious disease pathogens [12].

In the realm of infectious diseases like the COVID-19, public awareness and perceptions are the key primary care factors and play a major role in preventing the spread of the disease, particularly in settings with poor infrastructure and healthcare systems like most low and middle income countries, where limited capacity is available to cater to disease outbreaks [12,14]. Unfortunately, several studies have noted the knowledge gap of infectious diseases awareness regarding environmental factors [15], and the non-compliance to the WHO's COVID-19 control measures, especially in Sub-Saharan Africa, have been attributed to ignorance and misinformation, thereby raising questions about people's KAPs towards COVID-19 pandemic [16]. Further, research shows a lack of a harmonized response to the COVID-19 risk, implying that the design and execution of control initiatives are based on the poor KAP gaps of various socio-demographic groups [17]. Hence this study assesses the KAPs of socio-ecological and socio-anthropological determinants of COVID-19 disease amongst the inhabitants of Lusaka District.

2. Materials and Methods

2.1. Conceptual Framework

This study adopted a KAP model approach which is a representative tool used to collect information from a specific population on what is known, believed, and done in relation to a specific field [17].

2.2. Study Design

The study employed a cross-sectional design using interview-based questionnaires to survey individuals’ knowledge, attitude and perceptions on social, ecological, and anthropological determinants of COVID-19 disease.

2.3. Study Population and Sample Size

The target populations were there inhabitants of Lusaka District of Zambia. Four compounds of this district were randomly selected for the study. These were; Kalingalinga, Mtendere, Chaisa, and Lilayi compounds.

The sample size for this study was calculated using Krejcie and Morgan, [18] sample size determination formula. The sampled number was distributed between the areas of study depending on the percentages each compound constitutes to the total district population.

Where is the required sample size

N is the given population size of the group under consideration (Lusaka District)

P is the estimated Prevalence/proportion of contamination

d² is the degree of accuracy

X² is 1.96 Confidence level

In this study N=1,747,152

Assumption: in an outbreak situation where the disease is infectious and spreading like the case of COVID-19, the degree of accuracy was 0.05, while the prevalence of possible infection was estimated at 0.5 (50%) of the total population (different for endemic diseases where the prevalence is likely to be known).

The selection of the 384 participants from the four study areas was distributed proportionately using the formula (X/N * 384).

N=sum of the total population of the four compounds chosen for the study (178527)

Calculated proportionately, 29, 43, 85, and 228 participants were the sample size for Lilayi, Chaisa, Kalingalinga, and Mtendere, respectively.

2.4. Inclusion Criteria

The participants of this study were individuals aged 18 years and above who had lived in the compounds of interest for the last 6 months (January–June 2021) prior to the study and were willing to participate.

2.5. Sampling Techniques

The participants for this study were selected by a simple random sampling based on the inclusion criteria. For each compound, the participants were recruited from a market setting in the community as this point was convenient to capture many participants in a short time space.

2.6. Variables of the Study

2.6.1. Independent Variables

The independent variables are Strata (origin of participants), age, gender, marital status, education levels and income levels. The choice of these variables was guided by the study of Khattak et al. [1].

2.6.2. Dependent Variables and Scoring

The dependent variables were “level of knowledge and perception” and attitude towards COVID-19. 15 questions on knowledge and perceptions were considered in this study, cutting across social, ecological and anthropological variables. Each correct answer in the knowledge/perceptions section was awarded 1 point. A score of (11-15) positives responses to the questions of knowledge and perception is represented by 1, implying good knowledge; (6-10) represented by 2 signifying average knowledge and (0-5) represented by 3 signifying poor knowledge. i.e., 1=good knowledge, 2=average knowledge and 3=poor knowledge. Adopted from Elshammaa et al. [19], overall, levels of knowledge and perceptions, and attitude, were classified in the following manner, i.e., high (above 80%), moderate (60% to 79%), and low (less than 60%).The choice of the ecological variables for this study was guided from prior the studies [11,20], and the anthropological variables were guided by Friedler [12].

