Assessing Knowledge, Attitude and Practices (KAP) Towards COVID-19: A Cross-sectional Study in Kenya

: COVID-19 is a severe acute respiratory disease that has rapidly spread across the world from the first case that was reported in China in December 2019. The main symptoms of a person infected with corona virus are fever, dry cough, shortness of breath, fatigue, dyspnea and myalgia. One of the main tool employed to control the pandemic is providing the community with correct information about the disease. High knowledge, right attitude towards COVID-19 and are adhering to suggested practices is the most effective approach to control community transmission. It is against this background that this study sought to assess COVID-19 knowledge, attitude and practices (KAP) among Kenyans. An online cross-section survey was used to collect data between July 26-31, 2020. From the findings, 9.1% of the respondents indicated that their relatives, friends or themselves had contracted COVID-19. There is high knowledge of COVID-19 in Kenya, with 83.97% (82.4, 85.54) aware of its symptoms and preventative measures. With regard to containment of the disease, 55% are optimistic than measures instituted by Kenyan government will eventually control its spread. Daily MoH briefing (56%) and mainstream media (55%) are the main and trusted sources of information about COVID-19. Despite, most persons indicating they wore mask and washed hands while in crowded place, 60% indicated other people were not observing the measures. Gender, age group, education level and occupation influence the COVID-19 knowledge level.


Background
The COVID-19 (coronavirus disease) is a severe acute respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that was first reported in Wuhan city, China in December 2019.Rapid transmission is mainly through close contact with an infected person [18].However, details about the disease are continuously evolving and, as such, infections may be occurring through other routes.The main symptoms of a person infected with corona virus are fever, dry cough, shortness of breath, fatigue, dyspnea and myalgia.[2,5,18] Since the first case in December 2019, the disease spread widely and speedily to other parts of the world.It spread to over 200 countries and was declared a global pandemic by World Health Organization (WHO) on March 11, 2020 [3].
By the end of July 2020, there were more than 17 million positive cases recorded, with at least 670, 000 deaths globally.
In Kenya, the Ministry of Health (MoH) confirmed the first corona virus case on March 12, 2020.In the same month, President Uhuru Kenyatta directed the implementation of preventative measures to reduce human-to-human transmission.These measures included restriction of international travels from and to countries with corona virus cases, closure of learning institutions, working from home except for essential services personnel, insistence on cashless transactions, and prohibition of congressional meetings, among others.
In the beginning of May 2020, WHO detected high and large-scale community transmission in many African countries.WHO advised respective governments to institute measures to curb human-to human transmissions.Due to community transmission, global and local experts projected A Cross-sectional Study in Kenya over 2 million deaths from the pandemic in Sub-Saharan countries in the worst-case scenario of unmitigated spread of the virus [1].This necessitated the Kenyan government to institute movement restrictions -cessation of movement-in areas which the MoH considered to be infection hotspots (Nairobi, Mombasa and Kilifi).In addition, nationwide curfew from 7.00 p.m to 5.00 a.m countrywide was declared to limit human movements and interactions.
Despite the containment measures put in place, the number of COVID-19 cases and deaths have steadily increased with over 19, 000 positive cases and 300 deaths by the end of July 2020.Earlier, on July 6, President Uhuru Kenyatta lifted the cessation of movement in the said COVID-19 hotspots.As a result, the Ministry of Health initiated a campaign to promote personal and public health behavior, such as regular hand washing and observing social distance in crowded places.Despite many achievements from this approach, the challenge of misinformation, mainly in form of promotion of unscrupulous COVID-19 treatments and ineffective preventative methods on social media (Facebook, WhatsApp, Instagram, Twitter among others), have presented a serious hurdle to the fight against the spread of the virus [7,11,12,15].
The knowledge, attitude and practices (KAP) towards COVID-19 disease largely determine the preparedness of Kenya to concede behavioral change advocated by Ministry of Health.KAP studies provides the foundation for interventions required to correct misinformation and misconceptions about COVID-19.Therefore, evaluating the knowledge, attitude and practices about the disease among Kenyans would be a better basis for providing insights to improve awareness and help in the development of preventative strategies and programs.The lessons from SARS outbreak is that knowledge and attitude towards an outbreak determines the level of panic and emotion, which can consequently affect and complicate containment strategies [7,12,15].This study will provide a community's status with regard to COVID-19 knowledge, attitude and practices among Kenyans.In addition, the findings of this study will help the government to develop strategies to improve public and personal hygiene in the community.

Study Design
A quantitative approach was employed to achieve the objective of the study.A survey was used as a means of collecting data due to its many advantages including high accessibility to a large population [14].A cross-sectional study using data collected through an online self-reported questionnaire seemed appropriate to collect data in the current context of restricted movements.To assess the level and association with social factors of COVID-19 knowledge, attitude and practices among Kenyans, descriptive statistics (percentages and means) and multivariate regression were employed.

Data Collection
The cross-sectional survey was undertaken between July 26-31, 2020.Since it is not feasible to undertake nationwide sampling during this period, the research opted to use an online survey using Google Form, where only persons above the age of 18 years were eligible to participate.The numerous shortcomings encountered with internet-mediated survey were high non-response rate and inaccessibility by a section of the targeted population [8].Dusek et al. and Mirabeau et al. [4,8] propose different strategies to downplay the weakness of online survey, which include direct contact, referrals, and affiliation.In light of these challenges, researchers employed many approaches to reach many respondents across the country within the one-week data collection period.For this study, community leaders, social media influencers and mobilizers were involved in broadcasting and sharing of the survey on their social media platforms (Facebook and WhatsApp).Facebook and WhatsApp were mainly used to share the survey since they are the most popular social media platforms in Kenya [6].Clicking the link to the survey was deemed as a consent to participate.From the process, 353 respondents clicked the link and submitted the survey.The data was then analyzed to address the objectives of the study.

