Knowledge, attitude, and practice of COVID-19 screening and vaccine uptake among women attending Maimusari Primary Healthcare in Jere Local Government, North East, Nigeria

ABSTRACT

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, caused over 6.8 million deaths globally as of March 2023. The knowledge, attitude, and practices (KAP) of people to COVID-19 varied in different locations around the world. In this study, we investigated the KAP of women attending Maimusari Primary Healthcare in Jere Local Government, Borno state during the pandemic with a view to understanding the KAP related to COVID-19 across different demographics of women.

Methods

A cross-sectional survey was carried out using self-administered questionnaire on 400 women attending the health facility. The questionnaire surveyed participants’ demographic characteristics, knowledge, attitude, practices, and willingness to take vaccine. Descriptive and inferential statistics was used to analyze the data.

Results

Of the 400 participants, a higher proportion were between the ages of 20 and 29 (36.2%), Kanuri by tribe (47.2%), from monogamous family (66.0%) with less than 5 in terms of family size (64.8%) with no formal education (57.8%). The overall mean knowledge score was 13.64 ± 2.36, which differs significantly (p < 0.05) among age, ethnic group, marital status, family size and educational level. Educational level (χ2 = 12.329, p = 0.000) and age (χ2 = 58.943, p = 0.000) were associated with having good knowledge while ethnic group (χ2 = 52.59, p = 0.000) and family size (χ2 = 4.32, p = 0.038) were associated with having a positive attitude. Finally, 68.8% of the respondents were willing to get vaccinated while 82.2% considers the vaccines are safe.

Conclusion

The findings in this study suggest that after the peak of the pandemic, majority of the respondents demonstrated good knowledge, positive attitude and undertook safe practices toward minimizing the transmission of COVID-19. However, over 60% have not taken the vaccine suggesting the need for improved awareness on vaccine safety.

KEYWORDS:

• COVID-19
• knowledge
• attitude
• Nigeria
• vaccination

1. Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus is responsible for COVID-19, which was declared by the World Health Organization (WHO) as a pandemic on March 11, 2020 [1]. The global pandemic was responsible for over 450 million and 6 million confirmed cases and deaths, respectively, since its emergence in 2019 [2]. Several strains of the virus have been documented since its emergence suggesting a possible multi-point transmission of the SARS-CoV-2 [3,4]). The COVID-19 pandemic brought about disruption of financial and social system of many nations in low and middle-income countries (LMICs), thereby aggravating the existing wealth inequality in these climes [5,6]. Additionally, it has led to health crises leading to morbidity and mortality while simultaneously disrupting the world economy and fragile society [5,7].

The first confirmed case in Nigeria was reported on the 27^th of February 2020 [8,9]. The government of Nigeria preemptively announced series of strict measures, with the adoption of a lockdown in March 2020, as well as nationwide public awareness campaign about COVID-19 prevention and control measures [10]. Social distancing, population-wide lockdowns, hand hygiene and face mask wearing were other steps taken by the relevant authorities to stem the spread of the virus [11,12]. The most significant development after the declaration of COVID-19 as a pandemic was the announcement of an effective vaccine against the virus. Vaccines constitute highly effective tools for eliminating vaccine-preventable disease and are regarded as a cost-effective intervention to control disease that can compromise public health. Vaccines have been described as one of the most potent and cost-effective public health approaches in preventing communicable diseases [13]. The COVID-19 pandemic has led to the accelerated development of a handful of vaccines, which are safe and effective against SARS-CoV-2 [14,15,16].

One of the major barriers to implementing vaccination campaigns within the context of a pandemic is vaccine hesitancy, which is a delay in acceptance or refusal of vaccination despite the availability of vaccination services [17]. The World Health Organization regards vaccine hesitancy as one of the top ten global health threats in 2019 [18]. Vaccine hesitancy has been documented among health care workers and other health care providers [19–21]. Several factors have been identified as possible predictors of unwillingness to be vaccinated such as low educational status, lack of information, fear and mistrust of authorities, racial minority background and poverty [19–21]. Negative attitude to vaccination result in low vaccine uptake thereby exacerbating efforts to control vaccine preventable diseases [22]. In addition to lack of knowledge toward the vaccine, religiosity may impede vaccine acceptance [23,24]. Despite the ample scientific evidence that supports the development of vaccines and its accompanying safety and efficacy, the spread of myths and anti-vaccine information have greatly hampered mass vaccination campaigns in Africa [25].

The North East of Nigeria, like most parts of Nigeria, is a highly religious region with Islam as the most dominant religion [26]. Islamic jurisprudence places importance on the sanctity and safety of human life, and efforts such as vaccines uptake and advocacy, are highly encouraged in Islam.

However, vaccines’ products Halal status remains a concern [27]. Also, the heightened insecurity triggered by the Boko Haram crisis in the North East region has severely complicated the educational attainment of children in the region, with 31% literacy rate for girls [28]. These findings suggest young women in the region could be uneducated and may lack the requisite knowledge and positive attitude toward accepting vaccines. Knowledge, attitude, and practice (KAP) surveys are important tools to understand what is known, believed and done in the context of the topic of interest [29]. The data from KAP studies provide information for resource allocation in the planning and implementation of intervention measures [29]. Thus, this study aimed to investigate the knowledge, attitude, and practices (KAP) of COVID-19 screening and vaccination among women attending a primary health care center in Jere Local government area of Borno state. The study also explored if the willingness to take COVID-19 vaccine is associated with the socio-demographic variables as well as other predictors such as attitude.

