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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 30  |  Issue : 5  |  Page : 548-555

Knowledge, attitude, and practice of preventive measures against COVID-19 among pregnant women receiving antenatal care in Calabar, Nigeria


1 Department of Obstetrics and Gynaecology, University of Calabar, Calabar, Nigeria
2 Department of Community Medicine, University of Calabar, Calabar, Nigeria
3 Research Operations, Bruyere Research Institute, Ottawa, Canada

Date of Submission16-Jan-2021
Date of Decision29-Jun-2021
Date of Acceptance16-Jul-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Ezukwa Ezukwa Omoronyia
Department of Obstetrics and Gynaecology, University of Calabar, Calabar
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_16_21

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  Abstract 


Background: Implementation of preventive precautions remains the most important measure in the control of coronavirus 2019 (COVID-19) infection. This study was aimed at evaluating the extent of knowledge, attitude, and practice of COVID-19 prevention among pregnant women in Calabar, Nigeria. Methodology: Cross-sectional descriptive design and systematic random sampling method were utilized to recruit antenatal care clinic attendees, in the University of Calabar Teaching Hospital, Calabar, Nigeria. Study variables were assessed using structured questionnaires. Information was entered and analyzed with SPSS version 21.0. A percentage knowledge score of at least 75% was considered satisfactory. P-value was set at 0.05. Result: Two hundred and eighty-four women were studied and the mean age was 30.6 ± 5.0 years. Approximately half of the women (51.4%) were within the third trimester of pregnancy. The mean percentage knowledge score was 71.7% ±17.2%, and the overall level of knowledge was unsatisfactory in 43.3% of respondents. Most women agreed with the reality of existence of COVID-19 infection (90.1%), and 30.6% were of the opinion that the pandemic could be eradicated by prayers alone. Most women practised preventive measures including the use of face mask (89.1%), social distancing (84.2%), and regular handwashing (94.4%). There was a significantly higher mean total knowledge score as well as knowledge of preventive measures among users compared with non-users of face mask, and regular subjects were compared with non-regular subjects with regards to their handwashing practice (P < 0.05). Conclusion: Familiarity with COVID-19 prevention among pregnant women in the study context is suboptimal. There is a need to improve maternal health education provided during antenatal care visits, toward addressing misconceptions related to the pandemic.

Keywords: Attitude, COVID-19, knowledge, Nigeria, practice, pregnant women


How to cite this article:
Omoronyia EE, Eyong E, Omoronyia OE, Akpan U, Arogundade K, Ekanem EI. Knowledge, attitude, and practice of preventive measures against COVID-19 among pregnant women receiving antenatal care in Calabar, Nigeria. Niger J Med 2021;30:548-55

How to cite this URL:
Omoronyia EE, Eyong E, Omoronyia OE, Akpan U, Arogundade K, Ekanem EI. Knowledge, attitude, and practice of preventive measures against COVID-19 among pregnant women receiving antenatal care in Calabar, Nigeria. Niger J Med [serial online] 2021 [cited 2021 Dec 5];30:548-55. Available from: http://www.njmonline.org/text.asp?2021/30/5/548/327955




  Introduction Top


Coronavirus disease 2019 is a novel communicable respiratory illness that results from infection with severe acute respiratory syndrome coronavirus 2, scientifically classified as Orthocoronavirinae, which was initially found in Wuhan, China, in the later period of 2019.[1] The pandemic poses the largest worldwide public health disaster in a century with serious health and socioeconomic issues. The virus is highly infectious and disseminated mostly by salivary droplets or nasal discharges in the process of an infected individual coughing or sneezing.[2] Globally as of October 6, 2020, there were over 35 million confirmed incidents of COVID-19 which includes over one million mortalities in over 216 countries, area or territories. In Africa, there were 1,202,973 confirmed cases. In Nigeria, over 59,465 persons have been infected by the virus with over 1113 deaths.[3],[4] As a result of this grave and critical crisis, the WHO declared the coronavirus pandemic an international public health emergency on January 30, 2020, and enjoined all countries to work together toward halting the spread of COVID-19.[5]

Historically, respiratory infections have been hypothesized to raise the risk of severe morbidity and mortality among pregnant women. Studies have found that pregnant women from black, Asian, and minority ethnic origins were found to have a higher rate of hospital admission due to coronavirus than other women. Pregnant women who are older than 35 years, overweight or obese persons, as well as those with preexisting medical conditions such as hypertension and diabetes, are at risk of acquiring serious illness.[6] Pregnant patients with comorbidities may be at increased risk for developing serious illness and adverse outcomes. Because the pandemic is continuously evolving, pregnant women are advised to take steps to avoid becoming infected with COVID-19. New evidence suggests that it is possible for a mother to pass the virus on to her baby while she is pregnant.[7] Complications are more likely to occur in pregnant women who get COVID-19 such as miscarriage, preterm births, and fetal growth restriction. However, the data are extremely limited.[8]

