1 COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya Authors: Karen Austrian 1 *, Jessie Pinchoff 2 , James B. Tidwell 3.4 , Corinne White 2 , Timothy Abuya 1 , Beth Kangwana 1 , Rhoune Ochako 1 , John Wanyungu 5 , Eva Muluve 1 , Faith Mbushi 1 , Daniel Mwanga 1 , Mercy Nzioki 1 & Thoai D Ngo 2 Affiliations: 1. Population Council, Nairobi, Kenya 2. Population Council, New York, NY, USA 3. World Vision, Washington, DC 4. Harvard Kennedy School of Government, Cambridge, MA 5. Kenya Ministry of Health, Division of Community Health Services, Nairobi, Kenya *Corresponding author: Karen Austrian, PhD, MPH Senior Associate, Kenya, Poverty, Gender, and Youth Program Avenue 5, 3rd Floor Rose Ave Nairobi, Kenya Phone: +254 20 2713480 Email: [email protected](Submitted: 15 April 2020 – Published online: 20 April 2020) DISCLAIMER This paper was submitted to the Bulletin of the World Health Organization and was posted to the COVID-19 open site, according to the protocol for public health emergencies for international concern as described in Vasee Moorthy et al. (http://dx.doi.org/10.2471/BLT.20.251561). The information herein is available for unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited as indicated by the Creative Commons Attribution 3.0 Intergovernmental Organizations licence (CC BY IGO 3.0). RECOMMENDED CITATION Austrian K, Pinchoff J, Tidwell JB, White C, Abuya T, Kangwana B, et al. COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya. [Preprint]. Bull World Health Organ. E-pub: 6 April 2020. doi: http://dx.doi.org/10.2471/BLT.20.260281
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COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya Authors: Karen Austrian1*, Jessie Pinchoff2, James B. Tidwell3.4, Corinne White2, Timothy Abuya1, Beth Kangwana1, Rhoune Ochako1, John Wanyungu5, Eva Muluve1, Faith Mbushi1, Daniel Mwanga1, Mercy Nzioki1 & Thoai D Ngo2 Affiliations: 1. Population Council, Nairobi, Kenya 2. Population Council, New York, NY, USA 3. World Vision, Washington, DC 4. Harvard Kennedy School of Government, Cambridge, MA 5. Kenya Ministry of Health, Division of Community Health Services, Nairobi, Kenya *Corresponding author: Karen Austrian, PhD, MPH Senior Associate, Kenya, Poverty, Gender, and Youth Program Avenue 5, 3rd Floor Rose Ave Nairobi, Kenya Phone: +254 20 2713480 Email: [email protected] (Submitted: 15 April 2020 – Published online: 20 April 2020)
DISCLAIMER This paper was submitted to the Bulletin of the World Health Organization and was posted to the COVID-19 open site, according to the protocol for public health emergencies for international concern as described in Vasee Moorthy et al. (http://dx.doi.org/10.2471/BLT.20.251561). The information herein is available for unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited as indicated by the Creative Commons Attribution 3.0 Intergovernmental Organizations licence (CC BY IGO 3.0).
RECOMMENDED CITATION
Austrian K, Pinchoff J, Tidwell JB, White C, Abuya T, Kangwana B, et al. COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya. [Preprint]. Bull World Health Organ. E-pub: 6 April 2020. doi: http://dx.doi.org/10.2471/BLT.20.260281
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Abstract:
Objective: Urban slums are at high risk of COVID-19 transmission due to the lack of basic housing, water, and sanitation, and overcrowding. No systematic surveys of slum households’ experiences exist to date.
Methods: A mobile phone knowledge, attitudes, and practices survey was conducted March 30-31, 2020. Participants were sampled from two study cohorts across five urban slums in Nairobi, Kenya.
Findings: 2,009 individuals (63% female) participated. Knowledge of fever and cough as COVID-19 symptoms was high, but only 42% listed difficulty breathing. Most (83%) knew anyone could be infected; younger participants had lower perceived risk. High risk groups were correctly identified (the elderly - 64%; those with weak immune systems - 40%) however, 20% incorrectly stated children. Handwashing and using hand sanitizer were known prevention methods, though not having a personal water source (37%) and hand sanitizer being too expensive (53%) were barriers. Social distancing measures were challenging as 61% said this would risk income. A third worried about losing income, only 26% were concerned about infecting others if themselves sick. Government TV ads and short message service (SMS) were the most common sources of COVID-19 information and considered trustworthy (by >95%) but were less likely to reach less educated households.
Conclusion: Knowledge of COVID-19 is high; significant challenges for behavior change campaigns to reach everyone with contextually appropriate guidance remain. Government communication channels should continue with additional efforts to reach less educated households. A strategy is necessary to facilitate social distancing, handwashing and targeted distributions of cash and food.
