Assessment of preventive behavior and associated factors towards COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia: A community-based cross-sectional study.

BACKGROUND: The world is being challenged by the COVID-19 outbreak that resulted in a universal concern and economic hardship. It is a leading public health emergency across the globe in general and developing countries in particular. Strengthening good preventive behavior is the best way to tackle such pandemics.
OBJECTIVE: The study assessed preventive behavior and associated factors towards COVID-19 among residents of Qellam Wallaga Zone, Oromia Region, Ethiopia, 2020.
METHODS: A community-based cross-sectional study was conducted with a multistage sampling technique. Data were collected by interview and analyzed using SPSS version 23.0. Binomial logistic regression was used to test the association between the variables. An Adjusted Prevalence with 95% CI was used to express the associations and interpret the findings.
RESULTS: Among 634 participants, 417(65.8%) were from urban residences, and 347 (54.7%) belongs to a female. Age ranges 18 years through 87 years. Only 68(10.7%) participants showed good preventive behavior for COVID-19. The majority of them (84.7%) perceived that the disease is very dangerous and 450(71.0%) of them believe that they are at high risk. More than 17% of the respondents have sufficient knowledge. Respondents with sufficient knowledge about COVID-19 were about 2 times more likely to exercise good preventive behavior compare to those with insufficient knowledge, [(APR: 2.1; 95% CI: [1.2, 3.9)]. The urban residents was 3.3 more than that of rural residents to practice good preventive behavior, [(APR: 3.3; 95% CI: [1.6, 6.4)]. Respondents who use social media as a source of information were more than 2 times more likely to have good preventive behavior compared to those who did not, [(APR: 2.3; 95% CI: [1.3, 3.4)].
CONCLUSION: Adoptions of COVID-19 preventive behavior in the study population is very low. Due emphasis should be given to rural residents. Risk communication activities should be strengthened through effective community engagement to slow down and stop the transmssion of the disease in the community.

1. Introduction

Novel-coronavirus disease (COVID-19) is currently a public health emergency of international and local concerns [1]. The coronavirus belongs to a family of nidovirus that may cause various symptoms such as cough, fever, breathing difficulty, and lung infection. These viruses are common in animals worldwide, but very few had been known to affect humans [2].

Coronavirus disease was first found in Wuhan, China in late December 2019. The World Health Organization (WHO) used the term 2019 novel coronavirus to refer to a coronavirus [3]. The WHO announced that the official name of the 2019 novel coronavirus disease (COVID-19) to differentiate from other strains existing of the virus [4]. The current reference name for the virus is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was reported that a cluster of patients with pneumonia of unknown cause was linked to a local Huanan South China Seafood Market in Wuhan, Hubei Province, China in December 2019 [5].

Since 31 December 2019, millions of people diagnosed with having the disease. Until August 09, 2020, more than 20 million confirmed cases, and more than 733,000 deaths were reported globally and the majority of the cases and deaths belong to the USA and Europe. The African continent is becoming the continent in which it is on spreading [6]. As of August 09, 2020 Ethiopia reported 22,253 confirmed cases and 390 confirmed deaths [7].

Personal protective practices such as rigorous hand hygiene, cough etiquette, and use of face masks, maintaining social distancing can contribute to reducing the spread of COVID-19. Ultra-careful hand-washing schemes, including washing of hands with soap and water for at least 40 seconds, or cleaning hands with alcohol-based solutions, recommended in all community settings in all transmission scenarios [8].

Evidence shows that effective preventive behavior depends on one’s knowledge, attitude, and other socio-demographic characteristics. Most importantly arrays of floating rumors, myths, and misperceptions regarding the spread, treatment, and nature of the virus can substantially affect people’s knowledge, attitude, and adherence to standard COVID-19 protective measures. Thiswill in turn worsen the spread of the virus regardless of the beliefs [9, 10]. Thus, for effective risk communication programming, it is timely and imperative to assess people’s level of understanding and adherence to standard precaution measures in Ethiopia and the study area. Therefore, this study aimed to assess the level of preventive behavior and associated factors among residents of Qellam Wallaga Zone of Oromia region, Ethiopia. The finding will help the local, regional and nationalplanners to devise effective strategies to prevent and control the spread of COVID-19 in the community.