COVID-19 has a variety of effects on infected persons. Most patients with the virus will recover following mild or moderate sickness and therefore do not need to be hospitalized.[1],[8] Dry cough, fever, and exhaustion are the most prevalent symptoms. Less common symptoms include body aches and pains, headache, discoloration of limb extremities, skin rash, conjunctivitis, sore throat, loss of taste, and smell. Severe symptoms include chest pain, breathlessness, chest pain, and loss of speech.[8] Regular handwashing with clean water and soap effectively prevents or decreases the risk of spread of COVID-19. Other preventive measures include the use of hand rub containing alcohol as well as social distancing of at least 2 m between individuals, especially while coughing or sneezing, avoiding direct contact with the face, covering the mouth and nose when sneezing or coughing, and staying at home during illness. Additional measures include avoiding needless travel and avoiding crowded places, as well as refraining from smoking and other behaviors that damage the lungs.

In Nigeria, several preventive measures including adhering to the WHO recommendations have been taken to prevent the virus from spreading further. In addition, media initiatives to inform the general public about these preventive actions have been launched in addition to interstate lockdown and restriction of movements. People's compliance with these steps is critical for preventing infection and slowing spread. This largely depends on their knowledge, attitude, and practices toward COVID-19. The goal of this research was to assess the knowledge, attitude, and practice of COVI-19 prevention among pregnant women receiving antenatal care, during this era of COVID-19 outbreak.


  Methodology Top


Study setting

This was a descriptive cross-sectional survey conducted among antenatal care attendees at the University of Calabar Teaching Hospital (UCTH) between July 1 and September 30, 2020, using interviewer-administered questionnaires. UCTH is a federal teaching hospital located at the centre of Calabar Metropolis. It provides tertiary health services to around 2 million people in Cross River State, as well as referral services for adjoining states and the Republic of Cameroon. It also receives referrals from private clinics, primary and secondary health facilities within the catchment area. The hospital operates four antenatal clinic sessions, a booking clinic, and four postnatal clinic sessions a week. A family planning clinic operates daily. The clinics are operated by a team of consultant obstetricians and resident doctors working together with the nurses. Antenatal care is provided routinely for all patients who present themselves for it as well as high-risk pregnancies referred to the centre. These constitute the booked patients. Other patients who had no antenatal care are classified as unbooked.

Study design

Descriptive cross-sectional design was used to assess knowledge, attitude, and practice of COVID-19 prevention by pregnant women receiving antenatal care.

Study population

The study population comprised of pregnant women receiving antenatal care in the UCTH during the period of research.

Eligibility criteria

Inclusion criteria

All antenatal care attendees, regardless of their gestational age, were eligible to participate in the study.

Exclusion criteria

Critically ill pregnant women were excluded.

Simple size estimation

The sample size for this survey was estimated by using the Leslie Kish formula for a single proportion as follows: [9]

N = Z2 pq/d2

In the formula, N is the estimated sample size.

Z is the standard normal distribution value at 95% CI which is equal to 1.96.

P is the estimated proportion of pregnant women with adequate knowledge of COVID-19 infection (0.80), as reported in a previous study conducted in South-south, Nigeria,[10] and q = 1 − P = 0.20.

d is the margin of error taken as 5%.

This computation yielded 245.9, then with the assumption of a 10% nonresponse rate, the estimated sample size was calculated as 270.

Sampling technique

A systematic random sampling technique was used for the recruitment of subjects into this research. A sampling interval of 3 was used to recruit subsequent subjects. The interval was computed by dividing the estimated number of daily ANC attendance, by allocated sample size for each day of the study period. The first subject was selected by balloting among the initial three ANC attendees on the daily register, and subsequent subjects were recruited using the calculated sample interval. If a selected pregnant woman was ineligible or did not consent to participation, the next attendee on the register was selected, and sampling continued from that point until the allocated sample size was completed.