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Background
In the initial stage of the Novel coronavirus 2019 (COVID-19) pandemic (January-February
2020), sub-Saharan Africa reported some of the lowest infection rates; steadily increasing since
then.(1) By April 2020, the World Health Organization detected community transmission in
some African countries. Global health experts and African governments project the potential for
more than two million COVID-19 deaths in sub-Saharan Africa if no action is taken.(2) Fragile
health systems will exacerbate the impact of the outbreak and limit the ability to conduct
adequate surveillance and control.(3) Concerns regarding the spread of misinformation on
COVID-19 including unsupported treatments or promotion of ineffective preventive behaviors
have been reported in other countries and are critical to correct to minimize confusion.(4, 5) Of
particular concern are the estimated 1 billion people globally who reside in urban slums.(6)
These communities are at disproportionately high risk of COVID-19 transmission and the least
equipped to handle an outbreak. The implementation of personal hygiene and public health
behaviors that are necessary to curb the spread of COVID-19, such as hand washing and social
distancing, may be challenging if not impossible in these settings.(7)
It is estimated that 60 to 70% of Nairobi’s more than 4 million residents reside in urban slums.(8)
Slums are characterized by high population density, small informal dwellings, lack of access to
clean water, multi-generational households, shared sanitation facilities among multiple
households, a high level of both inter- and intra-social mixing within slums and other areas in
Nairobi, transient residence, and poor health outcomes related to both poor environmental
conditions and inability to pay for medical care.(9-13) Compared to the rest of Nairobi, slum
dwellers have a higher overall mortality rate,(13) higher rates of mobility around Nairobi,(14)
and the population is vulnerable to economic shocks, as most residents rely on income from the
informal sector. As data suggest a bidirectional relationship between poverty and health exists in
these slums,(13) the dual economic and health crises posed by COVID-19 will be particularly
dire. Disease outbreaks in past pandemics have been accelerated in slum settings: the spread of
Ebola during the 2014-2016 pandemic was propelled by the densely populated slums in Guinea,
Liberia, and Sierra Leone, and Zika took hold in favelas in Rio de Janeiro, Brazil.(15, 16) Slum
dwellers can face higher viral infection rates compared to non-slum communities; a modeling
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study of a New Delhi slum demonstrated that even with widespread vaccination and social
distancing measures, slum populations would experience 44% higher rates of influenza.(17)
The Kenyan Ministry of Health (MOH) launched a COVID-19 Taskforce to steer the country’s
prevention, containment and mitigation measures. To prevent the devastating health, social and
economic impact of a COVID-19 outbreak, containment is an important first step. In addition,
ongoing mitigation efforts will be required. With the detection of the first case of COVID-19 on
March 13, 2020, the Government of Kenya banned international flights entering and leaving
Kenya on March 26, and closed schools and banned large social gatherings;(18) banning these
events, including specific cultural and faith practices such as mass prayer gatherings, large
weddings and funerals, are critical to prevent super-spreading events that could accelerate
transmission of the virus.(19) Health authorities need timely and actionable data to design
policies and interventions and make evidence-based adjustments as the outbreak evolves. To
date, no systematic survey has been conducted in urban slums in sub-Saharan Africa, although
recent commentaries, newspaper articles and blogs warn how dire the situation will be if
COVID-19 takes hold. The Taskforce requires data on slum dwellers’ knowledge, attitudes and
practices (KAP) related to COVID-19 to understand the awareness and needs of urban slum
residents in Nairobi. This and future surveys can inform the Kenyan government’s strategy in
spreading public health messages, evaluate the effectiveness of those efforts, and assess the
needs of urban slum residents that can be addressed in relief efforts such as food distributions.
Collecting KAP information has long been useful in informing prevention, control, and
mitigation measures during outbreaks. During the 2014 Ebola response, KAP surveys yielded
critical information on the prevalence of misconceptions about Ebola transmission and
prevention, and the need to prevent stigmatization of Ebola survivors and foster safer case
management and burial practices.(20) In other recent outbreaks, such as SARS or Zika, KAP
surveys were used to assess how providers could better triage patient calls to fever hotlines and
measure how the public responded to mitigation efforts.(21-24) To date, peer-reviewed COVID-
19 KAP surveys have comprised of a brief online survey in China and a phone-based survey
among high-risk adults in the US;(25, 26) these surveys are not relevant in African slum settings.
We conducted the first KAP survey among households living in urban slums in Nairobi to
answer the following questions:
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1. What are the current knowledge levels and prevailing attitudes reported by
households related to COVID-19?
2. What are the key sub-groups with the biggest knowledge and attitude gaps?
3. What are the main channels through which people are receiving information about
COVID-19 and what sources are considered most trustworthy?
4. What are the barriers to practicing risk reduction behaviors, and what would people
do if they experienced symptoms of COVID-19?
