Knowledge, Attitudes, and Practices Surrounding COVID-19 among Sudan Citizens during the Pandemic: An Online Cross-sectional Study

Background: A number of protective and cautionary protocols have been adopted to control the rapid spread of COVID-19 in Sudan. People’s commitment to these protocols is affected by their knowledge, attitudes, and practices (KAP). Objective: To measure the Sudanese population’s KAP in relation to COVID-19 during the pandemic. Method: A web sample was enrolled with success via the authors’ relations with citizens and standard media in Khartoum, Sudan. A self-administered online KAP questionnaire was completed by the respondents. Results: Among the study sample (n=2336),66.4% between 18 and 29 years old, 60.7% were ladies, 75.9% had a high school education, and 76.1% were Khartoum citizens. The general correct rate of the knowledge questionnaire was 84.7%. The majority of the participants (94.8%) were ready to commit to the decision of staying at home. A large proportion of the participants (92%) frequently washed their hands or using antiseptic. Conclusion: Health teaching programs geared to enhancing COVID-19 knowledge are useful for Sudan citizens fostering positive attitudes and disseminating knowledge relating to helpful practices. Due to the limited sample representativeness, we must be cautious when generalizing these findings.


Introduction
Coronaviruses are a big family of viruses which can cause health problems in animals and humans. In humans, many coronaviruses are known to cause respiratory illnesses starting from the common cold to more severe diseases like Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) [1].
A continuing pandemic of pneumonia related to a novel coronavirus, called severe respiratory syndrome coronavirus 2 (SARS-Co-2), was reported in Wuhan, Hubei

Measures
The self-administered online questionnaire contained two parts: demographics variables which are: gender, age, marital status, education, occupation, and place of current residence. And questions about knowledge, attitude, and practices towards COVID-19.
Knowledge part had 17 questions: 9 regarding clinical presentations, 3 regarding transmission routes, and 5 regarding prevention and control of COVID-19 (Table 1).
Attitudes towards COVID-19 were measured by 3 questions: about the thinking on the control of COVID-19 successfully, the belief in winning against COVID-19 and adherence to the decision of staying at home. The practices of participants were evaluated by 4 actions: going to a crowded area, wearing a mask when going out in last few days, using tissues when coughing or sneezing, and washing hands with soap and water or using antiseptic.
All questions were answered on a Yes/No basis.

Data analysis
Data analyses were conducted with SPSS. Frequencies of correct knowledge answers and different attitudes and practices were described. Multivariable linear regression analysis using all of the demographic variables as independent variables and knowledge score as the outcome variable was conducted to determine factors related to knowledge. Similarly, binary logistic regression analyses were used to determine factors related to attitudes and practices.

Results
A total of 2,336 participants completed the study questionnaire. Within this population, 1,552 (66.4%) were between 18 and 29 years old, 1,418 (60.7%) were ladies, 1,773 (75.9%) have a high school education, and 1,778 (76.1%) were Khartoum citizens. Other demographic features are including in Table 2.
Nearly all the participants (94.8%) were ready to commit to the decision of staying at home. The attitude towards this question considerably varied among genders (OR 3.206 (2.179, 4.717) ( Table 5).
60.9% of respondents had not visited any crowded area however 49.3% wore masks when going outside in the days immediately prior to their taking the survey. There was still a significant portion of the respondents who had visited crowded areas (30.1%) and had not worn masks when leaving home (50.7%), (Tables 6 and 7).
Also, a large portion of participants (86.6%) used tissues when coughing or sneezing, and (92%) frequently washed their hands or used antiseptic. The rates of these two practices considerably varied among demographic classes (Tables 8 and 9).