2. Materials and methods

2.1. Study setting and duration

Maiduguri is the capital of Borno state in North-East Nigeria. Livestock farming and other agricultural activities including fishing and cultivation of crops are some of the key occupations of the inhabitant of Borno state. Majority of the inhabitants are of the Kanuri tribe, however, there are over 100 minority ethnic groups resident in the state. Maimusari primary health care is situated at Jere LGA, Maiduguri, Borno state, North East Nigeria. The clinic has various departments including administrative/finance department, general outpatient’s department, laboratory, pharmacy, and a maternity complex. The study commenced on the November 1, 2022 and concluded on November 29, 2022.

2.2. Study design and study population

This study adopted a descriptive cross-sectional study design involving women patients seeking care at a public primary healthcare facility. The data were collected from November 1 to 29, 2022, from Mondays to Fridays. Cross sectional studies are useful in measuring the prevalence of a disease or of a risk factor in a population. Thus, this study design is helpful in assessing the disease burden and healthcare needs.

2.3. Eligibility/inclusion criteria for sample selection

Eligibility/inclusion criteria for the research included all consenting women who attended various clinics such as ante-natal clinic, post-natal clinics, gynecology clinic, family planning clinic, immunization clinic, and general outpatients’ clinic from 8:00 am to 4:00pm, from Monday to Friday.

2.4. Sampling technique and sample size determination

The study population of interest in this study consists of female patients seeking care at the Maimusari Primary Health Care in Maiduguri. Thus, those willing to participate served as the respondents. The underlying principle of non-probability convenience sampling technique, which relies on participants at a given location. The availability of participants at the clinic and the willingness to participate in the study made this technique suitable. This sampling technique allowed the study to be conducted in a fast and cost-effective manner. The following formula is used for Qualitative research, (single proportion).

n = Z_α ² pq

d²

Where n is the minimum sample size

Z_α is the standard normal deviate corresponding to a 2-sided level of significance of 5% ie 1.96

P is the proportion of outcome of interest from previous study or report i.e., 56% i.e., 0.56 [30]. Q = 1-P, i.e., 0.44 d is the desired level of precision (usually at 5% for single proportions); d varies for single means i.e., 0.05

Therefore, n = 1.96 ² × 0.56 × 0.44

0.05²

n = 0.95/0.0025 = 380

Therefore, the minimum sample size required for the study was 380.

The sample size determination formula used allowed the generation of data that would meet the research objective with a 95% confidence level.

2.5. Diagnosis of COVID-19 in the study area

Diagnosis of COVID-19 in the study area is largely clinical following high index of suspicion after presenting with the cardinal symptoms of the disease such as dry cough, difficulty with breathing and high pyrexia. After which the COVID-19 emergency response team is notified.

2.6. Data collection and quality assurance

A semi-structured questionnaire was designed using previous KAPs study on COVID-19, including materials on coronavirus disease formulated by WHO and Africa Centre for Disease Control [31]. The semi-structured questionnaire consists of four (4) sections. Responses were recorded appropriately against each question. Section one contains relevant questions regarding the demographic characteristics of the participant’s age, ethnic group, religion, marital status, family settings, family size, occupation, and educational level. In the second and third sections, there are 20 questions (including primary and secondary questions) related to knowledge and 6 questions on attitude related to COVID-19. A dichotomous scale (yes or no) was employed, where each correct response for both knowledge and attitude was assigned 1 point, and incorrectly answered questions were assigned 0 points. The total knowledge score ranges from 0 to 20 and the total attitude score ranges from 0 to 6. The average responses were calculated for each parameter, resulting in mean knowledge and attitude scores of 13.64 ± 2.36 and 0.63 ± 1.35, respectively. A mean knowledge score within the range of 0–13 was categorized as poor knowledge, while a mean score of 14–20 was indicative of good knowledge regarding COVID-19. Similarly, a mean attitude score within the range of 0–1 was characterized as a negative attitude, and a score of 2–6 was classified as a positive attitude, consistent with the criteria used in a similar study by Ejeh et al. [31]. Finally, the fourth section contains 6 questions regarding the practices of the respondents about COVID-19. The response modalities were “yes”, “no”, and “I don’t know”. Frequency counts and percentages were used for COVID-19-related practices. Measures taken by the participants who had contact with infected persons and the reasons why some of the participants were not screened were represented on a bar chart.

The final version of the questionnaire required an approximated time of 10 min to be completed.

2.7. Data analysis

Microsoft Excel program was used for data capture and coding leading to further analysis using SPSS version 20. Descriptive statistics such as mean with standard deviation (SD) for continuous variables and frequency distribution for categorical variables were undertaken. One-way analysis of variance was performed to find the mean difference in the knowledge and attitude scores among the demographic variables. Pearson’s chi-square test was conducted to determine the association between knowledge and attitudes regarding COVID-19. Binary logistic regression analysis was carried out to find the significant predictor for knowledge, attitude, and willingness to take the COVID-19 vaccine (as outcome variables) with demographic variables using odds ratio (OR) with 95% confidence interval (CI). The output from the univariable analysis was used in the multivariable model with a p value set at < 0.2. A stepwise approach was used in the building of the multivariable model creating a main effect model with the significant level set at α = 0.05.