2. Methods and materials

2.1. Study design and population

This study was conducted among residents of Qellam Wallaga Zone in the Oromia region. The capital of this Zone, Dambi Dollo, is located at about 637 km away from Addis Ababa, the capital city of Ethiopia. Qellam Wallaga Zone has a total population of about more than 1 million. Previously there was only one general hospital in this zone. Since 2019, three primary hospitals started to give service even if inadequate facility. The area is politically and physically disadvantaged where no research conducted and published till the current time.

2.2. Sample size determination and sampling procedures

2.2.1. Sample size determination. The sample size was calculated by using a single population proportion formula assuming that 50% preventive behavior for COVID-19 in the community; design effect of 1.5 and 10% non-response rate. This yield total sample size of 634 individuals.

2.2.2. Sampling procedures

The sampling method was multistage random sampling technique. In the first stage 3(25%), (Dambi Dollo, Sadi Chanka, and Dale Wabera), out of 12 districts were selected by simple random sampling method. Then, in each selected district, three Gandas (the smallest administrative unit in Oromia) were selected using a simple random sampling technique and within each selected Ganda 211.33 households were selected using a random sampling method. The total samples were allocated on an equal proportion to each selected Gandale. Households were the main sampling unit and eads of the households were primarily considered for interview from the selected households. For household heads that were not available, another person in the household who could properly respond to the questions were interviewed. The primary outcome of the study was preventive behavior towards COVID-19. The covariates of interest include socio-demographic characteristics, access to and source of information, knowledge, and perception towards this disease.

2.3. Variables and measurements

2.3.1. Outcome variable

2.3.1.1. Preventive behavior for COVID-19. Refers to the respondents’ preventive activities that are recommended by WHO and MOH to reduce the spread of COVID-19 within the previous 2 days preceding the survey. It was measured by eight items with 5 point Likert scale response categories such as always, most of the time, sometimes, rarely, and never. The items include: wash hands regularly with soap and water; keep sanitizer based cleaner ready in case there is no water and soap for handwashing; don’t touch mouth, nose, and eyes with the unclean hand; use a tissue or inner hand during coughing and sneezing; keep a distance of at least 2 meters from other people; cook meat and fish before eating; non-hand touch greeting, and don’t travel crowded places. Finally, a composite variable termed comprehensive preventive behavior was produced by summing up the items as “good preventive behavior” for those who practiced all the preventive measures most of the time and above and “poor preventive behavior” for the regression analysis and discussion.

Socio-demographic factors: These variables were used to assess the individual background information which includes sex, age, residence, marital status, religion, ethnicity, and educational status.

Information about COVID-19: this includes access to and exposure to information, sources, and trust for the source of information about COVID-19.

Knowledge: refers to the individual awareness and understanding about the disease. Four different dimensions were assessed including the general knowledge (three items), mode of transmissions (seven items), signs and symptoms (seven–items), and prevention methods of COVID-19 (seven-items), making a total of 24 items. Finally, researchers create a single dichotomous variable from the items depending on the score as insufficient knowledge for those who scored less than 80% and sufficient knowledge for those who scored 80% and above to use in the analysis.

Perception: refers the respondents’ insights about COVID-19 in general. This includes perception about the severity of the disease and perceived susceptibility for COVID-19.

2.4. Data collection instrument and technique

2.4.1. Data collection tool

The questionnaire was developed by the researchers as part of this study. The researchers reviewed relevant literature on COVID-19 including the Risk Communication & Community Engagement (RCCE) Action Plan Guidance for Covid-19 Preparedness & Response and the WHO advice on self-care recommendations as a base to develop the tool. Knowledge of the researchers about the local perceptions and practice were also helped to enrich the study tool. Then it was assessed by other public health experts to ensure the validity of its content. The questionnaire was translated into Afan Oromo and back-translated into English to ensure consistency of the translations. Exhaustive items were constructed to measure the intended variables. The tool has six parts. Part I deal with the socio-demographic characteristics of the study subjects and is assessed on eight items. Part II contains questions related to access to and source of information on COVID-19 which is measured by three multiple response questions. Part III relates to knowledge and contains six main questions some with multiple responses. Part IV comprehends 10 items relevant to perception about COVID-19. Part V measured the preventive behavior of the respondents with 8 items derived from recommendations by WHO and MOH on 5 Likert scale.

