What’s known The level of communities awareness about COVID-19 like how the disease transmitted and the way of prevention mechanisms to some extent is known. What’s new Adherence about the real practice towards COVID-19 prevention mechanism is not known so that this study adds the extent of the communities adherence about the real practice towards COVID-19 prevention in the study area which is not known in the study area. 1 INTRODUCTION

In late 2019, the World Health Organization was alerted a cluster of pneumonia cases in Wuhan, China.1 This viral infection was attributed to a novel corona virus named 2019-n COV, which causes the disease Coronavirus Disease 2019 (COVID-19). In early March 2020, the WHO announced that the spread of COVID-19 must be assessed as a “pandemic”.2 The pandemic is challenging both for developed and developing nation's healthcare system, social, economic, and psychological well-being of humanity. Low- and middle-income countries (LMIC) are profoundly influenced because of deficient medical equipment and fundamental supplies for victims that result in a disastrous loss of life.2

Preliminary data about fatality rates ranged from 0.5% to 3%, but these rates vary by different parameters such as age and coexisting medical conditions. COVID-19 was found to be highly transmissible, with the average infected person spreading the disease more than three other individuals.3 Communities around the world are facing extraordinary challenges to effectively slow the spread of COVID-19 and sustain their healthcare systems. Numerous countries have implemented measures, such as curfews, home quarantine, social distancing, and isolation of infected populations that severely hamper many day-to-day activities.4, 5 Additionally, governments have asked or required citizens to adopt behaviors (such as wearing masks and washing hands regularly with water and soup or sanitizers) at high levels of compliance that they will need to maintain for an extended period of time, probably until treatments and vaccines are widely available.6

These measures have the objective of decreasing the reproduction of new infections, to less than one, and thus suppressing the local spread of the virus.7 This situation raises a unique challenge for scientists and practitioners in understanding how to ensure adequate public cooperation and compliance. Mobilizing an effective public response to a pandemic requires clear communication and trust.8 Because risk reduction measures such as social distancing and self-quarantine can rarely be enforced entirely by coercion, particularly in democratic societies, the public must understand what is required of them and be persuaded of the importance of complying. Corona viruses are a family of viruses that can cause illnesses such as the common cold, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS).9

Currently, globally, over 123,591,014 confirmed cases and 2,724,113 deaths were reported. In Africa, over 874,036 confirmed cases and 18,498 deaths are reported. After the first case testified on 13 March in Ethiopia, the number of cases and death raised to 185,641 and 2,647, respectively.6 Even though the outbreak is a global pandemic, it is important to note that the problem needs more attention in Africa because the African countries have limited healthcare system capacity to control the pandemic.15 Practicing level of COVID-19 prevention measures in the study area was not well-defined. Therefore, this study aimed to determine status of adherence towards COVID-19 prevention measures in Hosanna town.

2 METHODS 2.1 Study setting

The research was conducted in the town of Hossana, Hadiya Zone, South Ethiopia. It is situated 178 km from the city of Hawassa, the capital of the regional state, and 232 km from the capital of Ethiopia, Addis Ababa. The city of Hossana has one of three administrative areas (subcities) comprising eight kebeles. The town has a total population of 161,220 with male comprising 49% and female comprising 51%. The city has one referral hospital and three government health centers that provide the public with health care. The major ethnic inhabitant was Hadiya.

2.2 Study design and period

A community-based cross-sectional study was conducted from 3 to 29 January 2021.

2.3 Source population and study population

All individuals 18 years of age and above residing in Hossana Town were the source populations, and the sample populations were all individuals 18 years of age and above in the town's selected smallest administrative unit.

2.4 Sample size determination

The sample size was determined by using single population proportion formula by considering the following statistical assumptions: confidence level (Cl), 95% proportion = 50%, margin of error 5% = 0.05. Final sample size was 384.

