Knowledge, attitudes, practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon.

Severe Acute Respiratory Syndrome Coronavirus 2 (COVID 19) has plagued the world with about 7,8 million confirmed cases and over 430,000 deaths as of June 13th, 2020. The knowledge, attitude, and practices (KAP) people hold towards this new disease could play a major role in the way they accept measures put in place to curb its spread and their willingness to seek and adhere to care. We sought to understand if: a) demographic variables of Cameroonian residents could influence KAP and symptomatology, and b) KAP could influence the risk of having COVID19.A cross-sectional KAP/symptomatology online survey was conducted between April 20 to May 20. All analyses were performed using SPSS version 23. Of all respondents (1006), 53.1% were female, 26.6% were students, 26.9% interacted face to face and 62.8% were residents in Yaoundé with a median age of 33. The overall high score was 84.19% for knowledge, 69% for attitude, and 60.8% for practice towards COVID 19. Age > 20 years was associated with a high knowledge of COVID 19. Women had lower practice scores compared to men (OR = 0.72; 95%CI 0.56-0.92). 41 respondents had ≥3 symptoms and only 9 (22.95%) of them had called 1510 (emergency number). There was no significant difference between KAP and symptomatology. The presence of ≥ 3 symptoms in 4% of respondents (with 56% of them having co-morbidities) supports the current trend in the number of confirmed cases (8681) in Cameroon. The continuous increase in the number of cases and the overall good KAP warrants further investigation to assess the effectiveness of the measures put in place to curb the spread of the disease. Sensitization is paramount to preclude negative health-seeking behaviors and encourage positive preventive and therapeutic practices, for fear of an increase in mortality.

Introduction

According to the World Health Organization (WHO), viral diseases continue to emerge and represent a serious issue to public health. In the last twenty years, several viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) from 2002 to 2003, and H1N1 influenza in 2009, have been recorded. Most recently, the Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia in 2012 and now the new Coronavirus disease 2019 (COVID-19) has plagued the world. COVID-19 is an emerging respiratory disease caused by the highly contagious novel coronavirus (SARS-CoV 2) and was first detected in December 2019 in Wuhan, China [1-3]. This new virus has quickly spread globally afflicting 215 countries. As of June 13th, 2020, over 7.8 million cases and 430,000 deaths have been reported globally [4].

In Cameroon, the first case confirmed on the 6th of March 2020 was a French national who arrived Yaoundé. To control and avoid the rapid spread of the ongoing COVID-19 outbreak in the country, several measures were adopted by the government. These measures include the limitation of the number of passengers of public transportation; the closing of all schools; quarantine and care for infected people or suspected cases; closure of borders and suspension of flights; suspension of issuance of entry visas to Cameroon; gatherings of more than 50 people prohibited; bars, restaurants, and public places closed from 6 pm; consumer flow regulations set up in markets and supermarkets; urban and inter-urban travel only undertaken in cases of extreme necessity; overloading in public transport vehicles prohibited; implementation of virtual meetings; avoiding close contact such as shaking hands or hugging and covering the mouth when sneezing.

The number of those infected is still on the rise and after the government uplifted some of the COVID-19 restrictive measures on bars, taxis, restaurants. Several other cases were confirmed later amounting to 8681 cases, 4836 recovered and 212 deaths [4]. The infection rate and the resources needed to battle this disease can be expected to increase exponentially.

Currently, there is no approved treatment for COVID-19 and no clinical trial data supporting any prophylactic treatment. In the absence of this approved treatment, available treatments are directed at relieving symptoms and the panic of no approved treatment can lead to embracing other non-standard options. Agents previously used to treat SARS and MERS are potential candidates to treat COVID-19 [5] as well as various agents with apparent in vitro activity against severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). These include chloroquine and hydroxychloroquine, also used in the prevention and treatment of malaria and/or chronic inflammatory diseases. Remdesivir, an antiviral drug is being touted as a possible coronavirus treatment [6].

Responses to epidemics in Africa have been challenged by limited infrastructure and fragile healthcare systems. This includes the lack of adequate surveillance to assess the scope of the outbreak, and inadequate systems for the prevention, diagnosis, and management of a disease. Cases of COVID 19 as with other diseases are broadly classified as suspected, probable, and confirmed [7]. Assessing the symptoms of COVID 19 (suspected cases) is a preliminary step in the diagnosis and management of this disease.

Person to person transmission (community spread) is currently ongoing in the country, making it necessary to control the disease to avoid its rapid spread throughout the country. To guarantee successful disease control, people’s adherence to preventive and control measures are essential. This adherence is highly dependent on the population’s knowledge, attitudes, and practices (KAP) towards COVID-19 following the KAP theory. A previous study indicates that the knowledge level and attitudes towards infectious diseases are associated with the level of panic among the population, which can further complicate attempts to prevent the spread of the disease, thus prompting alternative treatment sources [8].

Due to shortages in diagnostic kits in our setting during our study, a questionnaire to gauge the symptomatic trend was issued to Cameroonians to strategically define an approach to address the outbreak. In this study, according to guidelines for clinical and community management of COVID-19 by the Cameroon National Health Development Plan, our objective was to evaluate the factors influencing the knowledge, attitudes, and practices of Cameroonian respondents on COVID 19 and also evaluate the associations between the demographics, KAP and symptoms of COVID 19.

Methodology

Ethical consideration

The Ethical Committee of the Institute of Medical Research and Medicinal Plants Studies, Yaoundé, approved the study protocol and procedures before the formal survey.

Study design

This cross-sectional survey was conducted from April 20 to May 20, two weeks after the partial confinement was implemented in the country. Because it was not feasible to do a community-based national sampling survey during this period, data was collected online. Relying on the authors’ networks with local people living in all the 10 regions of Cameroon (S1 Table), a one-page recruitment sheet was posted to groups and individuals via “WhatsApp”, email, websites accounts. This page (S1 Appendix) contained a brief introduction to the background, objective, procedures, voluntary nature of participation, declarations of anonymity and confidentiality, and notes for filling in the questionnaire, as well as the link of the online copy questionnaire. The associations between the demographics and KAP, symptoms and KAP, comorbidities, symptoms of COVID 19 with age, and gender were assessed.

The independent variables were symptomatology, demographic characteristics (gender, age, profession, working environment, city of residence).