Methods
In March 2020, the Population Council, in collaboration with the Kenyan Ministry of Health
COVID-19 Taskforce, conducted the first round in a series of mobile phone surveys with a
sample of households across five urban slums in Kenya. The study participants were randomly
sampled from two existing longitudinal cohort studies with adolescents and young people in
Nairobi urban slums, the Adolescent Girls Initiative-Kenya (AGI-K) and NISITU (Nisikilize
Tuiengane): Listen to Me, Let’s Grow Together. The AGI-K cohorts in Kibera and Huruma
totaled 2,565 households as of the 2019 round of data collection. The AGI-K cohort was part of a
four-arm randomized controlled trial testing the impact of programs designed for adolescent
girls, which included a baseline in 2015, a second round of data collection in 2017 and a third
round in 2019.(27) The NISITU cohort consisted of 4,519 households in Kariobangi, Dandora
and Mathare slums. NISITU is a quasi-experimental study evaluating the effects of a gender
transformative program for girls, boys and young men. The NISITU baseline was conducted in
early 2018 and the second wave of data collection in late 2019. For both cohorts, an initial
household listing was conducted in the study sites to create a sampling frame of eligible
adolescents for the study. The last round of data collection for each was recent (completed in
December 2019 for AGI-K and in January 2020 for NISITU), therefore phone numbers for each
head of household were up to date. All households were eligible for inclusion as long as an adult
was reached on the phone.
Due to the restriction of movement in Nairobi and concerns for spread of COVID-19, in-person
surveys were not possible. As a result, a short, 30-item questionnaire was designed to be
conducted via mobile phone. We searched for any publicly available existing survey instruments
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on COVID-19, but most were from developed settings such as Italy or the United States and less
relevant in the Kenyan context (e.g., Geldsetzer 2020).(28) We identified a peer-reviewed KAP
survey from China(26) but for Africa only found unpublished information including an SMS-
based rapid survey with limited sample size (450 per country in Kenya, Nigeria, and South
Africa).(29) Where possible, questions were adapted or pulled from standardized questionnaires
on water, sanitation and hygiene (WASH) and behavior change, including the Demographic and
Health Survey and the WHO/UNICEF Joint Monitoring Program, to ensure the validity of the
questions. A total of 77 Kenyan enumerators were trained remotely on the phone survey
instrument (using Webex) and the full survey instrument was piloted with 154 participants. The
training focused on phone-based interviewing techniques and a question-by-question review of
the tool to ensure quality of the phone interview. All Research Assistants had previously
completed an online research ethics certification offered by NIH or FHI 360. The enumerators
were also selected from a team that had extensive experience working with vulnerable
populations.
A random sample was drawn from the phone number pool of both NISITU and AGI-K
household contacts, stratified by location. For households with more than one contact number,
one number per household was randomly selected for inclusion in the sampling frame. We
estimate a minimum of 400 participants per site were required at baseline (+/- 5% confidence
interval calculation from a conservative 50% prevalence estimate); a total of 2,009 were included
in this round. As the sample was randomly drawn from the pool, and there was no randomization
of intervention at this stage, no design effect of the study was considered. Data collection took
place on March 30-31, 2020.
The final questionnaire included questions regarding basic demographics, awareness of COVID-
19 or coronavirus, knowledge of symptoms, risk groups and transmission, perceived risk, current
behaviors being implemented to prevent COVID-19 infection, channels of information and
trustworthiness of each source, fears or concerns regarding the outbreak, and barriers to carrying
out promoted preventive behaviors such as handwashing, quarantine, and social distancing.
Enumerators completed 10-20 surveys per day and each phone number was tried up to three
times.
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We received expedited ethical approval for this rapid survey due to the urgent nature of the
pandemic and need for information, and in our initial surveys we had asked if we could recontact
participants. The Population Council IRB had approved initial protocols for the AGI-K (p661)
and NISITU (p829) cohorts, as well as the AMREF ESRC (P143/2014 and P407/2017). The
Ministry of Health provided written approval to conduct the KAP surveys with these cohorts.
The new survey was collected using Open Data Kit and exported to STATA v15 for analysis. All
personally identifiable information was removed to ensure confidentiality; each household
received a coded ID number. Participants were told they could terminate the study at any time.
No financial or other incentives were given for taking part in the study, and participants were
also told they would not lose any benefit by refusing to take part. The COVID-19 survey was
merged with AGI-K and NISITU household level data for additional information on household
characteristics. All survey responses were tabulated by gender, age, education level, and location
to generate basic descriptive tables and inter-group differences were assessed for statistical
significance within each category using chi-square tests with a significance level of .05.