To assess attitude, 05 questions are considered to characterize the attitude variable. The rating (3-5) is represented 1 signifying good attitude, and (0-2) is represented by 2, signifying poor attitude.

2.7. Data Collection Tools and Method

2.7.1. Data Collection Tool

The data collection instrument was an interview-based questionnaire constructed with guided information of possible ecological determinants of COVID-19 from existing literature [11,21] and anthropological determinants from the WHO’s cultural determinants of health [22]. The instrument was prepared in Microsoft word document in the English Language and Nyanja. The questionnaire consisted of five sections; respondents’ socio-demography characteristics, Knowledge and perception questions on possible social, ecological, and anthropological determinants of COVID-19, and questions on attitude towards the COVID-19 pandemic.

2.7.2. Data Collection Method

Two qualified data collectors were recruited together with the principal investigator. Only two enumerators were chosen to reduce or eliminate bias. The data collectors received one day of sufficient training about the purpose of the study and the data collection procedure. The data collectors were informed about all precautions to be followed during the data collection process, such as social distancing, wearing a facemask, and hand sanitizers. Before the interview, participants were well-informed about the study, and participation was based on the participants' consent. Participants who could read and write were allowed to fill out the questionnaire personally, with directives from the data collectors or principal investigator where necessary. The data collectors or principal investigators filled it out for those who could not read and write. The data collection period was from June 14th to June 18th, 2021.

2.8. Data Management and Analysis

The data obtained from this study was coded to represent the compounds of interest. The questionnaires were also coded to avoid identification. The raw data was established in Microsoft Excel, 2019. This data was identified for duplicates, incomplete and missing entries were excluded. The coded data was transported to STATA version 14.0, where the data analysis was done. The data was analyzed in three stages;

Step 1: Descriptive analysis of each variable in frequencies and percentages, thus describing the patterns within the data set.

Step 2: Chi-square analysis to measure association and hypothesized factors between “levels of knowledge and perceptions” and attitude towards COVID-19.

Step 3: Logistic regression analysis to determine the predictors of knowledge, perceptions, and attitude at multivariate levels.

2.9. Quality Control

• The liability analysis of the questionnaire was done on 20 participants of the University of Zambia community and the Cronbach`s alpha coefficient of 0.76 indicating the internal consistency and reliability of the study instrument.

• The principal investigator kept in touch with the data collector to regularly check the process of the data collection till the end of the study.

2.10. Ethical Consideration

Ethical approval for this study was sought from the Excellence in Research Ethics and Science (ERES) CONVERGE IRB (ref No. 2021-June-09). A further approval letter was obtained from the Lusaka Health District Authority. Authorization to enter health facilities was obtained from the person in charge of each health facility included in the study. Participants' consent was sought, the participants' identities were withheld, and the information collected from participants was used only for research purposes

3. Results

3.1. Socio-demographic Characteristics of Participants

A total of 301 individuals participated in this study (Table 1), as outlined below with the demographic characteristics of the participants.

Moderately, more female participants were recruited at 54.5% compared to their male counterparts at 45.5%. The most frequent age range of the participants was between 18 and 28 years old, representing 53.2% of the respondents. With regards to marital status, 53.5% of the participants were single. Regarding educational status, 46.5% of the participants had attained or were still in college. Of the participants enumerated, 34.8% were unemployed while 58.0% had a monthly income of between K0 and K1000 (Table 1).

Table 1. Socio-demographic characteristics of study participants

All participants, 100%, had heard of COVID-19. The majority, 92.7% (95% CI: 89.7, 95.6),of the participants considered COVID-19 a severe disease with disruptive aspects of social life (Table 2). The majority [(58.1%) (95% CI: 52.5, 63.7)], primary source of information was social media (internet, Facebook). Over seventy percent of the participants [73.4% (95% CI: 68.4, 78.4)] acknowledged crowded places as media for the spread of COVID-19 disease, with 72.4% (95% CI: 67.2, 77.5) agreeing that COVID-19 is an airborne disease. Affirmative action’s of hand-washing, social distancing, and masking were recognized as key in reducing the spread of COVID-19 in communities by 71.4% (95% CI: 66.3, 76.6) of the participants (Table 2).