The dependent variables were knowledge, attitudes, practice, and symptoms of/towards COVID 19. Questions on knowledge were about the mode of transmission, attitude towards health-seeking behaviors and practices like avoiding crowded areas, wearing masks, washing hands and using sanitizers, taking vitamin C, citrus fruits, traditional concoctions, and drugs (chloroquine, ibuprofen, paracetamol). Symptomatology was assessed by someone presenting with fever, headache, dry cough/catarrh, throat irritation, diarrhea, difficulty breathing, and muscle pain. The symptomatology section was accompanied by associated comorbidities and diseases with similar symptoms.

Study population and eligibility criteria

Cameroonian residents, aged 18 years or more, employed or unemployed who understood the content of the recruitment page- and who agreed to participate in the study completed the questionnaire.

Measures

The questionnaire consisted of four parts: demographics, knowledge, attitudes, practices, and symptomatology. A COVID-19 KAP and symptomatology questionnaire was developed. The questionnaire had 32 questions: 7 items on knowledge, 4 items on attitudes, 9 items on practices, 5 items on symptomatology (for suspected cases), 5 on demographics, and 2 others (source of information). Questions were answered on a Yes/No basis with an additional “I don't know” option. Some open-ended questions were asked.

Statistical analysis

A score of 1 was attributed to a correct answer and 0 to a wrong answer for knowledge, attitude, and practice. The Knowledge range was 3–7, 1–4 for attitude, and 2–9 for practice. The overall scores of each individual were used to obtain mean scores for KAP. Blooms' cut-off was used. Frequencies of correct knowledge answers and various attitudes and practices were described. Multiple logistic regression analysis using all of the demographic variables as independent variables and knowledge/ practice score as the outcome variable was conducted to identify factors associated with knowledge and practice. Similarly, binary logistic regression analyses were used to identify factors associated with practices. Factors were selected with a backward stepwise method. Unstandardized regression coefficients (β) and odds ratios (ORs) at 95% confidence intervals (CIs) were used to quantify the associations between variables and KAP. Associations between demographic variables of gender and age were compared to comorbidities and symptoms (≥3). Also, associations between demographics and KAP were studied. Data analyses were conducted with SPSS version 23.0. The statistical significance level was set at p < 0.05 (two-sided).

Results

Socio-demographic characteristics

A total of 1006 participants completed the survey. The average age of those who participated was 33±11.2. The demographic characteristics of all the participants are presented in Table 1. Of all respondents, 53.1% were female and 26.6% were students in the university or high school. About the working environment, 26.9% of the participants interacted face to face with others (i.e customer services cashiers, hairdressers, traders, etc), 25.5% spent most of their time in the office, and 20.4% at home. Overall, 62.8% were residents of the capital city Yaoundé.

Table 1

Demographic characteristics of participants.

Demographics/characteristics	Number of respondents	Percentage (%)
Gender
• Male	472	46.9
• Female	534	53.1
Age
• <20	32	3.2
• [20–30]	361	35.9
• [30–40]	367	36.5
• [40–50]	139	13.8
• ≥50	107	10.6
Profession
• Health care worker	99	9.8
• Private sector worker	182	18.2
• Public service personel	141	14
• Retired	17	1.7
• Student	268	26.6
• Teacher/Lecturer	135	13.4
• Others (housewives, farmers, unemployed, taxi drivers, builders)	164	16.3
Working environment
• At home	205	20.4
• Face to face interaction with customers	271	26.9
• Hospital	102	10.1
• Office	257	25.5
• Outdoor environment	171	17.1
City of residence
• Yaoundé	632	62.8
• Douala	146	14.5
• Buea	89	8.8
• Others (cities from the 10 regions of Cameroon)	139	13.9

Source/ period of information on COVID 19

For the source/period of information, 41.9% of the respondents knew when the disease began (December 2019) and 14.4% only knew in March 2020 when the first case was reported in Cameroon. Greater than half of the respondents (54.5%) got the information on COVID 19 for the first time via the television during the first and last 15 days of the study, the respondents got the information primarily through television followed by Whatsapp and websites (Table 2).

Table 2

Source/ period of information on COVID 19.

Month/Source of information	Mouth to mouth	Newspaper	Television	Websites	Whatsapp	Total
DEC-19	25(6.0%)	27(6.4%)	246(58.7%)	77(18.4%)	44(10.5%)	419
JAN-20	14(5.1%)	13(4.8%)	141(51.6%)	46(16.8%)	59(21.6%)	273
FEB-20	19(11.2%)	6(3.6%)	84(49.7%)	26(15.4%)	34(20.1%)	169
MAR-20	28(19.3%)	7(4.8%)	77(53.1%)	13(9.0%)	20(13.8%)	145
Total	86(8.5%)	53(5.3%)	548(54.5%)	162(16.1%)	157(15.6%)	1006
Source of information of respondents within the first and last 15 days of study period
First 15 days of study	50(7.2%)	34(4.9%)	370(53.3%)	123(17.7%)	117(16.9%)	694
Last 15 days of study	36(11.5%)	19(6.1%)	178(57.1%)	39(12.5%)	40(12.8%	312
Total	86(8.5%)	53(5.3%)	548(54.5%)	162(16.1%)	157(15.6%)	1006

Knowledge related to COVID 19

For the mode of transmission, 94.3% knew that the disease could be transmitted by droplets when an infected person coughs, sneezes or speaks, 75.6% said through kissing infected person, 74.7% through a handshake, 88.3% through touching a contaminated surface and then touching your eyes, nose or mouth (Table 3). The results show that 84.19% (n = 847) respondents had high knowledge score of 4–7 on the transmission of the disease (Table 4).

Table 3

Knowledge, attitudes, and practices of COVID 19 among the 1006 respondents in Cameroon, n (%).