Results
Study participant characteristics
A total of 3,139 calls were placed and 2,009 surveys completed. About 26% of phone numbers
dialed did not go through or there was no response. Only 41 of those reached on phone (1%)
refused to participate. We interviewed a total of 2,009 adults, with women representing over half
(63%) of respondents (Table 1). Respondent ages were categorized as 18-24 years (22%), 25-34
years (20%), 35-49 years (35%) and 45+ years (24%). Most respondents had completed some or
all of primary school (40%) or had completed some or all of secondary school (44%). The
average household size was 5.1 (standard deviation: 2.1), with 120 (6%) saying they lived alone.
About half of households reported they used shared water points located outside of the house or
plot (50.3%), and 58.9% reported using a toilet shared by multiple households. Cooking was
most often done using kerosene (57.4%), LPG/natural gas (22.5%), or charcoal (14.3%).
Knowledge and perceptions of COVID-19
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Over 97% of participants had heard of coronavirus (COVID-19). Overall, knowledge regarding
COVID-19 symptoms and high-risk groups was accurate, although there were some
misconceptions regarding specific symptoms and incorrect identification of children as a high-
risk group. Awareness of fever and dry cough as the top two symptoms of COVID-19 was high,
with 77% of respondents correctly identifying fever and 86% cough (Table 2). However,
difficulty breathing was only mentioned by 42% of respondents even though this is a sign of very
severe infection. More than half reported sneezing (56%), even though this is not a COVID-19
symptom. Awareness was higher with increasing education; for example, 81% of those with
secondary or higher education listed fever compared with 55% of those with no formal
schooling. However, sneezing was also most frequently reported by those with higher education.
Of all respondents, the elderly were correctly identified as the most at risk group for severe
symptoms (by 64% of participants) followed by those who are already sick with weak immune
symptoms (26%) (Table 3). Knowledge of these two high risk groups was higher for those with
more education compared with none (e.g., 70% of those with higher education reported the
elderly as a high-risk group, compared with 59% of those with no school). Also, compared with
men, women were more likely to state that children (21% vs 16% of men) and pregnant women
(3.5% vs 1.3%) were at risk of severe symptoms, although they are not.
Overall, 35% of respondents perceived that they were at high risk of COVID-19 infection
(Figure 1). This perception of risk increases by age group (from 30% among 18-24 year-olds to
37% of 45+ year-olds). Among those who say they are at low or no risk, the main reasons for
this assertion are that they are already staying indoors. Being young was only listed by 3% of
respondents as a reason for being low risk. If diagnosed with COVID-19, 87% of respondents
say they would be very concerned.
The main fears reported by participants is that COVID-19 is a virus that may result in death
(68%), and that there is no cure or treatment (40%) (Table 3). However, people are also afraid of
losing their jobs (34%; but significantly more men than women; 39.1% vs 31.5%) and that it may
lead to food shortages (22%). Loss of employment and food shortages were ranked as higher
concerns for each increasing age group, with older people more concerned, whereas fear of dying
was higher among the younger age category (77% vs 61% of those older than 45 years).
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Lastly, participants were asked what they would do if they had symptoms of COVID-19. The
most likely response was “go to a clinic” (71%) (Table 5). Only 42% said they would call the
government’s toll-free hotline, and only 19% said they would stay at home more.
Sources of information about COVID-19
Participants reported receiving information on COVID-19 from a wide variety of sources,
through various channels; overall government messages were the most widely cited. Government
TV ads, SMSs and radio ads were the most frequently reported sources; however, exposure to
these sources was significantly higher for those with higher levels of education. For example,
81% of those with higher education received information through government SMS compared
with 66% of those without any schooling (Table 4). Those with higher education also were
significantly more likely to receive information from social media or the internet. Women were
significantly less likely to get information from social media, the internet, government SMSs, or
work sources compared with men. Overall, men and those with higher education received
information from a much larger number of sources and channels.
Trust in each of these sources varied. The most reported sources of information were from the
government (television ads, SMS, and radio ads). These were rated as trustworthy by almost all
participants (over 90% for each source) (Figure 2). Friends, acquaintances, and family were
considered slightly less trustworthy, and the internet/social media also less trustworthy. Only
66% of participants said social media was a trustworthy source of COVID-19 information, and
70% said the internet was trustworthy. Health providers (public or private facility, community
health workers) were cited as very trustworthy (over 90% of respondents said they are
trustworthy); however, they were some of the least reported sources of information for COVID-
19 (16-25% of respondents got information from them).