Table 2. Knowledge and perceptions of possible social factors determinants of COVID-19

Of the 301 participants involved in the study, 53.8% (95% CI: 48.2, 59.5) affirmed that the COVID-19 virus spreads more in colder climates or cold weather, and 68.1% (95% CI: 62.8, 73.4) of participants acknowledged sunlight has a role in deterring the spread of COVID-19 disease. A majority of the participants, 59.5% (95% CI: 54.0, 65.0), were of the opinion that environmental/air pollution does not affect the spread of COVID-19 disease, and 63.1% (95% CI: 57.6, 68.6) of the participants acknowledged that COVID-19 disease would spread faster in areas of high population density. When it came to the knowledge of deterrent factors for COVID-19, only 44.5% (95% CI: 38.8, 50.2) of participants affirmatively responded to opening the windows in a house to allow airflow as an aid in avoiding the spread of COVID-19. A majority of the study participants agreed that public transportation affects the spread of COVID-19 disease (Table 3).

Table 3. Knowledge and perceptions of possible ecological determinants of COVID-19 disease

With regards to hand hygienic practices, 63.5% (95% CI: 58.0, 69.0) of participants acknowledged that hand hygiene was not a common practice in the communities before the onset of COVID-19 disease, and over 80% of participants [(81.3% (95% CI: 76.3, 85.2)] believed that COVID-19 disease was real, and 53.5% (95% CI: 48.0, 59.2) affirmed that handshakes were still a common form of greeting practice in the communities despite understanding their role in COVID-19 transmission. Nearly 80% of participants [(76.0% (95% CI: 70.9, 80.6)] agreed that individual lifestyles exhibited by communities were more likely to promote the spread of COVID-19 (Table 4).

Table 4. Knowledge and perceptions of possible anthropological determinants of COVID-19 disease

More than sixty percent of participants [(61.8%) (95% CI: 56.3, 67.3)] still found themselves in crowded places for day-to-day activities despite the COVID-19 pandemic. Only 60.1% (95% CI: 54.6, 65.7) of participants attested that hand hygienic practices are more common amid the COVID-19 pandemic, and a small proportion [15.3% (95% CI: 8.0, 16.8)] of participants affirmatively agreed to use manner of greetings that can enhance the spread of COVID-19 in the communities amid the pandemic. Social activities such as markets, churches, and family gatherings were still ongoing in these communities amid the COVID-19 pandemic, with 30.1% (95% CI 25.6, 36.2) and 25.0% (95% CI: 20.0, 30.3) of participants acknowledging market and family gatherings as being the most common activities in the communities, respectively. Regarding being vaccinated against COVID-19, only 49.4% (95% CI: 43.2, 55.1) of participants affirmed the need for vaccinations (Table 5).

Table 5. Attitude towards COVID-19 disease

In terms of the influence on attitude by the knowledge and perceptions levels, the finds show that 88 (29.2 %) of participants were of good knowledge and good attitude. A Majority [61.1 % (184)] of them had good levels of knowledge and perceptions of how social, ecological and anthropological factors influence COVID-19 but were of a poor attitude towards COVID-19 (Table 6). Overall, there was no significant statistical association between levels of knowledge and perception and attitude towards COVID-19 (p=0.066).

Table 6. Influence of knowledge and perception on attitude Level of Knowledge

The multi-logistic regression analysis showed that participants levels of education (p=0.001) was statistically significant to their levels of knowledge and perceptions, with more [133 (44.2 %)] participants of higher education levels being of good knowledge and perceptions (Table 7). Further, gender [OR 1.5 (95% CI: 0.89, 2.42)] and levels of education [0R 1.2 (95% CI; 0.90, 1.50)] were slightly significant predictors to participants attitude towards COVID-19. More females were of both of good [60(20.0%)] and poor attitude [104(34.6 %] than their male counterparts, likewise more participants of higher levels of education were of both good [43(15.0 %)] and poor [97(32.2 %)] attitude (Table 8).