2.8. Ethical statement

Approval for the study was sought from the Borno State Ministry of Health, following the submission of the research proposal. Approval was conveyed before the commencement of the work. Informed consent was sought from all participants and approval was granted on an individual basis before completing the questionnaire.

3. Results

3.1. Baseline characteristics of the participants

The social and demographic characteristics of the study participants are displayed in Table 1. The data shows that among the 400 participants, 384 (96%) are adherents of the Islamic faith, compared to 16 participants (4%) who identified as Christians. Many of the respondents (145; 36.3%), were between the ages of 20 and 29. Also, in terms of ethnicity, the Kanuri, Babur, and Shuwa tribes constituted 47, 21, and 21% of the participants, respectively. A higher proportion of the participants are from monogamous family settings (264; 66.0%) while only 136 respondents (34%) are from polygamous homes. Table 1 shows that 57.8% of respondents lacked formal education while 53.8% are gainfully employed compared to 46.2% of respondents who are not gainfully employed.

Table 1. Socio-demographic characteristics of participants (n = 400).

Variables	Category	Frequency (n)	Percentages (%)
Age
	<20	124	31.00
	20–29	145	36.25
	30–39	92	23.00
	40–49	27	6.75
Ethnic group	>50	12	3.00
	Kanuri	189	47.25
	Babur	21	5.25
	Marghi	33	8.25
	Shuwa	21	5.25
	Hausa	61	15.25
Religion	Others	75	18.75
	Islam	384	96.00
Marital status	Christianity	16	4.00
	Ever married	338	84.50
Family settings	Never married	62	15.50
	Monogamous	264	66.00
Family size	Polygamous	136	34.00
	Less than 5	259	64.75
Occupation	Greater than 5	141	35.25
	Gainfully employed	215	53.75
	Not gainfully employed	185	46.25
Educational level	No formal education	231	57.75
	Formal education	169	42.25

3.2. Knowledge, attitudes, COVID-19 vaccine uptake and vaccination

Table 2 shows the responses of the participants to knowledge questions and attitude and practice statements on COVID-19. The responses to the knowledge-based questions show the knowledge of the participants ranged from 13.2% to 100.0%. Expectedly, all the respondents (100.0%) confirmed they had heard/read about COVID-19, although, 3.5% of the respondents were unaware that dry cough is a cardinal symptom of COVID-19 compared to 96.5% which indicated awareness of this symptom. Similarly, 80.8% and 86.0% of the respondents demonstrated awareness that fever and difficulty in breathing, respectively, were also common symptoms. Furthermore, 83.5% of the respondents were aware that COVID-19 can be transmitted by contact with respiratory droplets from infected persons, however, only 48% of the respondents believed COVID-19 could be transmitted by contaminated instruments, and 35.8% through sharing of sharp objects. Over 70% of respondents are aware of measures such as cleaning surfaces with diluted chlorine, alcohol-based sanitizers, and soap/detergents could kill the virus, although, 27% of respondents indicated water alone could also kill the virus.

Table 2. Knowledge, attitudes, and practices of COVID-19 screening and vaccination among women attending Maimusari Primary Healthcare in Jere, Borno state, Nigeria.

Statement regarding COVID-19	Responses
Knowledge statement about COVID-19 Yes	No (%)
1. Have you ever heard/read about COVID-19?	400 (100.0)	0 (0.0)
2. What are the cardinal symptoms of COVID-19? i. Dry cough ii. Fever iii. Difficulty in breathing iv. Painful urination v. Vomiting vi. Diarrhoea
	386 (96.5)	14 (3.5)
	323 (80.8)	77 (19.2)
	344 (86.0)	56 (14.0)
	53 (13.2)	347 (86.8)
	94 (23.5)	306 (76.5)
	67 (16.8)	333 (83.2)
3. How can COVID-19 be transmitted? i. Contaminated instruments ii. Respiratory droplets from infected persons iii. Sharing sharp object iv. From mother to her unborn child
	192 (48.0)	208 (52.0)
	334 (83.5)	66 (16.5)
	143 (35.8)	257 (64.2)
	227 (56.8)	173 (43.2)
4. What can kill the virus? i. cleaning surfaces with diluted chlorine ii. Alcohol-based sanitizers iii. Soap/detergents iv. Water alone
	310 (77.5)	90 (22.5)
	333 (83.2)	67 (16.8)
	330 (82.5)	70 (17.5)
	108 (27.0)	292 (73.0)
5. Do you know about COVID-19 prevention?	361 (90.3)	39 (9.7)
6. Do you know about the COVID-19 vaccine?	373 (93.2)	27 (6.8)
7. Can COVID-19 be prevented by vaccination?	355 (88.8)	45 (11.2)
8. Is COVID-19 curable?	262 (65.5)	138 (34.5)
9. COVID-19 affects the respiratory?	371 (92.8)	29 (7.2)
Attitude statement to COVID-19	Positive (%)	Negative (%)
1.COVID–19 is a serious health problem	364 (91.0)	36 (9.0)
2. Getting screened for COVID-19 is safe	366 (91.5)	34 (8.5)
3. Getting vaccinated is important	342 (85.5)	58 (14.5)
4. COVID-19 vaccine is safe	329 (82.2)	71 (17.8)
5. Self-isolation reduces the likelihood of exposing others after exposure to COVID-19	373 (93.2)	27 (6.8)
6. Infection prevention guidelines should be provided at work areas	374 (93.5)	26 (6.5)
Practice Statement on COVID-19	Yes (%)	No (%)	I don’t know (%)
1. Have you ever been exposed to COVID-19 risky conditions?	42 (10.5)	289 (72.25)	69 (17.25)
2. Have you ever received COVID-19 vaccine?	155 (38.8)	245 (61.2)
3. Have you ever been screened for COVID-19?	65 (16.2)	335 (83.8)
4. If the vaccine is provided, would you be willing to take it?	275 (68.8)	125 (31.2)
5. Would you be willing to pay for it?	227 (56.8)	173 (43.2)
6. How important do you think you should get vaccinated?	Important (%)	Not important (%)
	241 (85.3)	159 (14.7)