Discussion
Urban slums are poorly equipped for the COVID-19 pandemic, and the most at risk for
transmission as well as adverse effects on health and economic stability compared with other
urban areas and the rest of Kenya. Our survey is the first to assess knowledge, attitudes, and
practices, as well as identify the needs and concerns of a large sample of households across
urban slums in a sub-Saharan African city. Most of the available KAP findings to date are
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focused on studies in China and Italy, which differ in many ways sub-Saharan African informal
settlements and cities. Little is known regarding the current situation in urban slums as there has
not been a systematic assessment examining these issues. This information is critical for health
officials to understand how to address household needs through promoting key preventive
behaviors, such as social distancing and handwashing, as well as helping people cope with the
social, economic and physical challenges caused by long term restrictions on movement. Our
findings highlight the high levels of awareness and concern regarding COVID-19 transmission,
with key areas for improvement on communication of information regarding symptoms and risks
and recommendations on ways to support residents in urban slums during the implementation of
mitigation measures.
While our survey revealed high levels of knowledge of two primary COVID-19 symptoms,
namely fever and coughing, difficulty breathing was not accurately identified as a key symptom,
even though it is the one that signifies critical illness and potential need for hospitalization.(30)
Participants correctly identified high-risk groups; the elderly and those with compromised
immune systems were the top two high-risk groups identified. About 20% also listed children;
clarifying that children are not at high risk may help communities better prioritize and take steps
to protect at-risk groups. About a third of participants felt they were at high risk of infection,
with this proportion increasing by age group confirming that young adults may have lower
perceived risk. As slum households are comprised of highly mixed age groups, it will be
important to highlight that all age groups should take precautions and that the feasibility of intra-
household transmission prevention activities should be explored; in China, over 64% of clusters
documented were within familial households.(31) Almost all participants report they and their
households are already performing risk reduction behaviors including increased hand washing
with soap where possible, use of hand sanitizer, and staying home more.
Three major concerns emerged from our study. First, a low proportion of respondents reported a
concern that if infected, they would transmit the virus to others. This belief is critical to address
as data from China indicate both a large proportion of mild or asymptomatic COVID-19 cases
(80%) and a long incubation (contagious) period (median of 5.1 days) means that mildly ill
people may spread the disease.(30, 32) Second, the government’s messaging regarding actions to
take if symptoms are experienced or infection is suspected has not been clear, which may lead to
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confusion. 71% of urban slum dwellers said they would go to the clinic if they developed
symptoms. The World Health Organization (WHO) guidance is to stay home and call a health
provider if symptomatic, especially in light of limited testing capabilities in certain settings.(33)
If health facilities are over-crowded with those seeking tests or treatment, health facilities in
slums will quickly become overwhelmed. During Ebola, health facilities became focal points of
transmission themselves to both those seeking services and health care workers alike.(34) Third,
many study participants, mostly men and older adults, reported concerns about loss of income
and food shortages. This was one of the main reasons given for why quarantine or self-isolation
for 14 days was not feasible. People in urban slums will contribute to the rapid spread of the
virus if they continue to seek out employment or other income generating opportunities requiring
movement around slums and throughout the city. To prevent the possibility of spread, this calls
for the Kenyan government to deploy immediate cash and/or food assistance to the poor
(potentially using mobile money transfers). As a high proportion of participants reported not
having a separate space in their house to self-isolate, government actions need to consider the
implications of in-home exposure.
Lastly, we report key findings regarding sources of COVID-19 information, coverage for each
channel, and perceived trustworthiness of each source. Government messages via radio, TV or
SMS were the most likely source and were considered highly trustworthy. However, those with
less or no education were significantly less likely to report receiving these messages. Improved
targeting of messages or consideration for how to reach these vulnerable households is critically
important. Social media and the internet were also cited as sources of information, particularly
for men and younger adults, and were also considered less trustworthy compared to government
sources or health workers. This is promising as it suggests that those engaging with social media
and internet sources may scrutinize the information presented but spread of misinformation
should continue to be a concern particularly through these channels.(35) Formal health providers
including community health workers, as well as NGOs, were listed as some of the most trusted
sources of information but were some of the least cited sources of COVID-19 information. This
presents the opportunity to work directly with health workers and NGO partners to share
accurate guidance, connect people to the health system safely by helping detect symptoms,
conducting tests (if available), reporting cases, and potentially community health workers (with
appropriate safety precautions) can conduct screening and contact tracing and training.(36)
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There are both limitations and advantages to our study. We interviewed heads of household 18
years old and older, limiting our understanding of different members of the household mixing
with those outside of it for a variety of reasons (e.g., earning income, social reasons, or accessing
essential services), though we will collect this data in subsequent rounds to better inform
epidemiological models. This also limited our understanding of knowledge and perceptions to
adult participants. Future rounds of data collection may target adolescents, but privacy will be
challenging with a mobile phone-based survey. The survey is representative of households with
at least one adolescent household member that participated in AGI-K and NISITU and reside in
the five urban slums, but not full representative of all households in the area (e.g., households
with only one older adult or only very young children were not eligible for the initial survey).