2.4.2. Data collection technique

The data were collected by face to face interview using structured questionnaire. Twelve (at least diploma holders) data collectors and three master holder supervisors were selected, trained, and participated in field works. Self-protective measures were taken during the interview and the fieldwork in general, by interviewers such as the use of face masks, maintaining physical distancing, and alcohol-based hand rub.

2.5. Data quality control

To assure the quality of data, the following measures were undertaken including pre-testing of the questionnaire, the final version of the questionnaire was translated into the respondents’ language and intensive training was given to data collectors and supervisors and strict supervision was made.

2.6. Data analysis

The data were first checked manually for completeness and then coded; entered and cleaned using SPSS version 23. Descriptive analysis was used to describe the percentages and distributions of the respondents by socio-demographic and socio-economic characteristics. The main statistical method applied was a logistic regression with a binomial distribution and log link function. Variables which have a significant association with the dependent variable in the bivariate analyses at 0.25 were the primary target for multiple logistic regression model. Eligible variables were enter into the model to evaluate the methods that helps create a model that best fit the data and we found all the methods create similar quality model according the Hosmer and Limshow test of significance. Finally we use the stepwise forward (conditional) method to generate the model. Adjusted Prevalence ratio together with corresponding 95% confidence interval was used to interpret the findings “S1 Table”.

2.7. Ethical clearance

The ethical clearance was conducted according to the higher education institutions’ research ethics guideline. The ethical issues were checked and approved by Dambi Dollo University Institutional Ethical Review Committee. Then the official letter was received from the Dambi Dollo University Research and Technology Innovative directorate office. After having the official letter of the University, it was brought to the zonal health department, and selected district health office. A clear consent sheet was prepared and attached to the questionnaire for the data collectors to read for the participants just before the interview and written consent was obtained from individual participants. Confidentiality and privacy were maintained by excluding the name and ID of study participants from the questionnaire. Autonomy was maintained for both recruited & non recruited participants who are not willing to participate in the study was respected and they were not recruited in the study. All the enrolled participants were informed about the rights to withdraw from the study at any point in time. Justice was maintained by randomization to select the participants and veracity was maintained by truthfulness in each stage of the study.

3. Result

3.1. Socio-demographic characteristics of study participants

A total of 634 households from Sadi Chanka, Dale Wabara, and Dambi Dollo districts were included in the study with a response rate of 100%. The mean age of the respondents was 30.79 years with a standard deviation of 11.53 years. Three hundred and forty seven (54.7%) of respondents were females. Four hundred eighty nine (77.1%) have formal education. The majority, 604(95.3%) of the respondents were the Oromo ethnic group. Christians constitute more than seventy percent of the participants, 484(76.3%). Of the total respondents 485 (76.5%) of them are ever married; 242(38.2%) are farmers, and 417 (65.8%) reside in urban (Table 1).

Table 1

Socio-demographic characteristic of the study participants on assessment of preventive behavior and associated factors for covid-19 in Qellam Wallaga Zone, Oromia, Ethiopia, 2020.

Variables	Responses	Frequency (%)
Sex	Male	287 (45.3)
	Female	347 (54.7)
Age	< = 24	221 (34.9)
	25–34	187 (29.5)
	35–44	139 (21.9)
	45+	87 (13.7)
Education	No formal education	145 (22.9)
	Primary	215 (33.9)
	Secondary	189 (29.8)
	Tertiary	85 (13.4)
Occupation	Farmer	242 (38.2)
	Student	128 (20.2)
	Merchant	101 (15.9)
	Gov’t employee	86 (13.6)
	Daily labor	77 (12.1)
Marital status	Unmarried	149 (23.5)
	Ever married	485 (76.5)
Ethnicity	Oromo	604 (95.3)
	Amhara	22 (3.5)
	Gurage	7 (1.1)
	Other	1 (0.2)
Religion	Orthodox	70 (11.0)
	Protestant	414 (65.3)
	Muslim	147 (23.2)
	Other	3 (0.5)
Residency	Urban	417 (65.8)
	Rural	217 (4.2)

3.1.1. Access to information about COVID-19

Most of the respondents 551(86.9%) already had information about how to protect themselves from the disease; 542(85.5%) knew the symptoms, and 516(81.4%) of them had information about methods of transmission (Table 2).