Over 80% of the respondents indicated a positive attitude toward COVID-19. This is seen in their appreciation of the disease as a serious health problem (91%), willingness to be screened (91.5%), and the importance of vaccination (85.5%). Respondents also indicated confidence in the safety of the COVID-19 vaccine (82.2%) and awareness of self-isolation to reduce exposure to COVID-19 (93.2%). 10.5% of respondents acknowledged they had been in contact with confirmed COVID-19 cases, while 68.8% indicated a willingness to take the vaccine, although 43% of respondents indicated their unwillingness to pay for the vaccine.

There was poor practice of screening and vaccination for COVID-19 among the participants, only 65 (16.2%) have been screened for COVID-19, and 155 (38.8%) have received the COVID-19 vaccine. Despite the participants’ willingness to take the vaccine, these numbers are low, even though there is widespread awareness about the importance of screening and vaccination for COVID-19.

3.3. Mean knowledge and attitude scores across socio-demographic characteristics

Table 3 shows the mean knowledge score of the study participants on a scale of 0–20. The overall mean knowledge score of COVID-19 among women attending Maimusari primary healthcare in Jere, Borno state was 13.64 ± 2.36. The mean knowledge score significantly (p < 0.05) differs among age and ethnic groups, marital status, family size, and educational level. In the age groups, respondents over 50 years had the highest knowledge score (14.58 ± 0.79), while in the ethnic group category, the Hausa ethnic group registered the highest knowledge score (14.44 ± 1.20). The married respondents had a knowledge score of 13.86 ± 2.06 which significantly (p < 0.05) differs from the unmarried (12.48 ± 3.36). Also, respondents with a family size less than 5 had a significantly (p < 0.05) higher knowledge score (13.82 ± 2.15) compared with respondents from a family with greater than 5 (13.31 ± 2.67) (Table 3). Furthermore, a significant difference (p < 0.05) was observed concerning educational level, with respondents with formal education having a higher knowledge score (14.28 ± 1.82) compared with those with no formal education (13.18 ± 2.59). However, there were no statistically significant differences among other social and demographic variables such as religion, family setting, and occupation (Table 3).

Table 3. Mean knowledge and attitude scores across socio-demographic characteristics of women attending Maimusari Primary Healthcare in Jere, Borno state.

Variable	Number (%)	Knowledge, N=400		Attitude N=400
		Mean Score ±SD	P-Value	Mean Score ±SD	P-Value
Age group
<20	124 (31.00)	12.39±3.02^a	0.000	0.87±0.13	0.006
20–29	145 (36.25)	14.28±1.39^b		0.49±0.10
30–39	92 (23.0)	14.29±2.32^b		0.78±0.16
40–49	27 (6.75)	13.33±0.83^bc		0.03±0.03
>50	12 (3.00)	14.58±0.79^b		0.00±0.00
Ethnic group
Kanuri	189 (47.25)	13.13±2.67^a	0.001	0.78±0.11	0.000
Babur	21 (5.25)	13.76±2.42		2.00±0.59^b
Marghi	33 (8.25)	13.67±3.13		0.45±0.15
Shuwa	21 (5.25)	13.81±1.72		0.67±0.24
Hausa	61 (15.25)	14.44±1.20^b		0.23±0.08^c
Others	75 (18.75)	14.19±1.61^b		0.25±0.08^c
Religion
Islam	384 (96.00)	13.65±2.36	0.895	0.63±0.07	0.767
Christianity	16 (4.00)	13.56±2.44		0.56±0.22
Marital status
Ever married	338 (84.50)	13.86±2.06^a	0.003	0.56±0.07	0.041
Never married	62 (15.50)	12.48±3.36^b		1.03±0.22
Family settings
Monogamous	264 (66.00)	13.75±2.19	0.233	0.59±0.08	0.375
Polygamous	136 (34.00)	13.43±2.65		0.71±0.11
Family size
Less than 5	259 (64.75)	13.82±2.15^a	0.048	0.51±0.07	0.030
Greater than 5	141 (35.25)	13.31±2.67^b		0.85±0.14
Occupation
Gainfully employed	215 (53.75)	13.79±2.07	0.171	0.64±0.09	0.850
Not gainfully employed	185 (46.25)	13.46±2.65		0.61±0.09
Educational level
No formal education	231 (57.75)	13.18±2.59^a	0.000	0.59±0.08	0.536
Formal education	169 (42.25)	14.28±1.82^b		0.68±0.11

Mean ± SD, Columns with different superscripts (a,b, c) indicate statistical significance at p<0.05. Columns without superscripts are not statistically significant.