There are major benefits to using the pre-existing cohorts rather than random-digit dialing or
convenience samples: 1) the number of questions on the phone survey could be reduced by using
previously collected data on each household; 2) previous interactions with the households led to
a very high participation rate and only 41 refusals (1%); and 3) correct, updated phone numbers
as these households were recently contacted. This is the first systematic COVID-19 KAP survey
done with a large sample of residents of urban slums in an African setting.
Our study revealed considerably high knowledge of COVID-19 symptoms, risk groups, and high
levels of information from government sources. While mobile messages and TV commercials
have been shown to be effective in promoting handwashing behavior in non-emergency
settings(37), and messages leveraging prosocial(38) and deontological(39) motives may be
effective in the context of COVID-19, our findings suggest the next steps for behavior change
messaging campaigns should also focus on how to reach the most vulnerable (households in high
poverty, comprised of older family members, household members with comorbidities, low
education levels and low access to information or health services) and addressing concerns
regarding loss of employment/income and food shortages to ensure that households are better
able to comply with stay at home orders. Behavior change communication is critical and must be
tailored to the living conditions of poor residents in urban slums, promote feasible behaviors, and
use channels that will reach all sub-groups including those who are not literate or do not have a
phone. Strategies to increase access to water, soap and hand sanitizer, as well as improved solid
waste collection, will be critical to reduce the spread of COVID-19 as well as other diseases that
may become an issue under lockdown scenarios.(36) Lastly, we recommend tapping the health
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workforce, including community health workers, and NGO partners to disseminate guidance and
information as they are a trusted source, but also to support with case management and contact
tracing in the community. With proper personal protective equipment (masks, gloves, suits),
health workers, trusted NGO staff and youth leaders can direct people experiencing symptoms to
stay at home to prevent overwhelm of clinics and health facilities, potentially deploy mobile
clinics for symptom identification, testing and treatment, and lastly offer social support to those
who test positive and may face stigma or require additional resources and/or support to
quarantine themselves or a sick family member. As the epidemic continues to evolve, frontline
health workers and trusted NGO staff operating in these communities will be essential to identify
hotspots, conduct contact tracing, and provide treatment. Engaging this critical resource early on
in the response effort can potentially mitigate the severity of the COVID-19 impact.
Findings from our survey can also inform the broader Kenyan Ministry of Health strategy and
those of other African countries to ensure accurate information is effectively disseminated and
the needs of these communities are adequately addressed in the effort control the spread of
coronavirus in urban slums across the continent.
Conflict of Interest
The authors claim no conflict of interest.
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Tables and Figures
Table 1: Characteristics of respondents and their households
a Symptoms with less than 30% of respondents selecting it not presented but include no fever known, diarrhea, loss of taste, loss of smell, chest pain, chills, rash, dizziness, sore throat, body ache
Table 3: Fears and concerns regarding covid-19
Male Female 18-24 25-34 35-44 Over 45 Overall
Main fears and concernsa Death/it’s a virus that kills people
I may infect other people 206 (27.5) 313 (24.9) 113 (26.1) 116 (29.3) 184 (26.2) 106 (22.2) 519 (25.8)
a Other fears listed with fewer than 20% observations include it will lead to crime in the community, no transport will be available, inability to pay rent, don’t know where to get treatments, its hard to keep away from crowds, we are being lied to, being hospitalized, being quarantined, being separated from family
*denotes statistical significance p<0.05
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Table 4: Channels through which information on COVID-19 is received by gender and education
Sourcesa Male Female No School Primary Secondary Higher Ed Overall
Government TV ads 643 (85.8) 1040 (82.6) 53 (72.6) 642 (80.9) 757 (85.9) 228 (88.7) * 1683 (83.8) Government SMSs 607 (81.0) 963 (76.5) * 48 (65.8) 586 (73.8) 727 (82.5) 208 (80.9) * 1570 (78.2) Government radio ads
a Sources of information with less than 30% reported include public health facility (hospital, clinic), private health facility (hospital, clinic), NGO provider, pharmacy, community health worker, traditional healer, public announcement with a mega phone, books/magazines, posters or print advertisements, community meetings/spaces and work