Table 2

Exposure to information on COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia, 2020.

What information do you ever heard about COVID-19?	Frequency (%)
How to protect onself	551 (86.9)
Signs and Symptoms	542 (85.5)
Transmission methods	516 (81.4)
What to do if have symptoms	276 (43.5)
Risks and complications	193 (30.4)
Others*	18 (2.8)

3.1.2. Source of information about COVID-19

Household respondents were asked about the source of information on the coronavirus with multiple response items; from the total 2113 positive responses, the majority of them 429 (20.3%) was radio followed by the TV which was 394(18.7%). The least response was of the traditional leaders and others 38(2%) (Table 3).

Table 3

Sources of information on COVID-19 in Qellam Wallaga Zone Oromia, Ethiopia, 2020.

Source of information: N = 634		N (%)
From radio	Yes	429 (67.67%)
From TV	Yes	394 (62.15%)
Health facility	Yes	334 (52.68%)
From social media	Yes	253(39.91%)
Religious leaders	Yes	217(34.23%)
Any person from the community	Yes	152 (23.97%)
Friends	Yes	121 (19.09%)
Family member	Yes	111 (17.51%)
Community leaders	Yes	59 (9.31%)
Others	Yes	22 (3.47%)
Traditional healers	Yes	18 (2.84%)

3.2. Knowledge of COVID-19

Four dimensions of knowledge about COVID-19 were assessed in this study; general, mode of transmission, signs and symptoms, and prevention methods. of the total study subjects 213(33.6%), 87(13.7%), 33(5.2%) and 56(8.8%) of them gave correct response for the general, mode of transmission, signs and symptoms, and prevention methods dimensions respectively. Overall 130(20.5%) of the total respondents have sufficient knowledge while 504(79.5%) of them have relatively insufficient knowledge about COVID-19. Table 3 shows distribution of the knowledge about COVID-19 (Table 4).

Table 4

Knowledge about COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia, 2020.

Dimensions	Items	Yes	No	I don’t know
		N(%)	N(%)	N(%)
General knowledge about COVID-19	Does COVID-19 have a vaccine/treatment?	29 (4.6)	505 (79.7)	100 (15.8)
	COVID-19 only affect elderly	32 (5.0)	552 (87.1)	50 (7.9)
	One can completely cured from COVID-19 and be none-carrier	269 (42.4)	210 (33.1)	155 (24.4)
Mode of transmission	Corona virus can be transmitted by blood transfusion	100 (15.8)	520 (82.0)	14 (2.2)
	Coronavirus can be transmitted by droplet from an infected person	416 (65.6)	204 (32.2)	14 (2.2)
	Coronavirus can be transmitted by direct contact with an infected person	529 (83.4)	91 (14.4)	14 (2.2)
	Coronavirus can be transmitted by touching a contaminated object	376 (59.3)	244 (38.5)	14 (2.2)
	Coronavirus can be transmitted by sexual intercourse	171(27.0)	449 (70.8)	14 (2.2)
	Coronavirus can be transmitted by mosquito bites	100 (15.8)	520 (82.0)	14 (2.2)
Signs and symptoms	Fever	541 (85.3)	63 (9.9)	30 (4.7)
	Dry cough	563 (88.8)	41 (6.5)	30 (4.7)
	Shortness of breath	397 (62.6)	207 (32.6)	30 (4.7)
	Muscle pain	228 (36.0)	376 (59.3)	30 (4.7)
	Headache	409 (64.5)	195 (30.8)	30 (4.7)
	Diarrhea	173 (27.3)	431 (68.0)	30 (4.7)
	Sore throat	295 (46.5)	309 (48.7)	30 (4.7)
Prevention methods	Sleeping under mosquito net	43 (6.8)	585 (92.3)	6 (0.9)
	Wash hands regularly with water and soap	602 (95.0)	26 (4.1)	6 (0.9)
	Cover mouth and nose during coughing and sneezing	392 (61.8)	236 (37.2)	6 (0.9)
	Avoid close contact with a person who has a cough and fever	379 (59.8)	249 (39.3)	6 (0.9)
	Eliminate stagnant water	130 (20.5)	498 (78.5)	6 (0.9)
	Cook meat and egg well before eat	236 (37.2)	392 (61.8)	6 (0.9)
	Avoid contact with animals	182 (28.7)	446 (70.3)	6 (0.9)
	Avoid hand contact/shaking	540 (85.2)	88 (13.9)	6 (0.9)
Comprehensive Knowledge	Sufficient	130(20.5)
	Insufficient	504(79.5)