On the other hand, Table 3 shows the mean attitude score of the study participants on a scale of 0–6. The overall mean attitude score was 0.63 ± 1.35 which varies significantly (p < 0.05) among age (p = 0.006), ethnic group (p = 0.000), marital status (p = 0.041), and family size (p = 0.030). The Babur ethnic group had the highest mean attitude score of 2.00 ± 0.59 compared to other ethnic groups, although, this is significant (p < 0.05), it is noteworthy this ethnic group only constitutes 5.25% of the total respondents. Respondents <20 years of age, registered the highest mean attitude score of 0.87 ± 0.13 compared with other categories.

Also, the unmarried had a higher mean attitude score of 1.03 ± 0.22 compared to the married (0.56 ± 0.07). Lastly, a family size greater than 5 has a higher attitude score of 0.85 ± 0.14 compared to other categories (Table 3). However, there were no statistically significant differences (p > 0.05) among other variables such as religion, family setting, educational level, and occupation (Table 3).

3.4. Association between demographic variables and respondent’s knowledge and attitude to COVID-19

Table 4 shows the association between demographic variables and respondents’ knowledge and attitude to COVID-19 using Pearson chi-square. Generally, across the different variables and categories, the majority of respondents demonstrated good knowledge with few poor knowledge counts. There was a statistically significant association between knowledge and age group (χ2 = 58.943, p = 0.000) as well as the educational level (χ2 = 12.329, p = 0.000). On the other hand, most of the respondents had negative attitudes across the different variables and categories with fewer positive attitudes. However, there was a statistically significant association between attitude and ethnic group (χ2 = 52.59, p = 0.000), as well as family size (χ2 = 4.32, p = 0.038). The rate of good knowledge toward COVID-19 ranges from 39.5% to 100.0% while the rates of positive attitude to COVID-19 range from 0.0% to 8.1% (Table 4).

Table 4. Univariate analysis of the association between demographic variables and knowledge and attitude to COVID-19 among women attending Maimusari Primary Healthcare in Jere, Borno state.

Demographic characteristics	Knowledge (n=400)		Chi-square	P-value	Attitude (n=400)		Chi-square	P-value
	Poor	Good			Negative	positive
Age group
<20	75 (60.5)	49 (39.5)	58.943	0.000	117 (94.4)	7 (5.6)	2.871	0.580
20–29	36 (24.8)	109 (75.2)			140 (96.6)	5 (3.4)
30–39	18 (19.6)	74 (80.4)			87 (94.6)	5 (5.4)
40–49	12 (44.4)	15 (55.6)			27 (100.0)	0 (0.0)
>50	0 (0)	12 (100.0)			12 (100.0)	0 (0.0)
Ethnic group
Kanuri	71 (37.6)	118 (62.4)	3.592	0.610	179 (94.7)	10 (5.3)	52.59	0.000
Babur	8 (38.1)	13 (61.9)			14 (66.7)	7 (33.3)
Marghi	14 (42.4)	19 (57.6)			33 (100.0)	0 (0.0)
Shuwa	7 (33.3)	14 (66.7)			21 (100.0)	0 (0.0)
Hausa	16 (26.2)	45 (73.8)			61 (100.0)	0 (0.0)
Others	25 (33.3)	50 (66.7)			75 (100.0)	0 (0.0)
Religion
Islam	136 (35.4)	248 (64.6)	0.117	0.732	367 (95.6)	17 (4.4)	0.740	0.390
Christianity	5 (31.2)	11 (68.8)			16 (100.0)	0 (0.0)
Marital status
Ever married	114 (33.7)	224 (66.3)	2.214	0.137	326 (96.4)	12 (3.6)	2.62	0.105
Never married	27 (43.5)	35 (56.5)			57 (91.9)	5 (8.1)
Family settings
Monogamous	90 (34.1)	174 (65.9)	0.457	0.499	252 (95.5)	12 (4.5)	0.167	0.683
Polygamous	51 (37.5)	85 (62.5)			131 (96.3)	5 (3.7)
Family size
Less than 5	88 (34.0)	171 (66.0)	0.522	0.470	252 (97.3)	7 (2.7)	4.323	0.038
Greater than 5	53 (37.6)	88 (62.4)			131 (92.9)	10 (7.1)
Occupation
Gainfully employed	74 (34.4)	141 (65.6)	0.141	0.708	205 (95.3)	10 (4.7)	0.184	0.668
Not gainfully employed	67 (36.2)	118 (63.8)			178 (96.2)	7 (3.8)
Educational level
No formal education	98 (42.4)	133 (57.6)	12.329	0.000	224 (97.0)	7 (3.0)	1.999	0.157
Formal education	43 (25.4)	126 (74.6)			159 (94.1)	10 (5.9)