Study instruments

The study instrument was a semi-structured, interviewer-administered, pretested 40-item questionnaires, which comprised of four (4) sections. These sections were sociodemographic characteristics (11 items), knowledge of COVID-19 prevention (13 items), attitude toward COVID-19 prevention (6 items), and practices of pregnant women of preventive interventions against COVID-19 (10 items). The questionnaire was developed in view of findings from existing literature, and in tune with the national guidelines for health facility and community-based management of COVID-19, by both the Nigeria Center for Disease Control (NCDC) and WHO.

Pretesting of questionnaires

The questionnaires were pretested in UCTH among twenty randomly selected pregnant women. Appropriate corrections were made to the questionnaire based on the responses obtained. The internal consistency was assessed using Cronbach's alpha, with the attainment of a score of 0.82 before use for data collection.

Training of research assistants

Two resident doctors and two midwives were trained as research assistants for questionnaire administration. The assistants received three hours daily, 2-day training on the study variables, recruitment process, issues of confidentiality, and other ethical issues involved in human research.

Operational definitions

Knowledge

Information retained in memory with regard to what the participant knows about COVID-19.

Knowledgeable

Survey participants who gave correct answers to more than or equal to 70% of knowledge-based questions.

Not knowledgeable

Survey participants who answer fewer than 70% of knowledge-based questions.

Attitude

A predetermined way of thinking toward COVID-19 infection influenced by a combination of values, feelings, and beliefs.

Practice

The actions and activities that respondents are involved in, toward control and prevention of COVID-19 infection

Data analysis

The data collected were analyzed with SPSS (IBM) version 20, Chicago, IL, USA. Frequency and percentages of correct knowledge, attitude, and practice were presented using tables. Each correct response to questions assessing knowledge of COVID-19 contributes a unit score. Total knowledge score for each respondent was obtained by summing up all correct responses provided. The percentage knowledge score was derived by dividing the total score by the number of questions, then multiplying by 100. A knowledge score of at least 75% was considered satisfactory. T-test was used to compare mean age, gestational age, and parity between users and non-users of face mask, as well as respondents who did and those who did not practice regular handwashing. Independent t-test was used to compare mean values of continuous sociodemographic, obstetric variables as well as knowledge scores, between respondents who practised and those who did not practice each of the COVID-19 preventive interventions, including use of face mask and regular practice of handwashing. Chi-square was used to test the association between the practice of preventive measures and key categorical sociodemographic variables (such as level of education and marital status), as well as attitude toward COVID-19 prevention. A statistical significance level of P < 0.05 was used.

Ethical considerations

The UCTH Research and Ethics Committee approved the work. Informed written consent was also obtained from the study participants. Confidentiality and anonymity of participant data and responses were maintained throughout the study by excluding the names and any other identifiers of participants from the questionnaire.


  Results Top


Three hundred and eight ANC attendees were approached, but 284 gave complete data, yielding response rate of 92.2%. The mean age was 30.6 ± 5.0 years, ranging from 18 to 46 years. The median parity was 1.5. The mean actual and booking gestational ages were 26.5 ± 6.7 (12–40) and 20.1 ± 5.5 (11–38) weeks, respectively. Most women were within 20–40-year old (96.1%), married (93.0%), Christian (98.2%), had tertiary education (69.0%) [Table 1]. Approximately half of women each were within the second and third trimester, respectively.
Table 1: Sociodemographic and obstetric characteristics (n=284)

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Approximately two-thirds of women (67.3%) knew that there was currently no cure for COVID-19, while most women knew of the main clinical presentations (86.3%) and benefits of early symptomatic management (90.8%) [Table 2]. Approximately two-thirds of women (65.8%) did not know of sneezing and stuffy nose as a symptom was more common in COVID-19 infection compared with the common cold. Most women (80.6%) knew that COVID-19 infection may spread through respiratory droplets, while approximately half (51.8%) considered eating or touching wild animals as sources of infection. 44% of the women felt that the virus cannot be transmitted if the patient was afebrile while 33.7% were of the opinion that the virus cannot be passed from mother to child. Majority of the women were aware of measures of prevention of COVID-19, including use of face mask (85.6%), proper wearing of face mask (93.3%), as well as isolation of cases (87.7%) and contacts (91.2%). However, 45.8% did not know that children and young adults also need to take precautions against COVID-19.
Table 2: Knowledge of different areas of coronavirus disease 2019 (n=284)

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The mean percentage knowledge score was 71.7 ± 17.2%, ranging from 12.5% to 100%. Overall, knowledge of COVID-19 was unsatisfactory in 43.3% of the women [Table 3]. One hundred and twenty-seven women (44.7%) had an unsatisfactory level of knowledge of clinical presentation and management, comprising poor (9.2%), fair (10.2%), and good levels of knowledge [Table 3]. Approximately half (49.6%) and 38.4% of women had an unsatisfactory level of knowledge of risk factors for transmission of COVID-19 and preventive measures, respectively.
Table 3: Frequency distribution of knowledge scores (n=284)