3.3. Perceptions about COVID-19

From the total 634 respondents, the majority of them (84.7%) perceived that the disease is very dangerous while about 4% of them thought the disease is not dangerous. Of total of 634 respondents, 450(71.0%) of them believe that they are at risk of acquiring the disease (COVID-19).

3.4. Preventive behaviors

Fig 1 indicates the distribution of preventive dimensions towards COVID-19. While the positive numbers on the right of the diagram indicate the frequency of respondents with preventive practice towards the disease, the negative sign before the numbers on the left side is to indicate the number of the respondents with behaviors that enhance the transmission of the disease. Among the top preventive behavior practiced always by the respondents was cooking meat before eating followed by wash hands regularly and non-hand touch greeting, 392(61.8), 327(51.6%), and 322(50.8%) respectively (. Overall about 1 in ten respondents showed good preventive behavior while the remaining respondents have shown poor preventive behavior (.

Fig 1

Distribution of COVID-19 preventive behaviors, Qellam Wallaga Zone, Oromia, Ethiopia, 2020.

3.5. Factors associated with COVID-19 preventive behavior

In this study three variables were found to independently associated with the respondents’ preventive behavior for COVID-19. Respondents with sufficient knowledge were found to be more likely to adhere to good preventive behaviors compared with respondents who have insufficient knowledge, APR (95% C.I) 2.1 (1.2, 3.9). Being urban resident and using social media were also independently positively associated with good preventive behavior for COVID-19 (Table 5).

Table 5

Factors associated with COVID-19 preventive behavior in Qellam Wallaga Zone, Oromia, Ethiopia, 2020.

Variables		Preventive behavior		Unadjusted PR (95% CI)	APR (95% C.I)
		Poor N (%)	Good N (%)
Knowledge about COVID-19	Sufficient	109(17.2%)	21(3.3%)	1.9(1.1, 3.3)	2.1 (1.2, 3.9)
	Insufficient	457(72.1%)	47(7.4%)	Ref	Ref
Residence	Urban	360(56.8%)	57(9.0%)	2.9(1.5, 5.8)	3.3 (1.6, 6.4)
	Rural	206(32.5%)	11(1.7%)	1	1
Social media as trusted source of information	Yes	86(13.6%)	20(3.2%)	2.3(1.3, 4.1)	2.3(1.3, 4.0)
	No	480(75.7%)	48(7.6%)	Ref	Ref

Note: We executed binomial logistic regression by entering the entire variables of the study using similar entry method to evaluate in case there is/are confounders which affect the observed associations and the model gave the same result as of the previous binomial logistic regression indicating that the potential confounders are well controlled in our analysis.

4. Discussion

The main aim of this study was to assess the preventive behavior of the respondents and associated factors. The level of preventive behavior on COVID-19 was low in our study. Of 634 respondents, only 68(10.7%) of them were practicing good preventive behavior. Evidence suggests that the spread of the disease has a direct relation relationship with the communities’ adherence to the recommended practice. For example, the potential for pre-symptomatic transmission underpins the importance of adherence to recommended preventive behaviors [11]. However, the finding from our study indicates about more than 8 in 10 respondents have poor adherence to the recommended preventive behaviors. This figure is very alarming towards the spread of the disease and necessitates further and rigorous enforcing and reinforcing efforts to strengthen the community’s preventive behavior against the disease.