Questions/ options	Yes (%)	No (%)
Knowledge of transmission (How is COVID 19 transmitted?)
K1. Droplets when an infected person coughs, sneezes or speaks	941 (94.3)	5.7 (57)
K2. Kissing an infected person	761 (75.6)	245 (24.4)
K3. Handshake	751 (74.7)	255 (25.3)
K4. Touching a contaminated surface and then touching your eyes, nose or mouth	888 (88.3)	118 (11.7)
K5. Blood transfusionF	77 (7.7)	929 (92.3)
K6. Sexual intercourseF	74(7.4)	932 (92.6)
K7. Contaminated foodstuffs	377 (37.5)	629 (62.5)
Attitude towards COVID 19 health-seeking behavior	Yes (%)	No (%)
A1. If you are living with someone working in a hospital milieu do you think they can contaminate you?	735 (73.1)	271(26.9)
A2. Are you willing to do a voluntary test for COVID 19?	724 (72)	282 (28)
A3. If you have another disease other than COVID 19, will you go to the hospital?	718 (71.4)	288 (28.6)
If No, why won’t you go to the hospital?
• Afraid of contamination	214 (21.3)	/
• Misdiagnosis	35 (3.5)	/
• Self-treatment	13 (1.3)	/
• To avoid stigmatization	9 (0.9)
A4. Do you prefer to be confined in the house or hospital for your medical care when you are tested positive for COVID 19?
• House	473 (47)	/
• Hospital	378 (37.6)	/
•I don’t know	155 (15.4)	/
Please explain the choice of staying at home
• Afraid of contamination	166 (38.6)	/
• Better home care with family	250 (58.1)	/
• Less costly	4 (0.9)	/
• Stigmatization	10 (2.3)	/
Practice on preventive measures
P1. Social distancing	843 (83.8)	163 (16.2)
P2. Washing hands and using sanitizers	951 (94.5)	55 (5.5)
P3.Total confinement	201 (20)	805 (80)
P4. Use of mask	1006 (100)	0 (0)
P5. Use of Traditional concoctionsF	361 (35.9)	645 (64.1)
P6. Taking chloroquineF	44 (4.4)	962 (95.6)
P7. Eating citrus fruits such as lemon and taking Vitamin C tablets	746 (74.6)	260 (25.4)
P8. Taking paracetamolF	46 (4.6)	960 (95.4)
P9. Taking IbuprofenF	10 (1.0)	996 (99)

FFalse answers

Table 4

Associations between background characters and Knowledge, attitudes regarding COVID 19.

Variable	Knowledge Score (4–7)	Knowledge Score(0–3)	(P-value)	Attitude Score (2–4)	Attitude Score (0–2)	(P-value)
	N (%)	N (%)		N (%)	N (%)
Overall	847 (84.19)	159 (15.8)		694 (69)	312 (31)
• Male	400 (84,7)	72 (15,3)	0,695	350 (74,2)	122 (25,8)	<0.001*
• Female	447 (83,7)	87 (16,3)		344 (64,4)	190 (35,6)
Age
• <20	20 (62,4)	12 (37,5)	0,003*	14 (43,8)	18 (56,3)	0.028
• [20–30]	293 (81,2)	68 (18,8)		257 (71,2)	104 (28,8)
• [30–40]	326 (88,8)	41 (11,2)		250 (68,1)	117 (31,9)
• [40–50]	119 (85,6)	20 (14,4)		96 (69,1)	43 (30,9)
• ≥50	89 (83,2)	18 (16,8)		77 (72)	30 (28)
Profession
• Health care worker	91 (91,9)	8 (8,1)	<0,001*	79 (79,8)	20 (20,2)	0.003*
• Private sector worker	163 (89,6)	19 (10,4)		112(61,5)	70 (38,5)
• Public service personnel	128 (90,8)	13 (9,2)		109 (77,3)	32 (22,7)
• Retired	17 (100)	0 (0)		13(76,5)	4 (23,5)
• Student	207 (77,2)	61 (22,8)		183 (68,3)	85 (31,7)
• Teacher/Lecturer	108 (80)	27 (20)		97 (71,9)	38 (28,1)
• Others	133 (82,9)	31 (17,1)		114 (63)	67 (37)
Working environment
• At home	168 (82)	37 (18)	0,146	129 (62,9)	76 (37,1)	0.007*
• Face to face interaction with customers	227 (83,8)	44 (16,2)		177 (65,3)	94 (34,7)
• Hospital	90 (88,2)	12 (11,8)		82 (80,4)	20 (19.6)
• Office	225 (87,5)	32 (12,5)		189 (73,5)	68 (26.5)
• Out door environment	137 (80,1)	34 (19,9)		117 (68.4)	54 (31.6)
City of residence
• Yaounde	538 (85,1)	94 (14,9)	0.009*	439 (69.5)	193 (30.5)	0.023
• Douala	130 (89)	16 (11)		91 (62.3)	55 (37.7)
• Buea	70 (78,7)	19 (21,3)		56 (62.9)	33 (37.1)
• Others	109 (78,4)	30 (21,6)		108 (77.7)	31 (22.3)

*Statistically significant at p <0.05

Attitudes towards COVID 19 pandemic

Attitude towards COVID 19 health-seeking behaviors was assessed. Of all respondents, 73.1% think they can be contaminated by health care workers, 28.6% refuse to go to the hospital even if they are suffering from another disease other than COVID 19. Out of the 28.6% of those who do not want to go to the hospital, 21.3% are afraid of being contaminated in the hospital with nosocomial infections like COVID19, 3.5% think the health personnel can misdiagnose their illness given that many other diseases have similar symptoms (Table 3).

Regarding people's willingness to do a COVID 19 test, 72.0% were willing to do a voluntary test among which 47% of them preferred the house over the hospital for their medical care if tested positive. People’s preference for house medical care is because they are afraid of being contaminated in the hospital (38.6%), their families can take good care of them and they feel comfortable at home (58.1%) (Table 3). Overall, 69% of respondents had a high attitude score of 2–4 for health-seeking behavior (Table 4).

Practices towards COVID 19 pandemic

All the respondents use masks (100%), 94.5% wash hands and use sanitizers, 83.8% practice social distancing, or don’t go to crowded places, while 20% are confined at home. Looking at what people take as preventive measures, 74.6% eat citrus fruits and take vitamin C tablets. We also observed that 35.9% resort to traditional concoctions, auto medications like chloroquine (4.4%), (5.6%) paracetamol, and Ibuprofen (Table 3).

Also, 60.8% of respondents were taking precautions (good practice) like avoiding crowded areas, wearing masks, washing hands, and using sanitizers, taking vitamin C and citrus fruits. Statistical significant differences in knowledge of disease transmission were observed with gender, working environment, and city of residence (Table 5).

Table 5

Associations between background characters and practice regarding COVID 19.