3.5. Relationship between demographic characteristics and attitude to COVID-19 screening and vaccination

Table 5 shows the relationship between demographic characteristics and attitudes to COVID-19 screening and vaccination. A statistically significant association was observed in most of the respondents from different ethnic group (97.3%, χ2 = 23.75, p = 0.000) and married respondents (92.9%, χ2 = 5.49, p = 0.019) agree that getting screened for COVID-19 is safe. Getting vaccinated was regarded as being important among respondent within 40–49 years old and those >50 years both having (100.0%, χ2 = 18.04, p = 0.001), including respondents that are Hausa by tribe (95.1%, χ2 = 18.77, p = 0.002), married (87.3%, χ2 = 5.56, p = 0.018), from monogamous family (88.6%, χ2 = 6.16, p = 0.013) and family size less than 5 (89.2%, χ2 = 8.07, p = 0.005). Lastly, the COVID-19 vaccine was regarded as safe from respondents >40 years old with about (100.0%, p = 0.000), including respondents that are from other ethnic tribes (93.3%, χ2 = 14.92, p = 0.011), Married (83.7%, χ2 = 3.26, p = 0.071), and family size less than 5 (86.5%, χ2 = 9.03, p = 0.003).

Table 5. Relationship between demographic characteristics and attitude to COVID-19 screening and vaccination among women attending Maimusari Primary Healthcare in Jere, Borno state.

Demographic variables	Getting screened for COVID-19 is safe				Getting vaccinated is important				COVID-19 vaccine is safe
	Agree	disagree	χ2	P-value	Agree	disagree	χ2	P-value	Agree	disagree	χ2	P-value
Age
<20	108 (87.1)	16 (12.9)	7.198	0.126	94 (75.8)	30 (24.2)	18.042	0.001	94 (75.8)	30 (24.2)	24.351	0.000
20–29	135 (93.1)	10 (6.89)			130 (89.7)	15 (10.3)			130 (89.7)	15 (10.3)
30–39	84 (91.3)	8 (8.7)			79 (85.9)	13 (14.1)			66 (71.7)	26 (28.3)
40–49	27 (100.0)	0 (0.0)			27 (100.0)	0 (0)			27 (100.0)	0 (0.0)
>50	12 (100.0)	0 (0.0)			12 (100.0)	0 (0.0)			12 (100.0)	0 (0.0)
Ethnic group
Kanuri	169 (89.4)	20 (10.6)	23.754	0.000	153 (80.9)	36 (19.1)	18.774	0.002	151 (79.9)	38 (20.1)	14.917	0.011
Babur	14 (66.7)	7 (33.3)			14 (66.7)	7 (33.3)			14 (66.7)	7 (33.3)
Marghi	31 (93.9)	2 (6.1)			28 (84.8)	5 (15.2)			27 (81.8)	6 (18.2)
Shuwa	20 (95.2)	1 (4.8)			18 (85.7)	3 (14.3)			14 (66.7)	7 (33.3)
Hausa	59 (96.7)	2 (3.3)			58 (95.1)	3 (4.9)			53 (86.9)	8 (13.1)
Others	73 (97.3)	2 (2.7)			71 (94.7)	4 (5.3)			70 (93.3)	5 (6.7)
Religion
Islam	351 (91.4)	33 (8.6)	0.108	0.742	330 (85.9)	54 (14.1)	1.482	0.223	317 (82.6)	67 (17.4)	0.600	0.439
Christianity	15 (93.8)	1 (6.2)			12 (75.0)	4 (25.0)			12 (75.0)	4 (25.0)
Marital status
Ever married	314 (92.9)	24 (7.1)	5.491	0.019	295 (87.3)	43 (12.7)	5.561	0.018	283 (83.7)	55 (16.3)	3.262	0.071
Never married	52 (83.9)	10 (16.1)			47 (75.8)	15 (24.2)			46 (74.2)	16 (25.8)
Family settings
Monogamous	241 (91.3)	23 (8.7)	0.045	0.832	234 (88.6)	30 (11.4)	6.161	0.013	223 (84.5)	41 (15.5)	2.620	0.105
Polygamous	125 (91.9)	11 (8.1)			108 (79.4)	28 (20.6)			106 (77.9)	30 (22.1)
Family size
Less than 5	239 (92.3)	20 (7.7)	0.572	0.450	231 (89.2)	28 (10.8)	8.066	0.005	224 (86.5)	35 (13.5)	9.033	0.003
Greater than 5	127 (90.1)	14 (9.9)			111 (78.7)	30 (21.3)			105 (74.5)	36 (25.5)
Occupation
Gainfully employed	200 (93.0)	15 (7.0)	1.387	0.239	181 (84.2)	34 (15.8)	0.647	0.421	174 (80.9)	41 (19.1)	0.555	0.456
Not gainfully employed	166 (89.7)	19 (10.3)			161 (87.0)	24 (13.0)			155 (83.8)	30 (16.2)
Educational level
No formal education	214 (92.6)	17 (7.4)	0.915	0.339	197 (85.3)	34 (14.7)	0.021	0.855	194 (83.9)	37 (16.0)	1.124	0.289
Formal education	152 (89.9)	17 (10.1)			145 (85.8)	24 (14.2)			135 (79.9)	34 (20.1)

3.6. Factors associated with the willingness of respondents to accept COVID-19

Table 6 shows socio-demographic variables that are statistically significant (p < 0.005) among family size and educational level. Respondents with a family size less than 5 were 4.8 times more likely (OR: 4.86; 95% CI: 2.17–10.89) to take the COVID-19 vaccine compared to a family size greater than 5. The relationship between attitude and willingness to take the COVID-19 vaccine shows that respondents who agreed to get vaccinated are 2 times more likely to take the vaccine (OR: 1.63; 95% CI: 0.757–3.501), although the results were not statistically significant (p > 0.05).