In this study urban residents were about three times more likely to have a good preventive behavior compared with rural residents, [(APR = 3.26; 95% CI: 1.65, 6.45)]. This difference may be due to the fact that urban residencies have accessibilities to different sources of information like TV and social media more frequently than rural residents. In addition to this, access to hygienic material and clean water may be a problem in rural parts in Ethiopia which can be another problem to adhere to the recommended behavior. According to a report from Central Statistics Agency on drinking water quality results from the 2016 Ethiopia Socioeconomic Survey, 74 percent of the population reported that it takes 30 minutes or less to collect drinking water [12]. Other study finding in Adama indicates only about 15% of beneficiaries could get 20 liters of water per day per capita in rural area [13]. This may indicates that accessing the rural area with necessary information and materials support is very important to control the spread of the disease.

The other variable having a significant association with the outcome variable is the respondent’s level of knowledge about the COVID-19. Facts from different studies indicate knowledge is an important part in the formation of behavior [14]. For example, a lack of comprehensive knowledge has shown increased risks for another infectious disease like HIV while lower risk behavior is linked to better respondents’ knowledge about HIV/AIDS [15-17]. A study was done in Ghana during the Ebola epidemic also shows that respondents of greater knowledge level were more likely engaged in preventive behavior [18]. According to the finding from our study, the respondents with sufficient knowledge were about two times more likely to practice the preventive behavior compared with those with insufficient knowledge, (APR = 2.140; 95% CI: 1.17, 3.93). This finding, in line with scientific reasons, clearly shows that as the community’s level of knowledge increases their level of practicing the preventive behavior improves. This in turn may tells us that information dissemination and reinforcement is mandatory to improve the public knowledge about the disease towards protecting them.

In our study the use of social media as a source of information was also significantly associated with preventive behavior for COVID-19. Now days the world has become a global village where everyone can share information and learn about new things in the world being at his/her residence while social influences are primary factor in the adoption of health behaviors [19]. According to findings from a study conducted on effect of medias, media not only provides new information that persuades individuals to accept it but also can informs listeners about what others learn, thus facilitates preventive behavior [20]. In our study, those who use social media as their source of information on COVID-19 were twice more likely to practice COVID-19 preventive behavior compared with those who didn’t, APR = 2.25; 95% CI: .258, 4.03). This may indicate that social media has significant power in the adoption of the recommended preventive behavior for COVID-19 and should be further strengthened.

5. Limitation of the study

Even if the study has its own strengths, it also has its own limitations. First, the preventive behavior of the respondents towards COVID-19 was classified in to good preventive behavior for individuals who scored 80% and above while poor preventive behavior for those respondents scored less than 80% in utilizing all forms of preventive activities on regular bases. This classification still doesn’t assure that the respondents with good preventive behavior in this study will be at lesser risk as COVID-19 needs complete practice of the preventive actions on regular bases. Second, we use equal proportion of the sampling procedure and therefore, the absence of sampling weighting procedure in our analysis may introduced bias.

6. Conclusions

Collective preventive behavior was very low in this study. Of the total 634 respondents, only 68(10.7%) of the them showed adherence to good preventive behavior for COVID-19. Urban residence, social media as source of trusted information, and sufficient knowledge about COVID-19 showed statisticallhy significant positive association with good preventive behavior. Due emphasis should be given to rural residents, improving social media coverage and utilization and means to improve knowledge about the disease to bring the intended level of preventive behavior in the community towards COVID-19.

Summary steps for the final model in determining predictors of preventive behavior towards COVID-19.

(DOCX)

Click here for additional data file.

(SAV)

Click here for additional data file.

English version of the study questionnaire.

(DOCX)

Click here for additional data file.

Questionnaire Afan Oromo version.

(DOCX)

Click here for additional data file.

11 Dec 2020

PONE-D-20-28112

ASSESSMENT OF PREVENTIVE BEHAVIOR AND ASSOCIATED FACTORS TOWARDS COVID-19 IN QELLEM WALLAGA ZONE OROMIA, ETHIOPIA: A COMMUNITY BASED CROSS-SECTIONAL STUDY

PLOS ONE

Dear Dr. Gutu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

An expert in the field handled your manuscript, and we are thankful for their time and contributions. Although interest was found in your study, several major concerns and comments arose during review. Notably, there are questions about the experimental design, statistical analysis, and data presentation. Please address ALL of the reviewer's comments in your revised manuscript.

Please submit your revised manuscript by Jan 25 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"We would like to acknowledge Dambi Dollo University for financial aid."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"No, The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

5. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 50

change term "binary" logistic regression for "binomial" logistic regression

169

use logistic regression "with binomial distribution and log link"

50

change Odds Ratio for Prevalence Ratio. reason: It is a cross-sectional, not a case control study.