Variables	Practice Score(3–9)	Practice Score (0–2)	(P-value)
	N (%)	N (%)
Overall	612 (60.8)	394 (39.17)
Gender
• Male	307 (65)	165 (35)	(0,008)*
• Female	305 (57,1)	229 (42,9)
Age
• <20	19 (59,4)	13 (40,6)	(0,138)
• [20–30]	203 (56,2)	158 (43,8)
• [30–40]	226 (61,6)	141 (38,4)
• [40–50]	91 (65,5)	48 (34,5)
• ≥50	73 (68,2)	34 (31,8)
Profession
• Health care worker	62 (62,6)	37 (37,4)	(0,030)
• Private sector worker	109 (59,9)	73 (40,1)
• Public service personel	86 (61)	55 (39)
• Retired	16 (94,1)	1 (5,9)
• Student	159 (59,3)	109 (40,7)
• Teacher/Lecturer	85 (63)	50 (37)
• Others	95 (61,3)	69 (38,7)
Working environment
• At home	127 (62)	78 (38)	(0,004)*
• Face to face interaction with customers	144 (53,1)	127 (46,9)
• Hospital	62 (60,8)	40 (39,2)
• Office	164 (63,8)	93 (36,2)
• Out door environment	115 (67,3)	56 (32,7)
City of residence
• Yaoundé	368 (58,2)	264 (41,8)	(0,007)*
• Douala	102 (69,9)	44 (30,1)
• Buea	55 (61,8)	34 (38,2)
• Others	87 (62,6)	52 (37,4)

*Statistically significant at p <0.05

Age > 20 years was associated to high knowledge and attitude scores on COVID 19 (Table 6). Women had lower practice scores compared to men (OR = 0.72; 95% CI 0.56–0.92) and Douala respondents had had high practice scores (OR = 1.16; 95%CI 1.13–2.45) when compared to those from Yaoundé (Table 6).

Table 6

Factors associated with knowledge and practice towards COVID 19.

Demographics/characteristics	Knowledge	P-value	Practice	P-value	Attitudes	P-value
	OR (95% CI)		OR (95% CI)		OR (95% CI)
Gender
• Male	1		1		1
• Female	0,92 (0.66–1.30)	0.65	0.72 (0.56–0.92)	0.010*	1.598(1.209–2.113)	0.001*
Age
• <20	1		1		1
• [20–30]	2.58 (1.21–5.54)	0.015*	0.88 (0.42–1.83)	0.73	3.366(1.563–7.249)	0.002*
• [30–40]	4.77 (2.17–10.47)	<0,001*	1.10 (0.53–2.29)	0.81	2.746(1.190–6.339)	0.018*
• [40–50]	3.57 (1.51–8.42)	0.004*	1.30 (0.59–2.85)	0.52	2.712(1.108–6.637)	0.029*
• ≥50	2.97 (1.23–7.13)	0.015*	1.47 (0.65–3.32)	0.36	3.347(1.310–8.553)	0.012*
Profession
• Health care worker	1		1		1
• Private sector worker	0.75 (0.32–1.79)	0.52	0.89 (0.54–1.47)	0.65	0.418(0.234–0.748)	0.003*
• Public service personnel	0.87 (0.35–2017)	0.76	0.93 (0.55–1.58)	0.80	0.817 (0.430–1.551)	0.536
• Student	0.30 (0.14–0.65)	0.002	0.87 (0.54–1.40)	0.57	0.614(0.166–2.273)	0.465
• Teacher/Lecturer	0.35 (0.15–0.81)	0.014	1.01 (0.59–1.73)	0.96	0.622(0.331–1.166)	0.138
• Others	0.42 (0.19–0.97)	0.041	0.95 (0.57–1.57)	0.83	0.385(0.212–0.698)	0.002*
City of residence
• Yaounde	1		1		1
• Douala	1.42 (0.81–2.49)	0.22	1.66 (1.13–2.45)	0.010*	0.715(0.480–1.064)	0.098
• Buea	0.64 (0.37–1.12)	0.12	1.16 (0.74–1.83)	0.52	0.689(0.425–1.118)	0.132
• Others	0.63 (0.40–1.01)	0.053	1.20 (0.82–1.75)	0.34	1.418(0.906–2.220)	0.127

*Statistically significant at p <0.05

Symptomatology and associated co-morbidities of COVID 19

Out of all the respondents, 71.7% reported no symptoms of the disease, while 5.0% reported fever, 8.3% dry cough/catarrh, 6.5% throat irritation, 13.1% headache, 0.9% diarrhea, 2.5% difficulty breathing, 6.0% muscle pain and 2.2% don’t smell odor or taste. Of all the respondents, 4.7% suffered from hypertension, 6.9% from a common cold, and 24.6% from malaria (Table 7). Significant statistical differences were observed with respondents having hypertension > 30 years when compared to those <30 years (Table 7). Forty-one respondents (4.1%) had more than 3 symptoms with only 9 (21.95%) who called while 32 (78.05%) did not call .

Table 7

Associations between age, gender with Comorbidity and symptoms of COVID 19.

		Gender		P-value	Age (years)		P-value
Comorbidities	All patientsN(%)	FemaleN(%)	MaleN(%)		<30N(%)	≥30N(%)
Hypertension	47 (4.7)	30 (5.6)	17 (3.6)	0.13	1 (0.3)	46 (7.5)	<0.001*
Cancer	2 (0.2)	2 (0.4)	0 (0.0)	0.50	0 (0)	2 (0.3)	0.257
Diabetes	12 (1.2)	8 (1.5)	4 (0.8)	0.39	1(0.3)	11 (1.8)	0.028
Cardiovascular diseases	7 (0.7)	3 (0.6)	4 (0.8)	0.71	1 (0.3)	6 (1.0)	0.178
Asthma	19 (1.9)	13 (2.4)	6 (1.3)	0.25	7 (1.8)	12 (2.0)	0.841
Respiratory tract infection	14 (1.4)	8 (1.5)	6 (1.3)	0.75	3 (0.8)	11 (1.8)	0.27
Common flu	69 (6.9)	37 (6.9)	32 (6.8)	0.93	26 (6.6)	43 (7.0)	0.81
Allergic cough	27 (2.7)	19 (3.6)	8 (1.7)	0.068	7 (1.8)	20 (3.3)	0.16
Tuberculosis	4 (0.4)	3 (0.6)	1 (0.2)	0.63	1 (0.3)	3 (0.5)	1.00
Malaria	247 (24.6)	112 (21.0)	135 (28.6)	0.005	93 (23.7)	154 (25.1)	0.6
Symptoms of COVID19
Fever	50 (5.0)	26 (4.9)	24 (5.1)	0.87	21 (5.3)	29 (4.7)	0.063
Dry cough/catarrah	84 (8.3)	38 (7.1)	46 (9.7)	0.13	27 (6.9)	57 (9.3)	0.174
Headache	132 (13.1)	85 (15.9)	47 (10.0)	0.005	54 (13.7)	78 (12.7)	0.641
Diarrhea	9 (0.9)	4 (0.7)	5 (1.1)	0.71	6 (1.5)	3 (0.5)	0.088
Muscle pain	60 (6.0)	27 (5.1)	33 (7.0)	0.19	23 (5.9)	37 (6.0)	0.905
Do not smell odor or taste	22 (2.2)	13 (2.4)	9 (1.9)	0.57	5 (1.3)	17 (2.8)	0.112
Difficulty breathing	25 (2.5)	13 (2.4)	12 (2.5)	0.91	9 (2.3)	16 (2.6)	0.075
Throat irritation	65 (6.5)	38 (7.1)	27 (5.7)	0.37	19 (4.8)	46 (7.5)	0.093

*Statistically significant at p <0.05

The association between the KAP and the symptomatology was assessed to see the influence of KAP on the risk of having the disease. Interestingly, there were no significant differences between those having symptoms and those without symptoms. Also, no significant difference was observed with those having <3 symptoms to those having >3 symptoms (Table 8).