*denotes statistical significance p<0.05
Table 5: Existing and anticipated behavioral responses to COVID-19
Behavior N (%) Behaviors you’re doing more now than one month ago
Stayed at home more 1591 (79.3) Stopped attending social gatherings 1885 (94.1) Kept a distance of at least 2 meters 1631 (81.5) Informed people of illness symptoms 1454 (73.2) Washed hands/used hand sanitizer more frequently 1942 (97.1) Checked the news more frequently 1766 (88.3) Nothing 1 (0.1)
Behaviors you would do if you had symptoms of COVID-19 Go to clinic 1434 (71.4) Call toll free number 846 (42.1) Go for Corona test 585 (29.1) Stay at home more 384 (19.1) Keep a distance of at least 1-2 meters 338 (16.8) Stop attending social gatherings 170 (8.5) Inform people of illness symptoms 107 (5.3) Wash hands more frequently 104 (5.2)
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Figure 1: Perceived risk of COVID-19 infection by age
Total 18-24 years 25-34 years 35-44 years 45+ years
High 35 30 36 37 37
Medium 31 30 30 31 32
Low 24 30 25 22 20
No Risk 7 9 6 6 7
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40%
50%
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70%
80%
90%
100%P
erce
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f R
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Age Categories
High
Medium
Low
No Risk
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Figure 2: Source of information of COVID-19 by trust in that source
0
10
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30
40
50
60
70
80
90
100
0
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Per
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Source of COVID-19 Information Trust this source
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References
1. Johns Hopkins COVID-19 Resources Center. COVID-19 Case Tracker 2020. Available from: https://coronavirus.jhu.edu/. 2. Walker P, Whittaker C, Watser O, Baguelin M, Ainslie K, Bhatia S, et al. The Global Impact of COVID-19 and Strategies for Mitigation and Suppression. Imperial College London. 2020. doi: doi: https://doi.org/10.25561/77735. 3. Makoni M. Africa prepares for coronavirus. The Lancet. 2020;395(10223):483. doi: https://doi.org/10.1016/S0140-6736(20)30355-X. 4. Ionnidis JP. Coronavirus disease 2019: The harms of exaggerated information and non-evidence-based measures. European Journal of Clinical Investigation. 2020;50(4). doi: https://doi.org/10.1111/eci.13223. 5. Vigdor N. Man Fatally Poisons Himself While Self-Medicating for Coronavirus, Doctor Says. . The New York Times. 2020. 6. UN-Habitat. Urbanization and development: emerging futures. World Cities Report 2016. . Nairobi, Kenya: United Nations Human Settlemnets Programme (UN-Habitat), 2016. 7. Dahab M, Zandvoort Kv, Flasche S, Warsame A, Spiegel P, Waldman J, et al. COVID-19 control in low-income settings and displaced populations: What can realistically be done? . 2020. 8. UN-Habitat. Kenya Habitat Country Programme Document (2018-2021). Nairobi, Kenya: 2019. 9. Ezeh A, Oyebode O, Satterthwaite D, Chen Y, Ndugwa R, Sartori J, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. The Lancet. 2017;389(10068):547-58. doi: https://doi.org/10.1016/S0140-6736(16)31650-6. 10. Johnstone-Robertson S, Mark D, Morrow C, Middelkoop K, Chiswell M, Aquino L, et al. Social Mixing Patterns Within a South African Township Community: Implications for Respiratory Disease Transmission and Control. American Journal of Epidemiology. 2011;174(11):1246-55. doi: https://doi.org/10.1093/aje/kwr251. 11. Waroux OlPd, Cohuet S, Ndazima D, Kucharski A, Juan-Giner A, Flasche S, et al. Characteristics of human encounters and social mixing patterns relevant to infectious diseases spread by close contact: A survey in Southwest Uganda. BMC Infectious Diseases. 2018;18. doi: https://doi.org/10.1186/s12879-018-3073-1. 12. Winter S, Dzombo M, Barchi F. Exploring the complex relationship between women’s sanitation practices and household diarrhea in the slums of Nairobi: a cross-sectional study. BMC Infectious Diseases. 2019;19(242). doi: https://doi.org/10.1186/s12879-019-3875-9. 13. Zulu E, Beguy D, Ezeh A, Bocquier P, Madise N, Cleland J, et al. Overview of migration, poverty, and health dynamics in Nairobi City’s slum settlements. Journal of Urban Health. 2011;88:195-9. doi: https://doi.org/10.1007/s11524-011-9595-0. 14. Salon D, Gulyani S. Mobility, poverty, and gender: travel “choices” of slum residents in Nairobi, Kenya. Transport Reviews. 2010;30(5). doi: https://doi.org/10.1080/01441640903298998. 15. Snyder R, Boone C, Cardoso CA, Aguiar-Alves F, Neves F, Riley L. Zika: a scourge in urban slums. PLoS Neglected Tropical Diseases. 2017;11(3). doi: https://doi.org/10.1371/journal.pntd.0005287. 16. Snyder R, Marlow M, Riley L. Ebola in urban slums: the elephant in the room. The Lancet Global Health. 2014;2(12):PE685. doi: https://doi.org/10.1016/S2214-109X(14)70339-0.