48

change multistage "systematic" sampling for multistage sampling

51

change test statistical significance for "to express the associations and"

116

remove word "systematic"

171

suggestion: detail the multiple stepwise process. specify if it was forward or backward. add a table to see the in which order the variables enter into the final model. review format in the output of summary(step.model$finalModel)in http://www.sthda.com/english/articles/37-model-selection-essentials-in-r/154-stepwise-regression-essentials-in-r/

165

observation: no details on how authors setup the survey sampling design prior to the logistic regression step. check: https://scialert.net/fulltext/?doi=ajms.2010.33.39

253

table 6 must specify the variables that were used to adjust the estimate. it also must show the unadjusted PR. put the outcome==1 in the right column (good prev behavior, in this case).

313

specify the reason of the restriction to make your data fully available

244

suggest to create figures to show the likert scale results as here https://www.r-graph-gallery.com/202-barplot-for-likert-type-items.html or here

https://cran.r-project.org/web/packages/sjPlot/vignettes/plot_likert_scales.html

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

22 Jan 2021

Response to academic editor’s comments

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

� Authors’ response: the manuscript revised according to PLOS ONE’s style requirements including the file naming

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

� Authors’ response: we revised and put the detail of study tool and its preparation under the “Data collection tool” subtitle in the manuscript and included a copy of both the original language and English, as Supporting Information with the revised manuscript.

3. Financial disclosure statement

Authors’ response: This study was funded by Dambi Dollo University. BG received the fund and used for the intended purposes. BG, GL, NF, BK, FS, WM, YS, LT, BY, KP and DS: received salary from Dambi Dollo University. The fund has no specific grant number. The university website is: http://www.dadu.edu.et.org.

4. Data availability

� Authors’ response: We uploaded the data file as Supporting Information with the revised manuscript

5. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

� Authors’ response: the title in the manuscript as well as on the online submission form are amended and identical

Response to reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

� Authors’ response: thank you

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

� Authors’ response: thank you for all the comments on statistical analysis, and data presentation. We amended all of them as suggested by the reviewer in our revised manuscript.

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

� Authors’ response: We uploaded our data as supporting information

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Authors’ response: Thank you

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:

48

Change multistage "systematic" sampling for multistage sampling

� Authors’ response: accepted and change made

50

Change term "binary" logistic regression for "binomial" logistic regression

� Authors’ response: modified as per the comment

50

Change Odds Ratio for Prevalence Ratio. Reason: It is a cross-sectional, not a case control study.

� Authors’ response: Prevalence Ratio replaced the Odds Ratio throughout the entire manuscript

51

Change test statistical significance for "to express the associations and"

� Authors’ response: change made and "to express the associations and" is used instead of “test statistical significance for”

116

Remove word "systematic" primarily

� Authors’ response: the word "systematic" is deleted

169

Use logistic regression "with binomial distribution and log link"

� Authors’ response: change made as per the comment

165

Observation: no details on how authors setup the survey sampling design prior to the logistic regression step. Check: https://scialert.net/fulltext/?doi=ajms.2010.33.39

� Authors’ response: we accept the observation and thoroughly explained the sampling design in our manuscript as “sampling technique”; all the necessary steps we followed to reach the study unit (the households) and the respondents has discussed in the manuscript.

171

Suggestions: detail the multiple stepwise processes. Specify if it was forward or backward. add a table to see the in which order the variables enter into the final model. review format in the output of summary(step.model$finalModel)in http://www.sthda.com/english/articles/37-model-selection-essentials-in-r/154-stepwise-regression-essentials-in-r/

� Authors’ response: Of course we planned to use multiple stepwise processes that would create the model that best fit our data based on the reality that we have large number of variables from our study. However, in our actual analysis all the methods produce similar model with similar Hosmer and Limshow’s model adequacy test result and as a reason we randomly used forward (conditional) method for variable entry in to the analysis. We also add a table titled “Variables in the Equation” from the output to see the in which order the variables enter into the final model as “supporting information” in our revised manuscript.