Discussion
According to our information this is the first study in Sudan measuring the KAP towards COVID-19 among Sudan citizens. In this preponderantly female, young, unmarried and moderately educated population, we found a general correct rate of 84.7% on the knowledge test, indicating that majority of participants have good knowledge about COVID-19.
Almost all the participants also display a positive attitude towards the COVID-19 epidemic: 85.1% thought that COVID-19 will be successfully controlled; 60.9% consider Sudan will defeat the virus; 94.8% were ready to commit to the decision of staying at home.
Despite this, the practices of Sudan citizens were different, we found that 69.9% avoided crowded areas, only 49.3% wore masks when leaving the home, 86.6% used tissues when coughing or sneezing, 92% frequently washed their hands or used antiseptic throughout the interval of the COVID-19 pandemic.
We additionally analyzed the features of KAP towards COVID-19 and identified some demographic factors related to KAP; these findings are helpful for public health policymakers and health workers to identify target populations for COVID-19 prevention and health education [2].
A high correct rate of COVID-19 knowledge in Sudan citizens was predictable as we conducted this study some time after the pandemic started, giving time for knowledge about the virus and countermeasures to be disseminated amongst the population. The seriousness of the situation ensured widespread TV coverage in addition to guidance made publicly available on the WHO website and the national campaigns for public education.
Comparing our findings with a cross-sectional KAP study towards COVID-19 among Chinese residents [2], we found most Chinese respondents were knowledgeable about COVID-19 (90% correct rate), slightly higher than the 84.7% rate in the respondents to our study. They had an optimistic attitude towards the COVID-19 pandemic: 90.8% believed that COVID-19 will finally be successfully controlled, and 97.1% had confidence that China could defeat the virus. Chinese respondents were very cautious: nearly all avoided crowded areas (96.4%) and wore masks when leaving the home (98.0%) much higher figures than we found in the Sudanese survey.
Although the Sudan government has made worthy efforts to control the virus outbreak, an unprepared country such as Sudan cannot mobilize an efficient national response. This is also true of neighboring countries in Africa, further facilitating the spread of the disease. Matters are complicated in Sudan by the grinding poverty, lack of household savings to offset lost income, lack of access to clean water, proper sanitation, and health supplies and the millions who are living in displaced person camps across Darfur where COVID-19 might spread rapidly with devastating results. Additionally, the unprecedented demand on an inadequate health care system (with only eighty ventilators and two hundred intensive care hospital beds) could well presage its collapse. Even government-run containment facilities cannot look after the sick for the required fourteen-day quarantines [6]. These factors contribute to the results of our survey. In particular, we draw attention to increasingly popular conviction that Sudan's high daily temperatures and young population will ensure the country avoids the worst effects of the disease. The young are displaying a tendency to perceive themselves as impervious to the disease. While this is not an uncommon response (the same conviction is visible in other countries) it is a potentially devastating one in a country like Sudan where different ages of people live under one roof [6].
The present study showed that 30.1% of citizens went to crowded areas and 50.7% did not wear masks when leaving homes in the days immediately prior to taking the survey, 13.3% did not use tissues and 8% did not wash their hands frequently. These potentially risky behaviors were most likely to be displayed by unmarried male gender of 29 years or less, with secondary school education or less, and poor COVID-19 knowledge. This correlates with findings from previous studies regarding age and gender patterns of risk-taking behaviors [2]. The considerably higher risk of practices among males could be ascribed to the need for working daily for the sake of living. We noticed that higher COVID-19 knowledge scores were found to be considerably associated with a lower likelihood of potentially dangerous practices towards the COVID-19 pandemic in our study. This indicates the importance of enhancing citizens' COVID-19 knowledge via health education, which can also result in improved practices relating to COVID-19. We recommend that the health education intervention targets certain demographic groups such as males, young aged and people with a low level of education.
We considered that poor knowledge, defeatist attitudes, and unacceptable practices relating to COVID-19 prevention are strongly associated with limited access to the internet and online health information resources, vulnerable populations such as older adults and rural people. Therefore, KAP towards COVID-19 among vulnerable populations needs special research attention.
In summary, our findings suggest that Sudan citizens of a relatively young age, in particular ladies, have had good knowledge, hopeful attitudes, and acceptable practices towards COVID-19 throughout the interval of the COVID-19 pandemic. Also, good COVID-19 knowledge is associated with acceptable practices towards COVID-19, suggesting that health education programs aimed at enhancing COVID-19 knowledge help encourage and keep safe practices. Finally, with additional national efforts toward public