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Most women agreed with the reality of the existence of COVID-19 infection (90.1%), had confidence in Nigeria overcoming the pandemic (85.5%), and thought that they had a responsibility toward the disease control (81.7%) [Table 4]. However, approximately one-fifth (18.7%) thought that COVID-19 was a scam by the government, while 30.6% considered that the pandemic could be eradicated by prayers alone.
Table 4: Attitude toward coronavirus disease 2019 pandemic (n=284)

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Approximately half of the women (51.8%) had recently gone to crowded places [Table 5]. Most women practiced preventive measures including the use of face mask (89.1%), social distancing (84.2%), regular handwashing (94.4%), and appropriately sneezed into their elbows (90.9%).
Table 5: Practice of coronavirus disease 2019 preventive measures (n=284)

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There was a significantly higher mean total knowledge score as well as knowledge of preventive measures among users compared with nonusers of face mask and women with consistent compared with inconsistent practice of handwashing [P < 0.05, [Table 6]]. Knowledge of risk factors and transmission was higher among users compared with non-users of face mask as well as women with consistent compared with inconsistent handwashing, though statistical significance was found only for use of face mask [Table 6]. Sociodemographic and obstetric characteristics were not found to be associated with the status of utilization of face mask or washing of the hands (P > 0.05).
Table 6: Factors linked with practice of key preventive interventions (n=284)

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  Discussion Top


The objective of the study was to evaluate the knowledge, attitude, and practice of preventive measures against coronavirus among pregnant women receiving antenatal care in Calabar. This study is important as pregnancy is considered a vulnerable period with a high possibility of transmission of coronavirus to mother and fetus.[7] The percentage of study participants who attained tertiary level of education was 69.0%. This is much higher than what was obtained in a study conducted on gravid women in Abakaliki, Nigeria (28.5%)[11] but much lower than that obtained in online surveys done in North-central Nigeria (90.4%),[12] China (84.4%)[13] and Iran (93.6%).[14] This is due to the fact that persons who partake in online surveys are usually people who have higher levels of education than obtained in the general population.[13],[14] The mean knowledge score among our study participants was 71.7% ±17.2% (ranging from 12.5% to 100%), which was higher than that obtained in a similar study among chronic disease patients in Ethiopia (37.4%).[15] It was lower than what was obtained in online surveys done in Cameroon (84.2%),[16] Malaysia (80.5%),[17] and China (90.0%).[13] However, the disparities in the scoring system applied in the different surveys and demographic considerations would not allow accurate comparisons of knowledge levels in the different studies.

Concerning the components of the knowledge area of this study, 44.7% of participants had unsatisfactory level of knowledge of clinical presentation and management while 38.4% had unsatisfactory knowledge of preventive measures. It is of great concern that approximately half had an unsatisfactory knowledge of risk factors and transmission. Out of this category, only 62.7% correctly responded that COVID-19 infection can be transmitted to their babies. Recent studies suggest a potential risk of vertical transmission of COVID-19 infection.[18],[19],[20]

This suboptimal degree of knowledge of preventive interventions against COVID-19 is of great concern, especially in this vulnerable group. Since the detection of the index case of COVID-19 in Nigeria on February 27, 2020, there have been many awareness sensitization campaigns by the Nigeria Center for Disease Control, Federal Ministry of Health and State governments in both the traditional media (radio, television, newspapers) and social media (WhatsApp, Facebook, internet) to educate the citizenry. There have also been many strategies for infection prevention and control, adopted by the Nigerian government and NCDC against COVID-19 infection. However, it appears that many of the study participants either have no access to the abundant information which has been made available or do not understand the information. This relatively low level of knowledge may also be explained by the relatively low percentage of study participants who attained tertiary level of education. Some studies done in China[13] and Iran[14] have identified a strong positive correlation between educational status and COVID-19 knowledge level of the population.

Yet, though most participants in this study agreed with the reality of COVID 19, a significant proportion considered the pandemic to be a scam by the government, and that it could be eradicated by prayer alone. These misconceptions may be contributing to impairment in infectious disease control, especially in developing country settings.

It is commendable that a high percentage (85.5%) of participants expressed optimism that Nigeria can overcome the menace of COVID-19. This suggests that they believe in the government strategies which were implemented during the study period. These strategies included the closure of international air and land borders, nationwide lockdown, banning of social and religious gatherings. It also suggests their willingness to adhere to the different precautionary and control interventions adopted nationwide.