2.5 Sampling techniques and procedures

All the eight kebeles in the Hossana town were involved in the study after proportional allocation of sample size for the all eight kebeles based on the size of households in each kebele. In each kebele, systematic sampling technique was employed after preparing sampling frame and calculating kth interval for each of the kebeles. The first household was selected by lottery method. Either of the parents or one of the family member age above 18 was the respondent in the household if the parents were not available during data collection.

2.6 Operational definitions 2.6.1 Adherence towards COVID-19 prevention measures

A handwashing function, using a facemask, maintaining physical space, not going to a crowded location, not touching face, covering mouth while sneezing or coughing, disinfecting locks from remote or mobile or door, and staying home during flu-like symptoms. Therefore, if he/she was able to answer “yes” to the median and above of the aforementioned composite variables, a person was considered to have good adherence to COVID-19 preventive measures.

2.6.2 Good knowledge

Participants who replied to the COVID-19 information items with a median and above scores were classified as having good knowledge, otherwise poor knowledge.

2.6.3 Favorable attitude

Participants who replied to the attitude questions on COVID-19 and its preventive measures with a median and above scores were classified as having a favorable or otherwise unfavorable attitude.

2.7 Variables 2.7.1 Dependent variables

Adherence to COVID-19 prevention.

2.7.2 Independent variables

Socio-demographic features, knowledge of COVID-19 prevention measures, and attitude to COVID-19 prevention measures were independent variables.

2.8 Data collection tools and procedures

The structured questionnaire was adapted from previous research and included the following components: socio-demographic components, knowledge of prevention measures for COVID-19, and attitude towards prevention measures for COVID-19.

People who are fluent have translated the questionnaire into the local language (Amharic). The questionnaire was pretested in the smallest administrative units (kebeles) on 5% of the sample size that was not included in the actual analysis. Six experienced BSc nurses and three supervisors were recruited and trained, respectively, for data collection and supervision. The training was provided for 1 day and included how to confirm privacy, the design of the instrument, and interview techniques as components of the training. The information was gathered through a face-to-face interview. Participants were asked if protective measures were performed, including avoiding handshaking; handwashing; physical distancing; avoiding touching the eyes, nose, and remote or door locks; or mobile disinfection.

2.9 Statistical analysis

Data were entered into Epi-data version 4.0.2.101 and exported for review to SPSS version 21. Descriptive analysis was estimated for different variables, such as frequency, percentage, mean, and standard deviations.

For the identification of factors associated with adherence to COVID-19 prevention measures, a binary logistic regression model was used. In bivariate analyses, all variables with a P-value of <.25 were included in the final multivariate analysis model to control all potential confounders. The odds ratio and 95% confidence interval (CI) were used to verify the presence and strength of the relationship between independent variables and the result variable. Finally, variables with a P-value of <.05 were declared to be statistically significantly correlated with adherence to COVID-19 preventive measures in the multivariable analysis.

3 RESULT 3.1 Socio-demographic characteristics of the study participants

Of the total sample needed (N = 384), 377 participants were included in the study, giving a response rate of 98.2%. Around 41.9% were in the 20-30 age groups. Of the study participants, about 294 (78%) were married, and 217 (57.6%) were females. There were 267 (70.2%) unemployed (Table 1).

TABLE 1. Socio-demographic characteristics of the study participants among Hosanna Town, South Ethiopia, 2021 Variables Categories Frequency Percent Age (in y) <20 78 20.7 20-30 158 41.9 31-40 109 28.9 >40 32 8.5 Sex Male 160 42.4 Female 217 57.6 Educational status Cannot read and write 82 21.8 Primary school 108 28.6 Secondary school 95 25.2 Higher education 92 24.4 Occupation Employed 110 29.2 Unemployed 267 70.2 Marital status Unmarried 83 22 Married 294 78 Household size 1-3 113 30 4-6 112 29.7 >7 152 40.3 Known chronic disease No 37 9.8 Yes 340 90.2 3.2 Knowledge and attitude of the respondents towards COVID-19 prevention measures

About 145 (38.5%) of all respondents had poor knowledge of COVID-19 preventive measures, and only 40.3% had poor knowledge of COVID-19 transmission methods. About two thirds of respondents were correctly informed of the symptoms of COVID-19 (Table 2).