Table 8

Associations between symptomatology and KAP.

Symptomatology	Knowledge Score (4–7)N(%)	KnowledgeScore (0–3)N(%)	P-value	Attitude Score (0–2)N(%)	Attitude Score (2–4)N(%)	P-value	Practice ScoreN(%)	Practice ScoreN(%)	P-value
No Symptom	628 (84.8)	113 (15.2)	0.419	516 (69.6)	225 (30.4)	0.456	454 (61.3)	287 (38.7)	0.638
Symptoms	219 (82.6)	46 (17.4)		178 (67.2)	87 (32.8)		158 (59.6)	107 (40.4)
0–3 symptoms	203 (83.2)	41 (16.8)	0.416	162 (66.4)	82 (33.6)	0.359	145 (59.4)	99 (40.6)	0.824
≥4 symptoms	16 (76.2)	5 (23.8)		16 (76.2)	5 (23.8)		13 (61.9)	8 (38.1)

*Statistically significant at p <0.05

Overall 23 respondents having ≥4 symptoms had underlying comorbidities and 10 of them had other diseases with symptoms similar to COVID 19 (Fig 1). Also, 168 (18.1%) out of 262 of those with symptoms did not have them recurrently.

Fig 1

Associations between the number of respondents with A) comorbidities, B) diseases with some common symptoms to COVID 19 and <4 symptoms or ≥ 4 symptoms of COVID 19.

Discussion

COVID 19 is spreading rapidly across the whole world and increasing exponentially in Cameroon [4]. This is one of the first studies that identify symptoms (suspected cases) of COVID 19 which is a thoughtful thing to do in a population experiencing a sudden outbreak. This method used to recruit participants is cost-effective and feasible given that the data was collected during a period of confinement and it can be employed as a rapid screening method in subsequent pandemic situations. In this study, predominantly women in an overall 84.19% had adequate knowledge about the mode of transmission of COVID 19. Akwa et al. [9] reported in his study that > 80% of respondents knew the disease is transmitted by a handshake, person to person, and contact with infectious droplets only. Our findings show that there is an increase in the knowledge perception of disease transmission since respondents now know it is transmitted by touching contaminated surfaces and then touching eyes, nose, or mouth. We found that 69% of respondents had a high attitude score towards hospital seeking behavior while 60.8% took the necessary precautions like avoiding crowded areas, wore masks, washing hands regularly as stipulated by the WHO and CDC guidelines [10]. The practice score was not as high as expected because 39.2% of people resorted to traditional concoctions and auto medications. These potentially risky behaviors were related to the female gender maybe because within Cameroon traditional context women are caregivers to the family. So communication initiatives, educational forums are needed to educate women on these risky practices.

The strict adherence to preventive practices could primarily be attributed to the very strict prevention and control measures implemented by local governments to put on masks and washing hands at every public place. The big question remains as to whether the masks are appropriately used given the current increase in the number of cases in Cameroon. The efficiency of social distancing may be compromised given that 26.9% of respondents interacted face to face (like in customer service points, banks, markets, etc), and the government later uplifted restrictive measures on bars and other leisure places.

The factors: gender, age, and city of residence which correlated positively with knowledge, practice for COVID 19 will be useful for public health policy-makers and health workers to recognize the target population for COVID-19 prevention and sensitization. The level of awareness on COVID-19 among Cameroonian residents was expected because 44.1% of the respondents knew that the disease outbreak was in December 2019 and 54.5% of the respondents got the information through the television before the first imported case in the country was recorded in March 2020. Sample characteristics such as; University students (BSc, Master, and Ph.D.) and private-sector workers, actively acquired knowledge of this infectious disease from various television channels, websites, and WhatsApp because of the alarming and global situation of the epidemic. So good sources of communication among Cameroonian residents in pandemic situations like this are the television, social media followed by mouth to mouth communication by those who don’t have access to these technologies. Cases of COVID 19 as with other diseases are broadly classified as suspected, probable, and confirmed cases [7]. Also, clinical symptoms vary from mild to moderate other than severe in old people with comorbidities [11]. Assessing the symptoms of COVID 19 (suspected cases) is a preliminary step in the diagnosis and management of this disease. This study showed that 41/1006 respondents had ≥ 3 symptoms (Fever, dry cough/catarrh, throat irritation, headache) linked to COVID 19. This estimate is hypothetical as some COVID 19 symptoms are equally clinical signs of other diseases like malaria and respiratory tract infections (bronchitis) [12]. Respondents experiencing ≥ 3 symptoms must seek medical help since the differential diagnosis of malaria or respiratory infections and COVID 19 is slim. Also, there are no significant differences in KAP between those having symptoms and those without symptoms. This warrants further investigation to assess the effectiveness of the measures put in place to curb the spread of the disease given the continuous increase in the number of cases and the overall high KAP score.

Also, hypertension was more prevalent in respondents > 30 years old with P-value <0.001. Arif et al [13] showed that hypertension is linked to old age with an overall prevalence of hypertension of 41.9% (95% CI: 37.2–46.6) in a total of 418 residents in Ethiopia ≥ 50 years old. Overall 23 respondents having ≥4 symptoms had underlying comorbidities and 10 of them had other diseases with symptoms similar to COVID 19 in our study. This could be potentially dangerous for these patients given that, previous studies on coronavirus death rates have also been shockingly higher in pre-existing comorbidity such as cardiovascular disease, Diabetes, Hypertension, Chronic respiratory disease, Cancer [14,15]. Of all the respondents,168 (18.1%) out of 262 of those with symptoms did not frequently or habitually experience such symptoms. Among the 168 respondents, those presenting with ≥ 3 symptoms were considered as suspected cases.