Table 6. Logistic regression analysis of factors associated with willingness to accept vaccine among women attending Maimusari Primary Healthcare in Jere, Borno state.

Variables	Category	Odd Ratio (OR)	95% CI	P value
Age	<20	0.000	0.000	0.000
	20–29	0.000	0.000	0.998
	30–39	0.000	0.000	0.998
	40–49	0.000	0.000	0.998
	>50	Ref	Ref	Ref
Ethnic group	Kanuri	0.099	0.040–0.241	0.000
	Babur	0.385	0.037–3.960	0.422
	Marghi	0.392	0.111–1.383	0.146
	Shuwa	0.401	0.087–1.848	0.241
	Hausa	0.783	0.273–2.239	0.648
	Others	Ref	Ref	Ref
Religion	Islam	3.208	0.559–18.333	0.191
	Christianity	Ref	Ref	Ref
Marital status	Ever married	0.178	0.064–0.492	0.001
	Never married	Ref	Ref	Ref
Family settings	Monogamous	0.628	0.297–1.327	0.223
	Polygamous	Ref	Ref	Ref
Family size	Less than 5	4.862	2.171–10.888	0.000
	Greater than 5	Ref	Ref	Ref
Occupation	Gainfully employed	1.296	0.726–2.315	0.381
	Not gainfully employed	Ref	Ref	Ref
Educational level	No formal education	0.089	0.042–0.189	0.000
	Formal education	Ref	Ref	Ref
Getting screened for COVID-19 is safe	Agree	1.036	0.516–4.238	0.466
	Disagree	Ref	Ref	Ref
Getting vaccinated is important	Agree	1.628	0.757–3.501	0.212
	Disagree	Ref	Ref	Ref
COVID-19 vaccine is safe	Agree	1.832	0.923–3.637	0.083
	Disagree	Ref	Ref	Ref
After exposure, self-isolation reduces the likelihood of exposing others	Agree	1.916	0.471–7.786	0.364
	Disagree	Ref	Ref	Ref

3.7. Practice relating to COVID-19 screening and vaccination

Forty-two participants in the study noted that they have had contact with suspected cases of COVID-19. Figure 1 shows the various post-exposure preventive measures by the respondents following exposure to infected or suspected persons or material. The bulk of the respondents (56.1%) acknowledged washing their hands with soap, followed by 21.9% of the respondents who isolated themselves after exposure. Lastly, only 2% acknowledged reporting their contact with a COVID-19 case.

Figure 1. Measures taken by respondents following exposure to infected person.

Only 65 (16.2%) of the participants were screened for COVID-19 during the pandemic. Figure 2 illustrates the reasons why most of the respondents do not want to screen for COVID-19. Many of the respondents 150 (45.2%) reported that the fear of adverse effects was the main reason why they did not want to subject themselves to COVID-19 screening, while the least was busy 15 (4.5%). Other reasons include lack of access 64 (19.1%) and awareness 49 (14.6%).

Figure 2. Reasons respondents do not want to be screened for COVID-19.

About 10%(42) of the total respondents in the study acknowledged having contact with suspected cases of COVID-19, and the response ranges from immediate reporting of the suspected case (2%), wash hand soap (56.1%) or self-isolation (21.9).

About 45% of the total respondents stated fear of adverse effect was a major reason for abstaining from COVID-19 screen while 19% indicated they had no access to testing.

4. Discussion

The spread and severity of COVID-19 disease is impacted by the knowledge, attitude, and awareness of members of a population. In Nigeria, there is limited access to basic social amenities in rural communities. Health inequality in rural communities is high, characterized by limited access to health facilities leading to poor perception and attitude toward health issues. This is compounded by low literacy rates, which makes information dissemination difficult in rural communities [32]. In this study, we showed that women attending Maimusari primary healthcare in Jere, a rural community in Borno state, Northeast, Nigeria have good knowledge and positive attitudes toward COVID-19 as well as good practices to minimize transmission.

The socio-demographic characteristics of participants (Table 1) showed the predominance of women below 40 years of age and over 80% are married and from monogamous families with a family size of five or less. The prevalent ethnic group, Kanuri, and faith (Islam) of the participants are comparable with the general female population in the Bornu region of northern Nigeria. The Kanuri ethnic group has previously been reported to be the most predominant ethnic group in the North East region of Nigeria and the Islamic faith predominates in the region [26,33]. The demography of our study suggests a true reflection of the wider North East region of Nigeria and it is plausible to make logical inferences from the data.