Table 7. Multivariate Logistic Regression of predictors of Knowledge and Perceptions

Table 8. Multivariate Logistic Regression of Predictors of Attitude towards COVID-19

4. Discussions

The outcomes of this study have been able to elaborate on the knowledge, attitudes, and perceptions of the possible socio-ecological and socio-anthropological determinants amongst the inhabitants of the Lusaka District of Zambia. Overall, this study found a moderate response (67.1%) of participants' knowledge and perceptions to social, ecological, and anthropological determinants of COVID-19, which is relatively low compared to the 90% of respondents' knowledge of COVID-19 demonstrated by other studies [23,24]. This means an estimated 33 people out of 100 (32.9%) inhabitants of the Lusaka district had poor knowledge and perceptions about these deterministic factors of COVID-19. This is consistent with Akalu, Ayelign, and Molla [21], who identified a high proportion of illiteracy for a pandemic disease such as COVID-19.

Specifically, in this study, the participants demonstrated a moderate understanding with regards to the social determinants of COVID-19 at 78.0%. Regarding ecological determinants, a relatively low proportion of understanding was registered at 54.8%. A moderate response of 68.6% was registered with regard to anthropological determinants. Few or no studies specifically took these three factors into perspective when assessing KAP determinants linked to COVID-19 occurrence. Most studies looked at one or more variables linked to these factors in isolation [25,26]. Access to well-packaged information is very vital in the case of a pandemic like COVID-19. A majority of participants had access to COVID-19 information from social media platforms, a result that is in line with an earlier study by Elshammaa et al. [19]. The relatively high proportion of young people in this current study could have partly been the reason for the frequent usage of social media platforms as a common source of COVID-19 information. Meanwhile, a cumulative 20% of participants got information from local health campaigns and billboards, and mostly, these were the older age range of the respondents. Further, in agreement with Akalu Ayelign, and Molla [21], most of the study participants acknowledged crowded places as a risk factor for COVID-19 infection. Earlier studies highlighted that crowded places were super spreader events (SSEs) [27,28]

Our present study only found a 51.1% overall score for participants' attitude towards COVID-19, which is contrary to another study [1], that found more than 90% positive attitude by participants towards COVID-19. This is relatively low despite the moderate (67.1%) by participants' responses on knowledge and perceptions. This low attitude performance could result from public familiarization with the existence of COVID-19, which has led to negligence in adhering to COVID-19 control measures. For instance, a larger proportion of the participants in this study found themselves in crowded places amid the COVID-19 pandemic, despite 73.4% acknowledging that crowded places were the medium of spread for the disease. This might have resulted from individuals being tired of staying home due to COVID-19 lockdowns and the low socio-economic status of most participants which will cause people jump out at every opportunity to make money. This can be seen from the majority of respondents who attested to market gatherings as the most common activity in their communities amid the pandemic. Notably, in disagreement with Tahir et al [29], who found an overall positive attitude towards COVID-19 vaccination, in this present study, only 49.4% of the participants were willing to be vaccinated against COVID-19, despite the 92.7% of participants who perceived COVID-19 as a serious disease with disruptive effects. This poor attitude towards the COVID-19 vaccine may have resulted from the rumors and side-effects surrounding the vaccine, which could have created fear in the minds of the population. Further, contrary to another study [30],that found a moderate-frequency hand-hygienic practice response rate in their study, this study found a low response rate to hand-hygienic practices amid the pandemic.

For an infectious disease like COVID-19 to be eradicated, it is highly dependent on the population's understanding of the risks of the disease and their attitude towards the disease. Unfortunately, this study found that the level of participants' knowledge and perceptions of the deterministic factors considered had no influence on their attitude towards the disease. These results disagree with Gao et al. [31], who showed that higher levels of adherence to COVID-19 control measures were highly significant with respect to the level of COVID-19 knowledge displayed by participants. The low attitude score and the insignificant relationship between the levels of knowledge and perception and the attitude towards COVID-19 displayed by the participants in this study indicate gaps in the translation of knowledge and perceptions into positive attitudes. These deficiencies in the KAP gaps are of concern since young people constitute a larger proportion of the population.

