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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: kaustrian@popcouncil.org (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

Characteristic N (%)

Total 2,009

Female 1260 (62.7)

Age 18-24 years 436 (21.6)

25-34 years 397 (19.7)

35-44 years 704 (34.9)

45+ years 478 (23.7)

Educational attainment

No school 73 (3.6)

Primary school 795 (39.6)

Secondary school 882 (44.0)

Higher education 257 (12.8)

Location

Kibera 460 (22.9) Dandora 275 (13.7) Huruma 414 (20.6) Kariobangi 443 (22.1) Mathare 417 (20.8) Household size (mean (sd)) 5.1 (2.1)

Water source

In own dwelling 90 (5.0) In own yard/plot 810 (44.7) Elsewhere 911 (50.3) Shared toilet

Yes 1178 (58.9) No 718 (35.9) No toilet 105 (5.2) Cooking fuel

Kerosene 1152 (57.4) LPG/Natural Gas 452 (22.5) Charcoal 287 (14.3) Biogas 48 (2.4) Electricity 26 (1.3) Wood 34 (1.7) Other 8 (0.4)

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Table 2: Awareness of symptoms and sub-groups at risk of severe sickness by gender, by education

Male Female No School Primary Secondary Higher Ed Overall Symptomsa Fever 576 (76.9) 966 (76.7) 40 (54.8) 572 (72.0) 720 (81.7) 208 (80.9) * 1542 (76.8) Dry cough 638 (85.2) 1087 ( 86.3)

1087 (86.3) 51 (69.9) 676 (85.1) 771 (87.5) 226 (87.9) * 1725 (85.9) Difficulty breathing 309 (41.3) 529 ( 42.0)

529 (42.0) 27 (37.0) 286 (36.0) 392 (44.5) 131 (51.0) * 838 (41.7) Sneezing 403 (53.8) 713 (56.6) 30 (41.1) 435 (54.8) 508 (57.7) 141 (54.9) * 1116 (55.6) Headache 364 (48.6) 620 (49.2) 32 (43.8) 387 (48.7) 441 (50.1) 124 (48.2) 984 (49.0) Who is at risk of getting severely sick from COVID? Everyone 183 (24.4) 258 (20.5) * 15 (20.5) 182 (22.9) 198 (22.5) 46 (17.9) 441 (22.0) Elderly 485 (64.8) 802 (63.7) 43 (58.9) 483 (60.8) 580 (65.8) 180 (70.0) * 1287 (64.1) Children 122 (16.3) 266 (21.1) * 13 (17.8) 153 (19.3) 162 (18.4) 58 (22.6) 388 (19.3) Pregnant women 10 (1.3) 44 (3.5) * 2 (2.7) 28 (3.5) 17 (1.9) 7 (2.7) 54 (2.7) People with HIV 53 (7.1) 111 (8.8) 4 (5.5) 53 (6.7) 82 (9.3) 25 (9.7) 164 (8.2) People who are already sick/weak immune systems

177 (23.6) 341 (27.1) * 21 (28.8) 174 (21.9) 238 (27.0) 84 (32.7) *

518 (25.8)

*denotes statistical significance p<0.05

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

506 (67.6) 858 (68.1) 332 (76.7) 263 (66.4) 479 (68.3) 290 (60.7) * 1364 (67.9)

There is no cure or treatment

306 (40.9) 487 (38.7) 178 (41.1) 143 (36.1) 291 (41.5) 181 (37.9)

793 (39.5)

Loss of job/income/closing business

293 (39.1) 397 (31.5) * 130 (30.0) 118 (29.8) 245 (35.0) 197 (41.2) * 690 (34.4)

Food shortages 159 (21.2) 278 (22.1) 80 (18.5) 67 (16.9) 159 (22.7) 131 (27.4) * 437 (21.8)

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

563 (75.2) 901 (71.6) 46 (63.0) 561 (70.7) 673 (76.4) 182 (70.8) *

1464 (72.9) TV programs 543 (72.5) 890 (70.7) 45 (61.6) 547 (68.9) 652 (74.0) 187 (72.8) * 1433 (71.4) Radio programs 532 (71.0) 846 (67.2) 40 (54.8) 539 (67.9) 628 (71.3) 169 (65.8) * 1378 (68.6) Friends 483 (64.5) 803 (63.8) 47 (64.4) 505 (63.6) 567 (64.4) 167 (65.0) 1286 (64.0) Acquaintances/ neighbors 414 (55.3) 742 (58.9) 45 (61.6) 472 (59.4) 493 (56.0) 145 (56.4) 1156 (57.6) Other family 389 (51.9) 684 (54.3) 47 (64.4) 407 (51.3) 481 (54.6) 137 (53.3) 1073 (53.4) Social media (Text, Facebook, Twitter, Snapchat) 417 (55.7) 486 (38.6) * 11 (15.1) 236 (29.7) 475 (53.9) 180 (70.0)

*

903 (45.0) Internet 383 (51.1) 412 (32.7) * 6 (8.2) 198 (24.9) 417 (47.3) 173 (67.3) * 795 (39.6) Work colleagues 346 (46.2) 375 (29.8) * 19 (26.0) 291 (36.6) 310 (35.2) 101 (39.3) 721 (35.9) Spouse 289 (38.6) 400 (31.8) * 20 (27.4) 296 (37.3) 295 (33.5) 78 (30.4) 689 (34.3) Church 222 (29.6) 403 (32.0) 23 (31.5) 260 (32.7) 261 (29.6) 79 (30.7) 625 (31.1)

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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nt o

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Figure 2: Source of information of COVID-19 by trust in that source

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Source of COVID-19 Information Trust this source

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