In the study, we found that participants have good COVID-19-related knowledge spanning the nine knowledge statements including awareness of COVID-19 symptoms, transmission, prevention, vaccination, and treatment (Table 2). The data showed over 80.0% of the respondents demonstrated good knowledge of the cardinal clinical symptoms of COVID-19 such as dry cough, fever, and difficulty in breathing. This observation aligns with previous studies in Tanzania and Jordan, where 69.0% and 71.4% of respondents demonstrated sufficient knowledge of these cardinal symptoms [34,35]. The high level of awareness of COVID-19 symptoms demonstrated in this study could be attributed to the role of mass media such as television, radio, social media, and the internet [11]. Currently, the availability of the internet for surfing the web has considerable penetration in Nigeria due to the affordability of internet data and mobile phone devices with over 85 million social media users documented in Nigeria [36]. 92.8% respondents also demonstrated sufficient knowledge that COVID-19 is caused by a virus that affects the respiratory system and is transmitted mainly via respiratory droplets from infected persons. This agrees with the observations documented by a similar study on KAP to COVID-19 in North-Central Nigeria [30].

The respondent’s attitude and knowledge of COVID-19 disease reflected in the mean attitude and knowledge scores (Table 3). The educational level and age were associated with having good knowledge while there was a statistically significant association between attitude ethnic group and family size (Table 4). This suggests the younger demographics of participants who are educated are more knowledgeable about the disease. A related study [37] showed that Africans, including Nigerians, between the ages of 18 to 49 are generally knowledgeable about COVID-19. This might be connected to similarities in access to information and awareness. However, studies in Cameroon, Egypt, and Ethiopia report that the study participants demonstrated low mean knowledge scores, and participants in the age group 50 and above had a lower mean knowledge score for COVID-19 [38–40]. This could be due to the limited availability of information at the time of these studies when the pandemic was in the early stages while the current study focuses on post-pandemic knowledge of the participants to improve knowledge and awareness for future public health crises.

The willingness of the population to accept the COVID-19 vaccine is essential in combating public health challenges (Tables 5 and 6). This study shows that over 68% of participants were willing to accept the vaccine if the vaccine is broadly made available. This finding agrees with a South African study which reports that 65% of participants indicated willingness to take the COVID-19 vaccine [41]. A previous study in Nigeria on male healthcare workers also showed a positive attitude toward the need to be vaccinated against COVID-19 [19]. Similarly, over 80% of respondents have a perception that the COVID-19 vaccine is safe. However, concerns raised regarding the safety of COVID-19 vaccines by 17% of the respondents in this study could be related to the long-term side effects, effectiveness, and efficacy [42]. Also, some respondents suggested that the vaccines were produced hastily, and the fast-tracked nature of its development was a concern and that it could be indicative of a conduit for the financial benefits of the pharmaceutical companies or authorities involved in delivering the vaccine. To dispel mistrust among the population and healthcare workers, public campaigns should be improved on vaccine development and clinical endpoints [43]. Unexpectedly, most of the women alluded that the fear of adverse effects was one of the reasons why they preferred to abstain from screening for COVID-19 (Figure 2). The gold standard test for SARS-COV-2 requires the screening of nasal or throat swabs or their combination using real-time polymerase chain reaction. The collection of swab samples is noninvasive with little or no adverse effects. Misinformation could be responsible for this response. Thus, women in Jere, Borno state need to be further enlightened that this method is safe with little or nothing to worry about. Also, the health and other relevant authorities should critically address these misconceptions while considering the culture and religious values of respondents [44].

COVID-19 vaccine acceptance rate varies considerably across different geographical regions and spaces with 64.0% in South Africa, and 54.0%−80.0% across most European countries according to a recent report [45,46]. The bulk of our respondents were willing to take the COVID-19 vaccine with about 68.8% acceptance rate leaving about 31.2% as COVID-19 vaccine hesitant. These numbers are quite remarkable and present an improvement compared to a previous study in Nigeria where the hesitancy rate was reported at > 70.0% among healthcare workers in Southeastern Nigeria [47]. In the early stages of the pandemic, vaccine hesitancy was higher with most persons expressing doubt over the vaccines due to the short period taken for its development including other conspiracy theories and worries about unforeseen future. Also, socio-cultural factors may strongly influence vaccine uptake decisions. Differences in COVID-19 vaccine hesitancy have been attributed to some factors including study population, study periods, and the impact the COVID-19 pandemic has had on a given study population [13]. To further improve herd health, there is a need for an effective communication strategy to dispel any misconceptions surrounding vaccine safety and efficacy.

A key limitation of the current study is difficulty with communication with a small group of the respondents (<5%) who did not understand the common languages such as Hausa, Kanuri, and English. This may have affected their response to the survey questions. However, robust mitigation plan such as the use of an interpreter was considered which would have significantly reduced the impact of these group of respondents. Additionally, the diagnosis of COVID-19 in the study area is mainly clinical. Relying on clinical diagnosis alone may reflect the actual prevalence of the disease.

In conclusion, the findings from this study revealed that women attending Maimusari Primary Healthcare in Jere Local Government, Northeast, Nigeria have good knowledge and positive attitudes toward COVID-19 as well as good practices to minimize transmission of the virus. Over 80% of the respondents agree that the vaccine is safe and that getting vaccination is important. Consequently, 68% of participants indicated a willingness to take the vaccine. However, this data should be interpreted cautiously as the small group of participants who are hesitant to take the vaccine and adjudge it as unsafe could boomerang to a significant proportion of the wider Northeast region of Nigeria. Therefore, the findings on the knowledge, attitude, and practices of these local inhabitants are important in the control of the virus and offer significant information for policies and intervention efforts in combating public health challenges, beyond the era of COVID-19. 

Disclosure statement

No potential conflict of interest was reported by the author(s).