Concerning the practice of preventive interventions against COVID-19, a significant percentage practiced the use of face/nose masks, social distancing, regular hand hygiene, and regular respiratory hygiene. However, almost half of the survey participants had recently visited a crowded location. This poor practice of a key preventive measure could be explained by the inability of the State government to strictly implement total lockdown and banning of social/religious gatherings within the state during the review period. This can also be explained by the fact that, according to our national statistics, this is a state with one of the fewest cases of COVID-19 infection in the country.[21] This also further suggests that many of the survey participants were unaware of the potential risk that COVID-19 poses to themselves and possibly their unborn babies.

In an analysis of the determinants of practice of preventive interventions against COVID-19, a higher level of knowledge of COVID-19 was found to be associated with regular use of face mask and practice of handwashing. This finding is not unexpected, considering that knowledge of the pandemic potentially yields improved perception of fetomaternal susceptibility, severity, and self-efficacy toward practices that reduces the risk of contracting the infection. Studies conducted in Egypt,[22] and Nigeria (Abakaliki),[11] also found a significant association between the extent of knowledge and practice of preventive interventions. These intermediate outcome measures are essential components required for change or adoption of healthy behavior, in tune with the health belief model.[23] Yet, knowledge may not always lead to practice, considering that there are several other determinant variables, including availability of resources for such practice. These resources such as availability of soap and running water for handwashing may not be consistently available in most resource-poor settings including Nigeria.

Furthermore, sociodemographic and obstetric characteristics were not discovered to be linked with the practice of preventive interventions. This suggests that no age, educational level, occupational, marital, gestational groups, or other characteristics are more or less likely to practice preventive measures. This finding may be due to potential similarity in the strength of determinants of the practice of these measures among the various groups. Such determinants include the availability of materials for practice, level of knowledge which are obtained from diverse media sources as well as maternal health education provided at antenatal care clinics. A similar study in Egypt also found a lack of association of age and marital status with practice of preventive measures.[22] Higher parity and educational attainment were, however, linked with adequate practice of preventive measures. Difference in grading system or assessment of adequacy in practice of preventive measures may account for differences in degree of associations found. Furthermore, a similar study in Abakaliki, South-east Nigeria, found older age, married status, higher parity, and lower level of education to be linked with the practice of preventive interventions.[11] Differences in sociodemographic characteristics of pregnant women, as well as their degree of risk perception in the study settings, may account for this variance in finding.

Knowledge of COVID-19 is a key determinant of the utilization of preventive interventions among pregnant women in the study setting. Sociodemographic and obstetric characteristics are not linked with the practice of preventive interventions. Consequently, all women should be targeted for more effective maternal health education, toward improvement in knowledge of COVID-19 and eventual practice of preventive strategies. There should be no priority focus on any groups or subgroups for educational and other relevant interventions, as well as monitoring and evaluation of effects of interventions.

The maternal mortality ratio in Nigeria is >800,000 per 100,000 live births,[24] majority of which are avoidable. This study has discovered a suboptimal level of knowledge and poor application of key preventive strategies for COVID-19. Consequently, the infection is more likely to occur among pregnant women, therefore potentially worsening our maternal mortality statistics. Hence, an emphasis should be placed on maternal health education in Nigeria, and indeed Sub-Saharan Africa to achieve improvement in knowledge and application of COVID-19 prevention strategies.


  Conclusion Top


This study assessed the level of knowledge and practice of COVID-19 prevention among pregnant women in Calabar because they make up part of the vulnerable group in the society. The degree of knowledge among the research participants was suboptimal and there was a poor practice of key preventive measures.

We recommend that maternal health education can be improved by incorporating awareness and sensitization campaigns, as well as Infection Prevention and Control (IPC) strategies during their regular antenatal visits. This would help to promote understanding, address misconceptions, and increase the practice of preventive interventions among pregnant women. Campaigns should also be carried out on the streets and public spaces. The information should also be translated into the local dialects to ensure a full understanding of all the information.

In addition, there should be a provision of economic palliative support to the grassroots, especially the vulnerable group such as pregnant women in the society. This would likely also encourage them to practice all the necessary preventive measures. Religious leaders and clerics should also be closely involved in the awareness and sensitization campaigns so that factual information can be given to their various congregations. Further studies in other sub-Saharan Africa settings are also recommended.

Financial support and sponsorship

Authors.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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