Knowledge and perception levels of the socio-ecological and socio-anthropological determinants of COVID-19 varied across different socio-demographic determinants, with levels of education being the only significant variable. These results agree with Al-Hanawi et al. [32], who found levels of education as a significant predictor of respondents' knowledge of COVID-19. The level of education attained, reflected in part, the amount of knowledge and perceptions linked to the majority of the participants' tertiary education, was seen to be higher. Further, the present study results found gender and level of education as significant predictors for attitudes towards COVID-19. These results are in conformity with other KAPs studies which showed a strong relationship between gender and attitude towards COVID-19 [17] and, an association between education and attitude towards COVID-19 [33].

The study showed some strength, which includes the following: Firstly, to the best of our understanding, this study is the first to investigate the COVID-19 KAP gaps specifically with respect to ecological and anthropological determinants. Secondly, the population mix in this study, involving individuals from all social backgrounds, is representative of the constituency of Lusaka District, and thirdly, this research was field-based. However, this study had several limitations, including the following: first, except for the strata sampling, sampling across other demographic variables was not done proportionately. This may have created a bias in the results.

5. Conclusion

The COVID-19 pandemic has continued to cause havoc on lives and livelihoods worldwide. Numerous factors are responsible for the spread of the disease, and these factors apply to varying extents in different contexts. While social and economic factors have been outlined as predominant contributors to the increased risk of COVID-19 infections, ecological and anthropological factors also control the infection risk.

This study provides insight into the Lusaka District population’s knowledge, attitudes, and perceptions regarding socio-ecological and socio-anthropological determinants of COVID-19 disease. Overall, most of the participants in this study had moderate knowledge and perceptions of these COVID-19 deterministic factors and low attitude performance towards preventing the disease.

A comprehensive understanding of the KAP gap with respect to the determinants of COVID-19 is crucial to avoid Africa from being the next epicenter of the pandemic. Our study contributes to the global efforts to capture KAP evidence with respect to ecological and anthropological determinants of COVID-19 disease.

6. Recommendations

Improving the KAP towards reducing the COVID-19 infection risk will ultimately serve the entire population. For the population to adequately follow standard infection control measures, the government needs to identify and strengthen the population's capacity with respect to the KAP gaps.

The data collection for this study took place in the midst of the COVID-19 pandemic outbreak, meaning that the prompt response by participants may be helpful to authorities in planning preventive strategies for future events.

We recommend the implementation of infection control programs that can be immediately achieved. These will include: operating effective television and radio programs on infectious disease control with well-guided information, adding infectious disease prevention as a curriculum into school programs, training more competent health educators and health promotion officers.

Further, we recommend a more nuanced and updated understanding of vaccines to improve and change participants' perceptions of the efficacy of current COVID-19 vaccines and encourage most of the population to enroll for the vaccines.

We have also highlighted gaps in this current evidence-based study. We recommend similar studies be conducted in different areas to provide more evidence for governments and populations' interests for further research.

Acknowledgments

The authors acknowledge the inhabitants of the Mtendere, Kalingalinga, Chaisa and Lilayi communities for providing the information that was used to put this manuscript together. We further acknowledge the data collectors for their patience in the process of data collection.

Conflict of Interest Statement

The authors of this paper declare that, they do not have any financial or personal relationship with other people or organizations that could inappropriately influence or bias the content of this paper. Therefore, the authors declare to have no competing interests.

Authors Contribution

All authors made substantial contributions in revising the manuscript critically for important intellectual content; agreed to submit it to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

AFF, SAK, LB, VB and HK developed the proposal for this study

AFF, SAK, and LB participated in data collection for this study

HK, SAK and JM did data entry, cleaning, analyzed and interpreted the data

VB and JM put together the first draft of the manuscript, proof reading and editing.

Funding

The research was supported by the African Center of Excellence for Infectious Disease of Humans and Animals (ACEIDHA) (grant number P151847) funded by the World Bank.

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