Knowledge, Attitude and Practices Indicators
The survey tool consisted two parts: demographic characteristics and KAP related questions.The general characteristic of the respondents included gender, age group, education level, marital status, occupation and place of residence (either urban or rural).
The questionnaire used in this study was adopted from the tool that was previously tested and used in China [17].However, the tool was reviewed to align to Kenyan context.There were 10 questions to test respondent's knowledge on COVID-19: K1-K9.The knowledge score was then divided by 9, as it ranges between 0 and 1.The aims of the study were to understand COVID-19 attitude among Kenyans, their confidence on instituted measures to control the spread of the virus, and whether they believe the disease will eventually be controlled (K10 -11).With regard to practices, it was essential to understand whether one had visited crowded places and whether they were observing the preventive measures (K12-13).(See Table 1

Limitation of the Study
Sampling was done through convenience sampling through a network of researchers who were encouraged to share the survey on social media platforms (Facebook and WhatsApp).Therefore, there may be a bias since those who are not on such social media platforms were not able to participate in the study.In addition, with regard to age distribution in Kenya, the sample of the study had an over-representation of persons below the age of 35 years.The under-representation of a section of the target population may have derailed the generalization of the findings [9,13].As such, a more systematic and inclusive sampling approach should be employed to improve the level of representation and generalizability of COVID-19 knowledge, attitude and practices in Kenya.
Another limitation of this study was the likelihood that respondents were likely to give desirable response.Since it is a self-reported survey, respondent were likely to give answers about attitude and practices based on what they perceived was expected of them [9,10].

Results and Discussion
A total of 353 participants completed the survey.Majority of the respondents were below 35 years of age (91.5%), 232 (65.7%) were males, 293 (83.0%) had a bachelor degree and above, 64 (18.1%) respondents indicated to be unemployed, and 217 (61.5%) said they live in urban settings (See Table 2

Community's Source of COVID-19 Information
While the threat of COVID-19 has triggered a serious global health concern, of greater danger is the fear surrounding the disease that is fueled by widespread of health misinformation.According to [15,16], distinguishing facts from outright health misinformation during an outbreak is a daunting task especially in the current era of social media.In the current situation of COVID-19 outbreak, 56% of Kenyans indicated to receive information on COVID-19 from mainstream media (Radio, newspapers, and Television), 55% from daily MoH's briefing, while 55% source information from social media platforms (Facebook, Instagram, Twitters etc) (See Figure 1  The level of trust of information from available sources were varying.Among the popular sources of information, daily briefing by the Ministry of Health was the most trusted source of COVID-19 information with 90% highly or somewhat trusting the information given on this forum.For those who get updates about the pandemic from mainstream media 87% highly or somewhat trust the conveyed information.However, despite 55% of the respondents sourcing their information from social media platforms, only half of those (50%) highly trust the information (See Figure 2 above).

Knowledge and perception of COVID-19
Overall, the average knowledge score of COVID-19 symptoms and practices is 0.8397 [0.8239, 0.8554], indicating high knowledge about COVID-19 pandemic.However, the average knowledge level changes with sociodemographic characteristics of the respondents.Distribution, by proportion, of respondents for each knowledge indicator is shown in Table 3 below.Overall, 93% of the respondent indicated that they know the main symptoms of COVID-19, while 4% were not sure.With regard to whether the measures instituted by the Kenyan government will eventually control the spread of the virus 55% are optimistic it will be controlled, 27.2% are not sure while the rest (17.8%) do not believe the disease will be controlled (See Figure 3 above).Multiple linear regression model (Table 4 below) showed that female gender (vs male, coef.=00601,P=0,014), age group 34+ years (vs <35 years, coef.=0.3998,P=0.000), level of education of primary/secondary (vs University, coef.=0.2685,P=0.000) and employed occupation status (vs not employed, coef.=0.2044,P=0.000) were significantly associated with the level of knowledge score.

Practices Towards COVID-19
Of the all the respondents, half of the respondents (50%) indicated to have visited a crowded place in the recent past.In crowded places, 91% indicated to have worn masks, 67% maintained the proposed social distance and 83% applied sanitizers regularly.However, 60% of the respondents indicated that other persons were not observing the measures (See Figure 4 above).Evidently, the failure of the majority of Kenyans to adhere to the recommended COVID-19 preventive measures may explain the high community-tocommunity transmission experienced in Kenya.

Conclusion
It is not in doubt that that knowledge, attitude and practices among Kenyans is the main determinant of how the pandemic will affect the community.This study sought to assess the knowledge, attitudes and practices of Kenyans towards COVID-19.To achieve the objectives of the study an online cross-sectional survey was applied.In Kenya, where the population is predominantly youthful and educated, the level of knowledge about the COVID-19 symptoms and preventive measures was evidently high.From the study, it is evident that most respondents are knowledgeable about COVID-19 (83.97%).Daily briefing by the Ministry of Health (MoH) and mainstream media were posited as the main sources of information about the pandemic in Kenya.About observing the proposed measures in crowded places, despite majority indicating they observed the measures, there was a significant proportion (60%) of respondents reporting that other persons were not observing the same.Only half of the respondents believed that the pandemic will eventually be control through the measures instituted by the Kenyan government.Sociodemographic characteristics, including gender, the level of education and occupation, were shown to influence the level of COVID-19 knowledge.

Figure 2 .
Figure 2. Level of Trust on Source of COVID19 information.

Table 1 .
Knowledge, attitude and practices Indicators.

Table 2 .
Demographic characteristics of Survey Respondents and knowledge score (with confidence interval).

Table 4 .
Results of multiple linear regression analysis on sociodemographic factors associated with knowledge on COVID-19.