The presence of ≥ 3 symptoms in 4% (56% of them with co-morbidities) of the population surveyed supports the current trend in the number of confirmed cases (8681) in Cameroon. Thus widespread testing in the community is relevant because <22% of people with COVID 19 symptoms seek help. Given that 32(78.05%) of respondents who had more than 3 symptoms and did not call 1510, won’t be able to manage their conditions appropriately without the counsel of medical personnel they will further contribute to the spread of the disease. The hesitance to call was attributed to fear of getting contaminated, stigmatization if they are COVID 19 positive and misdiagnosis. Having symptoms and also comorbidities is high risk and not seeking help at the hospital and resorting to traditional concoctions with no standard dosage and auto-medications is much riskier. This calls for more sensitization and discrete ways of managing cases.

Recommendations

COVID 19 outbreak has put the whole world under panic and in our context stigma. People’s attitudes and practices could stem from panic and stigma or the knowledge provided to them. One way to avoid this could be to create a confidential online system to share COVID 19 experiences and consult online which is one of the objectives of our study. A better approach would have been to use more sophisticated software technics like qualtrics (which we didn’t have in our settings) to geolocalize suspected cases and circumscribe a particular neighborhood for rapid and prompt intervention. Also, telecommunication industries could engage in sending daily consultation messages to the population on COVID 19 symptoms which could serve as baseline data for health personnel. The effectiveness of the prevention measures of COVID 19 still needs to be well established (total confinement being the best option) reason being that there is an increase in the number of cases regardless of a high KAP score observed in our study. Our study opens more doors for scholars who could use the same research design to collect data in similar situations; and learning from what is happening in Cameroon could be useful for comparative studies on COVID 19 experiences of other African countries. Women should be the primary target audience for behavior change initiatives by program managers on the management and understanding of COVID 19 disease. This behavior change initiative is of paramount importance to preclude negative attitudes of not going to the hospital (or calling 1510) when sick and encourage positive preventive and therapeutic practices, for fear of a rapid rise in mortality rate due to auto medications and traditional concoctions.

Limitations of the study

Due to limited access to the internet and online information resources, populations in remote areas were not interviewed since the disease is most prevalent in the cities.KAP studies for people at the grass-root level in Cameroon are needed to assess their preparedness towards the COVID-19 pandemic. The second limitation is the limited sample representativeness used to assess suspected cases, comorbidities, and the unstandardized assessment of attitudes towards health-seeking behavior, which should be developed via focus group discussion and in-depth interview accompanied by confirmatory tests. Thirdly, a KAP is a quantitative tool and that to focus on behavior change qualitative work would be necessary. Finally a poststratification analysis was not feasible in our study reason being that the latest census in Cameroon was carried out in 2005.

Survey questionnaire.

(DOCX)

Click here for additional data file.

City of residence of respondents.

(DOCX)

Click here for additional data file.

12 Jul 2020

Dear Dr Adela,

Thank you very much for submitting your manuscript "Knowledge, Attitudes, Practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

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PLOS Neglected Tropical Diseases

Andrés Henao-Martínez

Deputy Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: The objective as well as the hypothesis are both clearly stated. The challenge for the authors is to more clearly and strongly link the results to the hypothesis that the KAP can indeed impact the acceptance of recommended measures to interrupt transmission of the corona virus. One area that is not clear to me is the collection of information on symptomatology. This avenue of study did not clearly fit into the stated objectives as there is not effort made to tie individuals’ symptoms into the behaviors that a KAP seeks to establish. My recommendation is to look at whether self -reported symptoms plays a role in any of the three pillars of a KAP.

The study design is appropriate given that it was conducted during a time of partial confinement and self-quarantining. There are further comments on this in the discussion of the study’s limitations. The population is clearly described though (and again to be discussed later in the limitations section) the population is limited to urban dwellers possessing the necessary technology and are literate. This corresponds with the fact that apparently all respondents were employed with perhaps the exception of those listed under “other”. These factors are ones that may exclude those who are more vulnerable to disease i.e. those who are not as socially, economically advantaged. These factors should be noted in the study population and eligibility criteria section as well as in the discussion of limitations.

I would also recommend that the authors provide more context of the disease within Cameroon citing available statistics and explicitly stating what measures the government has taken to slow transmission. This would be much more helpful than the global overview of the pandemic that is given.

I defer the questions concerning sample size and statistical analysis to those who with more expertise than my own.

There are no ethical concerns though the authors could state if any recommendations and actions were made to those reporting symptoms that could indicate infection with the corona virus.

Reviewer #2: • The objectives stated are very superficial and no hypothesis are stated in the manuscript. It appears one of the attempts researchers made is to test the association of demographic characteristics on KAP. This part needs major revision of stating all the hypothesis testable from current data and articulating objectives.

• Study design to be improved stating dependent vs independent variables being studied with reference to each of the objective

• It seems study sample is taken from 4 cities, of above 18 years age, with WhatsApp, email & website facility. Details of total population of the 4 cities viz. population size, salient demographic and social features, economic and educational status and incidence/prevalence of covid-19 etc be given.

• Unless there is adequate justification to say this sample represents the general population of the 4 cities, the findings will be applicable to only to the sample category of the population. This may be one of the limitations.

• For the current visible hypothesis sample size would be adequate.

• The conclusions need to be rewritten based on the analysis which has to be in accordance with the objectives

To be mentioned briefly in the methodology:

• Category of respondents, proportion of the sample (affected/healthy/suspected), Sampling procedure applied.

• The activities mentioned in the manuscript like- suspecting the cases of covid-19, Assessing their symptoms, collecting the details of comorbidity etc are carried out as part this research study ? Whether primary or secondary methods used for every data collected.

• Clarify possible range of min-max KAP scores. If the scores (mentioned in line 144) 3-7, 1-4, 2-9 are achieved ones it is possible there are some false questions, which may be deleted from manuscript as they will be misleading the readers.

Details of analysis done mentioning the types tables and statistical tests used for testing each of the two variables.

Reviewer #3: The paper employs an online survey with offline recruiting to study the Knowledge, Attitudes, and Practices related to the COVID-19 in Cameroon. The analysis is ok, and the interpretation of the results is proper. My only concern with methods are the following:

1. The recruiting is problematic: the respondents were recruited by a poster that invited people to answer the survey. This builds in a bias inside the responses, dismissed because the authors find the disease's prevalence similar to the reported number of cases. I believe this is still problematic, and the authors have to point out some problems and some strengths of this 'snowballing sampling' process.