TABLE 2. Knowledge and attitude of the study participants about COVID-19 prevention measures among Hosanna Town, South Ethiopia, 2021 Knowledge towards prevention methods Poor 145 38.5 Good 232 61.5 Attitude towards prevention methods Unfavorable 152 40.3 Favorable 225 59.7 Heard about COVID-19 transmission No 37 9.8 Yes 340 90.8 Heard about COVID-19 complications No 61 16.2 Yes 316 83.8 Knows about mode of transmission No 143 37.9 Yes 234 62.1 Correctly knows COVID-19 symptoms No 92 24.4 Yes 285 75.6 3.3 Adherence towards COVID-19 prevention measures

This study showed that about 50.4% of the participants in the study had good adherence to preventive measures for COVID-19. Among the prevention measures, the most common practiced ones by the respondent were wearing mask when going outside and avoiding traveling to the crowd area. However, the respondent's least practiced elements were the physical distance 2 and above meters and the avoidance of touching faces (Table 3).

TABLE 3. Adherence towards COVID-19 preventive measures among respondents living in Hosanna Town, South Ethiopia, 2021 Categories Prevention measures Keeping physical distance 2 and above meters Yes, n (%) 120 (31.8) No, n (%) 257 (68.2) Wear face mask when going outside Yes, n (%) 245 (65) No, n (%) 132 (35) Cover mouth when coughing or sneezing Yes, n (%) 240 (63.6) No, n (%) 137 (36.4) Frequent handwashing Yes, n (%) 190 (50.4) No, n (%) 187 (49.6) Stay home when feel flu-like symptoms Yes, n (%) 250 (66.3) No, n (%) 127 (33.7) Avoiding touching face Yes, n (%) 120 (31.8) No, n (%) 257 (68.8) Avoid travel to a crowed place Yes, n (%) 290 (76.9) No, n (%) 87 (23.1) Disinfecting remote, mobile, or door locks Yes 80 (21.2) No 297 (78.8) Overall adherence towards COVID-19 prevention measures Poor, n (%) 187 (49.6%) Good, n (%) 190 (50.4%) 3.4 Factors associated with adherence towards COVID-19 prevention methods

Binary logistic regression was used to evaluate the relationship between all possible independent variables and adherence to COVID-19 prevention methods. In the bivariate analysis, variables such as age, sex, educational status, household size, marital status, COVID-19 transmission, COVID-19 complication, COVID-19 prevention measure knowledge, and COVID-19 prevention measure attitude were candidate independent variables for the multivariate analysis. Age, educational status, family size, marital status, and heard about complication of COVID-19 were statistically significant independent variables correlated with adherence to COVID-19 preventive measures after controlling for confounders in a multivariable binary logistic regression study. Therefore, respondents aged >40 years were 66% less likely than respondents aged <20 years to have strong adherence to the COVID-19 prevention measure (AOR: 0.34; 95% CI [0.131-0.912]).

Respondents with primary school education status were 68% less likely than respondents who could not read and write (AOR: 0.32; 95% CI [0.165-0.632]) to have strong adherence to COVID-19 prevention measures, and married participants were two times more likely than unmarried respondents to have strong adherence to COVID-19 preventive measures (AOR: 2; 95% CI [1.191-3.803]). And also, compared with family size 1-3, household family size 7 and above was 2.4 times more likely to have strong adherence with COVID-19 preventive measures (AOR: 2.4; 95% CI [1.322-4.366]). In addition, respondents were 51% less likely to have good practice in preventing COVID-19 complications compared with respondents who did not hear about the complications (AOR: 0.49:95% CI [0.242-0.979]) (Table 4).