244 suggest to create figures to show the likert scale results as here https://www.r-graph-gallery.com/202-barplot-for-likert-type-items.html or here

https://cran.r-project.org/web/packages/sjPlot/vignettes/plot_likert_scales.html

� Authors’ response: figures to show the likert scale results created as suggested

253

table 6 must specify the variables that were used to adjust the estimate. it also must show the unadjusted PR. put the outcome==1 in the right column (good prev behavior, in this case).

� Authors’ response: From the unadjusted analysis, we found only four variables which have a statistically significant association with the outcome variable namely residence, comprehensive knowledge, social media as trusted source of information, and traditional healers as trusted source of information. First, we used all these variables to determine the adjusted estimate. While the residence, knowledge and social media show statistically significant association in the model, traditional healers as trusted source has no statistically significant association with the outcome variable but still in the final model. Then we decided to use only the three variables to develop the model removing traditional healers as trusted source to compare the models’ adequacy in fitting the data. Excluding traditional healers as trusted source resulted in improved adequacy of the model from 0.126 to 0.282, according to Hosmer and Lemeshow Test of model adequacy. Therefore, because the variable (traditional healer as trusted source of information) has no statistically significant association adjusted to other variables in the model and removing the variable increases the model adequacy, we used only the three variables (residence, comprehensive knowledge, social media as trusted source) to adjust the estimate and generate the final model. And all the three variables remained in the model as you can see from table 6. We also revised table 6 to show the unadjusted PR, and put the outcome==1 in the right column (good prev behavior, in this case) as per the suggestions.

313 specify the reason of the restriction to make your data fully available

� Authors’ response: we submitted the data file as supporting information with the revised manuscript

23 Feb 2021

PONE-D-20-28112R1

Assessment of preventive behavior and associated factors towards COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia: A community-based cross-sectional study

PLOS ONE

Dear Dr. Gutu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 09 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for accepting the recommendations and congratulation for your efforts.

First, about the statistical analysis, I wonder if in your original procedures you applied a binomial logit regression (to estimate odds ratios) instead of a binomial log (to estimate prevalence ratios). My initial suggestion according to your study design was to update your analysis in case if it is required.

Also, I suggest to detail if you applied weights for survey analysis as explained here: https://dev.stats.idre.ucla.edu/stata/faq/can-i-use-working-weights-for-survey-analyses-in-spss/

Additionally, even though your statistical analysis followed a predictive procedure, have you evaluate how other covariates could affect the associations that you found? For example, the association between residence-behavior and knowledge-behavior could depend or be confounded by age, education or occupation. In case any of those apply as confounders, the reported estimates should be adjusted for this set of variables. This would not require to add more rows to the table 5, but specifing it as a caption or note at the end.

Related to this last point, I suggest to evaluate the consistency of the term "predictor" (as in subtitle 4.5) if you already applied "associated factor". Predictive modelling involve different objectives and procedures. Review Shmueli, Galit. "To explain or to predict?." Statistical science 25.3 (2010): 289-310. (https://doi.org/10.1214/10-STS330) and Chen, Lingxiao. "Overview of clinical prediction models." Annals of translational medicine 8.4 (2020). (https://doi.org/10.1214/10-STS330).

Furthermore, I recommend to add a limitation paragraph in the discussion section. There you could detail how your results may be affected by the validity or biases of the scale that you applied to define the outcome (preventive behavior), including references of previous experiences, if it apply. Also about the sampling procedure or the absence of sampling weighting procedure.

Lastly, I recommend to fix some writing typos like in lines 193, 194 or 223 from the "clean" copy of the manuscript. At line 188, it should end as "log link function". At table 4, you could add N(%) at the heading as in previous tables. At table 5, change the number "1" with "Ref." to detail the category of reference.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

10 Apr 2021

Comments accepted, amended and explained

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

20 Apr 2021

Assessment of preventive behavior and associated factors towards COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia: A community-based cross-sectional study

PONE-D-20-28112R2

Dear Dr. Gutu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

22 Apr 2021

PONE-D-20-28112R2

Assessment of preventive behavior and associated factors towards COVID-19 in Qellam Wallaga Zone, Oromia, Ethiopia: A community-based cross-sectional study

Dear Dr. Gutu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Frank T. Spradley

Academic Editor

PLOS ONE