Suggestion 1: Explain the recruiting process better and have an appendix with an example of the poster used for recruitment. Moreover, the word poster somehow gave me the idea that it was something physically placed somewhere. Luckily I read the paper twice, but some other people may have the same perception.

Suggestion 2: There certainly are strengths in snowballing a sample. The authors acknowledge that the sampling may be a limitation, but they could also discuss how it may be advantageous: cheap and feasible in a pandemics situation. This has to be stressed and perhaps suggested for similar studies.

2. The demographics: the authors should provide the demographics of the country and how they relate to their sample demographics. As their sample comes from people that know how to read, perhaps they should take the country demographics with these proper restrictions.

Suggestion: find out the country demographics and discuss how they relate with the survey one. One caveat here is that the last Census was taken in 2005. However, the authors could find projections in the BUCREP website (or at least explain why not possible to find reliable aggregated country-level data).

3. Answering time analysis: As the COVID grew over time, so did the media exposure and the knowledge from people. They had about one month of data collection going on. Did the patterns change from the first to the last 15 days? If so, how?

Suggestion: redo the analysis using the split sample of SPSS by dates, breaking in two or three subsequent periods.

4. Multilevel Regression and Post-stratification: Based on suggestions 2 and 3, you could also run a multilevel regression and poststratification on the covariates in a census to see if you could reweight the sample, to make the sample closer to the actual population in Cameroon.

Suggestion: check to see if you could apply multilevel regression, and have better estimates by each town or region. If not, at least raking the sample to make it closer to the proportions in the population. This piece might help to do the raking using SPSS (https://community.ibm.com/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=17fd2f0b-7555-6ccd-c00c-5388b082161b&forceDialog=0).

Should these points be addressed, I believe the paper will increase considerably in quality and breadth.

Minor points:

1. What program did you use to collect the answers? If Qualtrics, you have georeferenced information from the respondent.

2. Have you incentivized the responses in any way?

3. I am not an expert on Cameroon, but is there any social media that could have been used to boost the response rates?

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Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The analysis plan is followed as far as it goes. The reader is presented with the findings of concerning knowledge, attitude and practices through tables that are sufficiently clear. I would recommend avoiding the terms of good and right and wrong knowledge and other somewhat judgmental adjectives. The fact that the global understanding of the virus is in flux, what is seen as “good” may not be in another month. The authors should present to us what their baseline is for judging behaviors and knowledge. An example is that whether hospital seeking behavior should be considered as a positive behavior considering that nosocomial transmission is indeed a risk.

As noted above, the symptomatology does not provide any additional insight into the results of the KAP. I would recommend that if possible, the authors analyze the symptomatology data in light of the other findings of the actual KAP. Does having symptoms impact on attitude, on practice, etc.?

Reviewer #2: Analysis needs major modifications, and also will have to be articulated as per the modified objectives and analysis plan:

Table-2 can bring out a crucial finding if it can be made a cross table (source vs period) to asses the magnitude of effective and early means of communications among the study population.

Table-3: shows the response of total sample to the KAP questionnaire. No need to show the question as such in the table. Need to provide N value wherever only % is given.

• Table-4 seems to be primarily used for testing the association between level of knowledge of the total sample and demographic variables, which needs percentage corrections. Cross tabulations with independent variables in rows need to show row percentages, so that as in case of gender (table-4) it can be inferred, the proportion of respondents with high or low knowledge is more or less from which gender. Column percentages presently showing only the gender proportion, not of those with high and low knowledge in each gender. In the same row the test used for significance and (p= ) value details etc be mentioned. Mean scores has no importance.

• Similar tables be developed for testing any associations if in the objectives between any variables and the levels attitudes, practices, Symptomatology, Comorbidity with title specifying the association being tested in the table.

• Avoid using of value judgments by using ‘low knowledge(0-3)’ and ‘high knowledge(4-7)’ or adequate knowledge ( ) and inadequate knowledge( ) mentioning the score ranges instead of ‘right knowledge’ and ‘wrong knowledge’ in table-4. Similarly avoid using terms like ‘good practice’ & ‘wrong practice’ in table-5; positive and negative practices or risky or non risky /traditional and modern practices which are used in discussion may be used.

• All the tables like table-7, should show totals or (N= ) in proper place . From page-15 under symptomology need to specify the symptoms of what disease.

Findings from each of the figures and tables be clarified as per objectives.

Reviewer #3: The results are clear and intelligible. The tables and images are of excellent quality. The interpretations are precise and match the results in the tables. The writing is clear and concise, and I thank the authors for having written such a pleasant paper to read.

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: I find the discussion and conclusion sections to be in need of greater thought particularly in regard to the public health implications. I congratulate the authors for undertaking this work rooted in behavioral health as these are the elements that prior to the development of therapeutic drugs and vaccines that will reduce the infection and mortality rate. The data provided offers a number of avenues to explore within a public health context which need much more critical analysis. For example, In the last line of the first paragraph in the discussion section, it was stated that …”potentially risky behaviors were related to the female gender’’’”. This finding (which also needs to be better justified) opens up a number of doors for interventions with women as the target audiences whether it is communication initiatives, educational approaches, etc. The authors suggest a confidential on-line system to share experiences. In making this recommendation, the data from the KAP should be used by the authors to justify the idea.

My overall recommendation is for the authors to tie the data more directly into interventions that could be recommended to governmental and non-governmental organizations.

In terms of limitations, I think the authors overlook a number of issues here. Primarily, the use of the technology limits participation to those who have access to the various platforms used. Another limitation is the study depends on respondents being literate which also excludes many of Cameroon’s poor and as we see in various countries disparities along socio-economic lines of who gets infected are very clear. The relatively high % of people taking recommended precautionary measures could easily be related to their educational level, income, etc.

Though the disease may initially be more prevalent in cities, we have seen in other settings the migration to home villages bringing infection with them. Their recognition of the need for further work at the grass roots level is well taken and I would recommend it being a recommendation in the conclusion or discussion section.

Additionally, I would suggest that if the authors are not prepared to recommend interventions based on the results, they state that a limitation to the study is that a KAP is a quantitative tool and that to really focus on behavior change qualitative work would be necessary.

The final limitation of the study is the constant flux in the global knowledge of Covid-19 and what is considered best practices.

Reviewer #2: The conclusion- People’s attitudes and practices could stem from panic and stigma- to be verified whether it is out of stigma or provided knowledge to them.

Rest of the conclusions are suggestions to the programme, addressing them with online education receiving facility and who visit hospitals. Both seem to be out come of the responses.

The authors' discussions about KAP and raise in cases can not be made as 2nd time data not available.