20
17. Adiga A, Chu S, Eubank S, Kuhlman C, Lewis B, Marathe A, et al. Disparities in spread and control of influenza in slums of Delhi: findings from an agent-based modelling study. BMJ Open. 2018;8(1). doi: doi: 10.1136/bmjopen-2017-017353. 18. Kabale N. Coronavirus: Kenya takes bold steps after cases rise to three. The Nation. 2020. 19. Wong G, Liu W, Liu Y, Zhou B, Bi Y, Gao G. MERS, SARS, and Ebola: The Role of Super-Spreaders in Infectious Disease. Cell Host & Microbe. 2015;18(4):398-401. doi: https://doi.org/10.1016/j.chom.2015.09.013. 20. Jalloh M. Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic—Guinea, August 2015. Morbidity and Mortality Weekly Report. 2017;66. doi: https://doi.org/10.15585/mmwr.mm6641a4. 21. Deng J, Olowokure B, Kaydos-Daniels S, Chang H, Barwick R, Lee M, et al. Severe acute respiratory syndrome (SARS): Knowledge, attitudes, practices and sources of information among physicians answering a SARS fever hotline service. . Public Health. 2006;120(1):15-9. doi: doi:10.1016/j.puhe.2005.10.0. 22. Borges A, Moreau C, Burke A, Santos Od, Chofakian C. Women’s reproductive health knowledge, attitudes and practices in relation to the Zika virus outbreak in northeast Brazil. PLoS ONE. 2018;13(1). doi: https://doi.org/10.1371/journal.pone.0190024. 23. Lau J, Yang X, Tsui H, Kim J. Monitoring community responses to the SARS epidemic in Hong Kong: from day 10 to day 62. Journal of Epidemiology & Community Health. 2003;57:864-70. 24. Samuel G, DiBartolo-Cordovano R, Taj I, Merriam A, Lopez J, Torres C, et al. A survey of the knowledge, attitudes, and practices on Zika virus in New York City. BMC Public Health. 2017;18(98). doi: https://doi.org/10.1186/s12889-017-4991-3. 25. Wolf M, Serper M, Opsasnick L, O'Conor R, Curtis L, Benavente J, et al. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the US outbreak: A cross-sectional survey. Annals of Internal Medicine. 2020. doi: DOI: 10.7326/M20-1239. 26. Zhong B, Luo W, Li H, Zhang Q, Liu X, Li W, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020;16(10):1745-52. doi: doi:10.7150/ijbs.45221. 27. Austrian K, Muthengi E, Mumah J, Soler-Hampeisek E, Kabiru C, Abuya B, et al. Adolescent Girls Initiative – Kenya: Study Protocol. BMC Public Health. 2016 16(210). doi: DOI 10.1186/s12889-016-2888-1. 28. Geldsetzer P. Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey. Annals of Internal Medicine. 2020. doi: DOI: 10.7326/M20-0912. 29. Elliott R. Report: Coronavirus in Sub-Saharan Africa. Geopoll. 2020. Available from: https://www.geopoll.com/blog/coronavirus-africa/. 30. Centers for Disease Control and Prevention. COVID: What to Do if You Are Sick 2020 [April 3, 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html. 31. Wu Z, McGoogan J. Characteristics of and important lessons from the Coronavirus disease 2019 (COVID-19) outbreak in China. JAMA Network. 2020;323(13):1239-42. doi: Doi: 10.1001/jama.2020.2648.
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32. Lauer S, Grantz K, Bi Q, Jones F, Zheng Q, Meredith H, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Annals of Internal Medicine. 2020. doi: DOI: 10.7326/M20-0504. 33. World Health Organization. Coronavirus Disease Situation Reports Geneva, Switzlerland: World Health Organization; 2020 [cited March 25, 2020]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports. 34. Cooper C, Fisher D, Gupta N, MaCauley R, Pessoa-Silva C. Infection prevention and control of the Ebola outbreak in Liberia, 2014–2015: key challenges and successes. BMC Medicine. 2016;14(2). doi: https://doi.org/10.1186/s12916-015-0548-4. 35. Chou W, oh A, Klein W. Addressing health-related misinformation on social media. JAMA. 2020;320(23):2417-8. doi: doi:10.1001/jama.2018.16865. 36. Corburn J, Vlahov D, Mberu B, Riley L, Caiffra W, Rashid S, et al. Slum Health: Arresting COVID-19 & Improving Well-Being in Urban Informal Settlements. Journal of Urban Health. 2020. 37. Tidwell J, Gopalakrishnan A, Lovelady S, Sheth E, Unni A, Wright R, et al. Effect of two complementary mass-scale media interventions on handwashing with soap among mothers. Journal of Health Communication. 2019:1-13. doi: doi: 10.1080/10810730.2019.1593554. 38. Jordan J, Yoeli E, Rand D. Don’t get it or don’t spread it? Comparing self-interested versus prosocially framed COVID-19 prevention messaging. PsyArXiv Preprints. 2020. doi: 10.31234/osf.io/yuq7x. 39. Everett J, Colombatto C, Chituc V, Brady W, Crockett M. The effectiveness of moral messages on public health behavioral intentions during the COVID-19 pandemic. PsyArXiv Preprints. 2020. doi: 10.31234/osf.io/9yqs8.