TABLE 4. Factors associated with adherence towards COVID-19 prevention methods in Hosanna Town, South Ethiopia, 2021 Variables Categories Adherence status COR (CI) P-value AOR at 95%CI P-value Poor Good Age (in y) <20 37 (19.7) 41 (21.7) 1 1 20-30 79 (42) 79 (41) 0.9 (0.524-1.553) .71 0.95 (0.511-1.770) .87 31-40 51 (27.1) 58 (30.7) 1.02 (0.573-1.84) .93 0.94 (0.491-1.900) .92 >40 21 (11.2) 11 (5.8) 0.47 (0.201-1.111) .08* 0.34 (0.131-0.912) .03** Sex Male 91 (48.4) 69 (36.5) 1 1 Female 97 (51.6) 120 (63.5) 1.6 (1.081-2.463) .020* 0.9 (0.126-6.900) .94 Educational status Cannot read and write 30 (16) 52 (27.5) 1 1 Primary school 65 (34.6) 43 (22.8) 0.4 (0.211-0.690) .001* 0.32 (0.165-0.632) .001** Secondary school 48 (25.5) 47 (24.9) 0.56 (0.309-1.032) .06* 0.55 (0.330-1.271) .20 Higher education 45 (23.9) 47 (24.9) 0.6 (0.328-1.1060) .10 0.68 (0.0.344-1.33) .26 Occupation Unemployed 50 (26.6) 60 (31.7) 1 1 Employed 138 (73.4) 129 (68.3) 0.8 (0.499-1.216) 0.27 Marital status Unmarried 50 (26.6) 33 (17.5) 1 1 Married 138 (73.4) 156 (82.5) 1.7 (1.043-2.812) .03* 2 (1.191-3.803) .011** Household size 1-3 63 (33.5) 50 (26.5) 1 1 4-6 61 (32.4) 51 (27) 1 (0.623-1.782) .84 1.6 (0.819-3.053) .2 >7 64 (34) 88 (46.6) 1.7 (1.06-2.832) .028* 2.4 (1.322-4.366) .004** With known chronic disease No 170 (90.4) 170 (89.9) 1 1 Yes 18 (9.6) 19 (10.1) 1.05 (0.535-2.081) .87 0.73 (0.331-1.601) .430 Knowledge about prevention methods Poor 85 (42.2) 60 (31.7) 1 1 Good 103 (54.8) 129 (68.3) 1.8 (1.166-2.700) .007* 1.8 (0.0.552-5.775) .33 Attitude towards COVID-19 prevention strategies Unfavorable 86 (45.7) 66 (34.9) 1 1 Favorable 102 (54.3) 123 (65.1) 1.6 (1.038-2.378) .033* 0.88 (0.177-4.346) .87 Heard about COVID-19 transmission No 26 (13.8) 11 (5.8) 1 1 Yes 162 (86.2) 178 (94.2) 0.4 (0.184-0.804) .011* 0.45 (0.164-1.223) .12 Heard about COVID-19 complications No 42 (22.3) 19 (10.1) 1 1 Yes 146 (77.7) 170 (89.9) 0.4 (0.216-0.698) .002* 0.49 (0.242-0.979) .043** Knows about mode of transmission No 64 (34) 79 (41.8) 1 1 Yes 124 (66) 110 (58.2) 0.72 (0.473-1.091) .12 0.7 (0.375-1.338) .7 Bold and asterisk variables associated with adherance to covid-19 practice. ** Significantly associated. 4 DISCUSSION

This study showed that the community's overall adherence to COVID-19 preventive interventions was 50.4%. This outcome of this finding was almost identical to the study conducted in Gondar Area,10 with 51% of the overall adherence to preventive measures, but higher than the research made in Dire Dawa,9 North Shoa-Ethiopia,11 North West-Ethiopia,12 Dirashe district South Ethiopia,13 Uganda,14 and the Gulf of Mexico,15 which were 40.7%, 44.1%, 38.73%, 12.3%, 29%, and 47.1%, respectively. These discrepancies may be due to increasing cases of COVID-19 or increasing complications due to increased cases that forced the population in this study to apply preventive measures.

Only 31.8% of the common preventive measures maintain physical distance 2 and above meters, which is very small compared with the studies conducted in Dire Dawa,9 Gondar City,10 Dirashe District-South Ethiopia,1