The knowledge, attitude and Practices of the study sample can not be attributed the general population of Cameroon, Findings of the study sample , represent the behaviour a better community with on line communication facility.

However, as per the findings there are 41/1006 respondents had ≥ 3 symptoms; Provided out of them 32(78.05%) of respondents who had more than 3 symptoms and did not call 1510, this research may help to estimate how many more cases with symptoms and not positive to report in a complex of several communities of Cameroon, where there are confirmed cases 8681, 4836 recovered and 212 deaths.

Reviewer #3: The authors made a compelling case for why we should consider their data as important information to have wide-spread testing in Cameroon. They also claimed that the data suggest a few improvements that could be made, especially in the gender-related correction of misperceptions about the COVID. I agree with them that this is relevant to public health.

However, it would have been interesting to discuss a bit about how we can apply the knowledge acquired in Cameroon for other African countries.

Suggestion: improve the conclusion with recommendations, first, of how scholars could use the same research design to collect data in similar situations; and second, how learning what is happening in Cameroon helps us to understand the COVID experiences of comparable countries.

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Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: The paper needs copy-editing to ensure the authors’ intentions are being clearly communicated. Some comments follow:

Methodology

Line 22 – not clear “interacted face-to-face

Line 24 – positive needs to be defined as well as good

Conclusion:

Line 28 (1st sentence of paragraph) needs clarification

Line 29 – Information that would be welcome in Background

Summary:

Lines 46 – use of satisfactory and good

Line 49 – needs to be clarified

Introduction

Line 61 – delete “seems to be very contagious”

Line 66 – the phrase “ Some of these measures…” is insufficient. If there are others beyond what is listed, the reader would want to know them. If this is the complete list, delete “Some of”

Line 72 – The sentence needs some wordsmithing – ex The infection rate and ths the resources needed to battle this disease can be expected to increase exponentially

Lines 74-83 – I would consider deleting most of this discussion of treatments as much of it is in flux. The main point here is that without treatments available many may turn to “non-standard options”

Study Design

Line 110 – what other cities/what populations

Line 116 – restricted to literate respondents

Symptomatology

There needs to a clearer link between the KAP and reported symptoms. Otherwise it doesn’t really belong in this paper. Why are we interested in the symptoms. Was there any effort to explore their knowledge in terms of what symptoms are associated with CVD-19.

Discussion

Last line of the first paragraph: this seems very speculative while at the same time does not really explain why women may report riskier behaviors. If the authors want to pursue this line of thinking, a more in-depth look is warranted. If correct and more clearly justified, it does provide program managers with a primary target audience to for behavior change initiatives

The last paragraph explores more deeply the issues of signs and symptoms and implications than KAP but if possible should be analyzed in light of the KAP objectives stated in the beginning.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: As noted elsewhere, the authors have taken a bold step to look at the current pandemic from a behavioral perspective understanding the import that knowledge, attitudes and practices will play in reducing the transmission rate and lowering mortality. Prior to publishing, I think the paper requires further thinking as to how the findings can advance Cameroon’s efforts to limit the impact of the infection. I believe the data is there but more than just presenting the data is needed. A more robust discussion of interventions is needed as defined by the results of the study. If symptomatology is to be included, it needs to be linked to the stated objective of the paper, i.e. assess the knowledge, attitudes and practices. Anchoring the paper more firmly in the Cameroon context, worrying less about the global situation, will also be helpful to fully understand how to move forward.

Reviewer #2: • The title may be slightly modified to convey the main features of the study-whether it is on health population or affected peoples.

The concepts used in the study viz. Knowledge/perception, Attitudes, Practices, Symptomatology and co-morbidities may briefly be defined and explained from the scope of the current study.

Table-1: show (N=1006)

• In the profession- who all include others. housewives are part of the study or not.

• In working environment-instead of Face to face interaction with customers their place of work may be mentioned.

• Face to face interaction (Yes/No) may be given below if data is available.

• Following variables may be added: Education and family income/economic status, Disease related data (healthy/with early signs/confirmed of Covid-19)

Reviewer #3: In this paper, the authors study the Knowledge, Attitudes, and Practices regarding the COVID-19 using an online survey in Cameroon. The authors recruited, from April 20 to May 20, 1006 respondents, using social media and websites, and the recruitment page directed the respondents to an online survey comprised of 32 questions. They find that respondents have a consistent knowledge about the COVID pandemics and that their symptom check and comorbidity studies match the prevalence of COVID-19 in the Cameroonian population. They also find that women tend to be less informed about COVID, which is interesting, as, around the world, women seem to care more about the disease than men.

Although the paper has several merits, I suggest a few revisions that would improve the article if adequately carried out. In the methods section, I detail my suggestions, guiding what I think could be done to improve the piece.

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Reviewer #1: Yes: Chad MacArthur

Reviewer #2: Yes: MOTURU SOLOMON RAJU

Reviewer #3: No

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5 Aug 2020

Submitted filename: Responses to reviewers comments Plos COVID (1)E.docx

Click here for additional data file.

11 Aug 2020

Dear Dr Adela,

We are pleased to inform you that your manuscript 'Knowledge, Attitudes, Practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

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Andrés Felipe Henao-Martínez, M.D.

Deputy Editor

PLOS Neglected Tropical Diseases

Andrés Henao-Martínez

Deputy Editor

PLOS Neglected Tropical Diseases

***********************************************************

28 Aug 2020

Dear Dr Adela,

We are delighted to inform you that your manuscript, "Knowledge, Attitudes, Practices of/towards COVID 19 preventive measures and symptoms: A cross-sectional study during the exponential rise of the outbreak in Cameroon," has been formally accepted for publication in PLOS Neglected Tropical Diseases.

We have now passed your article onto the PLOS Production Department who will complete the rest of the publication process. All authors will receive a confirmation email upon publication.

The corresponding author will soon be receiving a typeset proof for review, to ensure errors have not been introduced during production. Please review the PDF proof of your manuscript carefully, as this is the last chance to correct any scientific or type-setting errors. Please note that major changes, or those which affect the scientific understanding of the work, will likely cause delays to the publication date of your manuscript. Note: Proofs for Front Matter articles (Editorial, Viewpoint, Symposium, Review, etc...) are generated on a different schedule and may not be made available as quickly.

Soon after your final files are uploaded, the early version of your manuscript will be published online unless you opted out of this process. The date of the early version will be your article's publication date. The final article will be published to the same URL, and all versions of the paper will be accessible to readers.

Thank you again for supporting open-access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases