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Adherence towards COVID-19 mitigation measures and its associated factors

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PLOS ONE
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OPEN ACCESS
Citation: Azene ZN, Merid MW, Muluneh AG,
Geberu DM, Kassa GM, Yenit MK, et al. (2020)
Adherence towards COVID-19 mitigation measures
and its associated factors among Gondar City
residents: A community-based cross-sectional
study in Northwest Ethiopia. PLoS ONE 15(12):
e0244265. https://doi.org/10.1371/journal.
pone.0244265
Editor: Francesco Di Gennaro, National Institute for
Infectious Diseases Lazzaro Spallanzani-IRCCS,
ITALY
Received: September 2, 2020
Accepted: November 22, 2020
Published: December 30, 2020
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0244265
Copyright: © 2020 Azene et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
PLOS ONE | https://doi.org/10.1371/journal.pone.0244265 December 30, 2020
RESEARCH ARTICLE
Adherence towards COVID-19 mitigation
measures and its associated factors among
Gondar City residents: A community-based
cross-sectional study in Northwest Ethiopia
Zelalem Nigussie Azene ID1*, Mehari Woldemariam Merid2, Atalay Goshu Muluneh2,
Demiss Mulatu Geberu3, Getahun Molla Kassa ID2, Melaku Kindie Yenit2, Sewbesew
Yitayih Tilahun4, Kassahun Alemu Gelaye2, Habtamu Sewunet Mekonnen5, Abere
Woretaw Azagew5, Chalachew Adugna Wubneh6, Getaneh Mulualem Belay6, Nega
Tezera Asmamaw6, Chilot Desta Agegnehu ID7, Telake Azale8, Animut Tagele Tamiru9,
Bayew Kelkay Rade9, Eden Bishaw Taye10, Asefa Adimasu Taddese2,
Zewudu Andualem11, Henok Dagne11, Kiros Terefe Gashaye12, Gebisa Guyasa Kabito11,
Tesfaye Hambisa Mekonnen11, Sintayehu Daba11, Jember Azanaw11, Tsegaye Adane11,
Mekuriaw Alemayeyu11
1 Department of Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences,
University of Gondar, Gondar, Ethiopia, 2 Department of Epidemiology and Biostatistics, Institute of Public
Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia, 3 Department of
Health Systems and Policy, University of Gondar, Gondar, Ethiopia, 4 Department of Psychiatry, College of
Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia, 5 Department of Medical Nursing,
School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia,
6 Department of Pediatric and Child Health Nursing, School of Nursing, College of Medicine and Health
Sciences, University of Gondar, Gondar, Ethiopia, 7 School of Nursing, College of Medicine and Health
Sciences and Comprehensive Specialized Hospital, University of Gondar, Gondar, Ethiopia, 8 Department of
Health Education and Behavioral Sciences, Institute of Public Health, College of Medicine and Health
Sciences, University of Gondar, Gondar, Ethiopia, 9 Department of General Midwifery, School of Midwifery,
College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia, 10 Department of Clinical
Midwifery, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar,
Ethiopia, 11 Department of Environmental and Occupational Health and Safety Institute of Public Health,
College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia, 12 Department of
Gynecology and Obstetrics, University of Gondar College of Medicine and Health Sciences, Gondar, Ethiopia
* znigussie35@gmail.com
Abstract
Background
Considering its pandemicity and absence of effective treatment, authorities across the globe
have designed various mitigation strategies to combat the spread of COVID-19. Although
adherence towards preventive measures is the only means to tackle the virus, reluctance
to do so has been reported to be a major problem everywhere. Thus, this study aimed to
assess the community’s adherence towards COVID-19 mitigation strategies and its associ-
ated factors among Gondar City residents, Northwest Ethiopia.
Methods
A community-based cross-sectional study was employed among 635 respondents from
April 20–27, 2020. Cluster sampling technique was used to select the study participants.
1 / 15
PLOS ONE
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
information files.
Funding: This study was funded by University of
Gondar. However, the funder had no role in data
collection, preparation of manuscript, and decision
to publish.
Competing interests: The authors have declared
that no competing interests exist.
Abbreviations: AOR, Adjusted Odds Ratio; CI,
Confidence Interval; COR, Crude Odds Ratio;
COVID-19, Coronavirus disease 19; MERS, Middle
East Respiratory Syndrome; OR, Odds Ratio;
SARS, Severe Acute Respiratory Syndrome; SD,
Standard Deviation; SPSS, Statistical Package for
Social Sciences; TV, Television; WHO, World
Health Organization.
PLOS ONE | https://doi.org/10.1371/journal.pone.0244265 December 30, 2020
Adherence towards COVID-19 mitigation measures and its associated factors
Data were collected using an interviewer-administered structured questionnaire. Epi-Data
version 4.6 and STATA version 14 were used for data entry and analysis, respectively.
Binary logistic regressions (Bivariable and multivariable) were performed to identify statis-
tically significant variables. Adjusted odds ratio with 95% CI was used to declare statisti-
cally significant variables on the basis of p < 0.05 in the multivariable logistic regression
model.
Results
The overall prevalence of good adherence towards COVID-19 mitigation measures was
51.04% (95%CI: 47.11, 54.96). Female respondents [AOR: 2.39; 95%CI (1.66, 3.45)],
receiving adequate information about COVID-19 [AOR: 1.58; 95%CI (1.03, 2.43)], and
favorable attitude towards COVID-19 preventive measures were significantly associated
with good adherence towards COVID-19 mitigation measures. Whereas, those respondents
who had high risk perception of COVID-19 were less likely to adhere towards COVID-19 mit-
igation measures [AOR: 0.61; 95% CI (0.41, 0.92)].
Conclusions
The findings have indicated that nearly half of the study participants had poor adherence
towards COVID-19 mitigation measures. Sex, level of information exposure, attitude
towards COVID-19 preventive measures, and risk perception of COVID-19 were factors
which significantly influenced the adherence of the community towards COVID-19 mitigation
measures. Therefore, it is crucial to track adherence responses towards the COVID-19 pre-
ventive measures, scale up the community’s awareness of COVID-19 prevention and miti-
gation strategies through appropriate information outlets, mainstream media, and rely on
updating information from TV, radio, and health care workers about COVID-19.
Background
Coronaviruses (Cov) are a large family of viruses that cause a wide range of illnesses ranging from
common cold to severe diseases [1, 2]. A novel coronavirus (nCov), also called SARS-CoV-2, is
the new strain of the virus that causes respiratory illness such as common cold, Severe Acute
Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) and has not been
previously identified in human population [3]. The first case of the COVID-19 epidemic was dis-
covered in Wuhan city, Hubei province of China with unexplained pneumonia on December 12,
2019, and 27 viral pneumonia cases, seven of them being severe, were officially announced on
December 31, 2019 [4].
Corona virus disease 2019 (Covid-19) typically shows flu-like symptoms such as fever, loss
of taste, and cough [5–7]. Though there is still much to discover about symptoms of the dis-
ease, it starts with a fever, followed by a dry cough, and it later leads to shortness of breath and
sore throat. The first report from China indicated that 80% of infections are mild, and only
20% of patients (15% severe and 5% critical) require hospital admission [5, 8, 9]. COVID-19 is
a new disease that is distinct from other diseases that have known so far across the globe such
as SARS, MERS, and influenza. Although coronavirus and influenza infections cause similar
symptoms, the new coronavirus is different with respect to significant community spread and
severity [1, 10]. Globally, the virus has affected 213 countries and territories and has resulted
in greater loss of life and the broader economic crisis. As of August 2, 2020, more than 18
2 / 15
PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

million people have been infected and half a million deaths were caused by the pandemic
worldwide [3, 11].
Considering its pandemicity and absence of effective treatment, the World Health Organi-
zation(WHO) has designed various mitigation strategies to combat the spread of COVID-19.
Among these, staying at home, social distancing, wearing masks, and applying hand hygiene
are the common precaution measures to break the pandemic. In addition, in response to the
pandemic, countries across the globe have taken various measures to slow the spread of the
virus down and protect vulnerable groups from getting infected of the virus [12]. These mea-
sures are vital in decreasing mortality and reducing the overburden of the health care systems
[13, 14]. Such protective measures are believed to decrease further COVID-19 transmissions
overall and in particular to protect individuals at increased risk for severe illness including
older adults, people with underlying medical conditions, and frontline health workers in par-
ticular [15–17].
Despite the repeated consensus that adhering towards such guidelines is the most effective
way to defuse the novel coronavirus, community’s risk perception and poor adherence
towards COVID-19 mitigation measuresremain problems. A significant proportion of com-
munities did not perceive the virus as a risk for health. People also think that it originated
from a laboratory, and mostly causes mild symptoms, and affects the elderly [18, 19]. These
negative behaviors toward COVID-19 in the community across the world remain a great con-
cern and can be mainly associated with lack of knowledge, misperception about the disease
[15], lack of appropriate information, and the social and economic factors as well as lack of
government concern. Although people’s adherence towards mitigation measures is highly
affected by their knowledge, behavior and practices, a lot of information they get in this area
might be fake and infodemic that potentially disturb the public and influence their measures
[15, 20]. Furthermore, most people supposed that COVID-19 is a stigmatized disease despite
efforts on risk communication and public education [20, 21].
In Ethiopia, there is an increasing number of COVID-19 cases. As of August 2, 2020, a
total of 17,999 confirmed cases and 284 deaths are reported. By August 6th, Ethiopia had
recorded 20,900 cases and 365 deaths, with a recent upsurge since mid-July, particularly in
the last fortnight. One-fifth of the cases (20%) but more than a quarter of the deaths (28%)
occurred in the past seven days, suggesting that the rate of mortality and the number of criti-
cal cases is increasing. Ethiopia ranks 68th worldwide and 8th in Africa with South Africa in
the lead followed by the two other countries with a population of more than 100 million:
Egypt and Nigeria, which have much lower numbers tested overall and per million inhabi-
tants than Ethiopia [22].
Since COVID-19 has been declared as a public health threat globally and nationally, the
Ethiopian government initiated a screening program, established quarantine and treatment
centers in addition to community awareness and strong enforcement to slow the nationwide
spread of the virus. In Gondar city, where the study was conducted, the risk of COVID-19
has become high. The closeness of the city to the Sudanese border and the city’s tourist desti-
nations will make it the second epicenter next to Addis Ababa. To this effect, there is a need
for information about the community’s adherence towards the recommended mitigation-
measures. However, to date, there is no study that assessed community’s adherence towards
COVID-19 pandemic in the study area. Therefore, our study aimed to assess the commu-
nity’s adherence towards COVID-19 mitigation strategies and its associated factors among
residents of the city of Gondar, Northwest Ethiopia. The findings of this study will help local
decision makers and COVID-19 task forces to design an effective intervention against the
pandemic.

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Methods
Study area
The study was conducted in Gondar city, Amhara regional state, Northwest Ethiopia. The city
is located in Central Gondar Zone, Amhara Regional State, and is 748 km far from Northwest
of Addis Ababa, the capital of Ethiopia and, about 180 kilometers from Bahir Dar city, the cap-
ital of Amhara regional state. It has an altitude of 12˚360 N 37˚280 E and longitude of 12.60N
37.467’E with an elevation of 2133 meters above sea level and is divided into 12 administrative
areas (sub-cities) which consist of 21 kebeles (the smallest administrative units in Ethiopia).
Gondar is among one of the ancient and largely populated cities in the country. The city has
now one comprehensive specialized hospital and eight health centers providing health services
to the population.

Study design and period

A community-based cross-sectional study was conducted from April 20 to 27, 2020.

Participants
The source population were all people 18 years of age and above residing in Gondar city, while
the study population were all people 18 years of age and above in the selected kebeles (the
smallest administrative unit) of the city.

Sample size calculation and sampling procedures

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%
Using the following single proportion formula: -
ðZa=2Þ2 x Pð1 PÞ
n¼
ðWÞ2

Where
n = initial sample size
Z = 1.96, the corresponding Z-score for the 95% CI
P = Proportion = 50%
W = Margin of error = 5% = 0.05
ð1:96Þ2 x 0:5ð1 0:5Þ
n¼ ¼ 384
ð0:05Þ2

By considering 10% non-response rate and a design effect of 1.5 the final sample size was
635. Finally, participants‘households were accessed using a cluster sampling technique.
From 22 kebeles, 8 kebeles (Kebele 7, Kebele 8, Kebele 9, Kebele 13, Kebele 16, Kebele 17,
Kebele 18, and Kebele 20) were selected by using the lottery method, then from each kebele
one to two Ketena/s (the lowest administrative cluster) were selected depending on the num-
ber of households. The selected Ketena/s were considered as clusters and all households in the
selected Ketena were included. Either of the parents in the household was interviewed or one

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

family member age above 18 years was the respondent in the household whenever the parents
were not available at the time of data collection.

Operational definitions
Adherence towards COVID-19 mitigation measures. Was a composite variable gener-
ated from handwashing, using a facemask, keeping physical distance, not travel to a crowded
place, homestay, and not travel to anyplace out of the city in the last 14 days. Hence, an indi-
vidual was considered as having good adherence towards COVID-19 mitigation measures if
he/she was able to answer ‘yes’ to the median and above of the aforementioned composite
variables.
Information exposure. Respondents were asked whether they heard or not about the var-
ious aspects of COVID-19. The responses were coded as yes or no and those who responded
with a median and above scores of the information exposure assessment questions were con-
sideredas having a good information exposure level about COVID-19.
Good knowledge. Participants who responded with a median and above scores of the
knowledge items about COVID-19 were labeled as having good knowledge otherwise poor
knowledge.
Favorable attitude. Participants who responded with a median and above scores of the
attitude questions about the COVID-19 and its preventive measures were labeled as having a
favorable attitude otherwise unfavorable attitude.
Risk perception of COVID-19 infection. Risk perception was measured by two psycho-
logical dimensions; perceived susceptibility and perceived severity. The first dimension was
proxied by how likely one considered oneself (his/her families) would be infected with
COVID-19 if no preventive measure will be taken. The second dimension was proxied by how
one rated the seriousness of symptoms caused by COVID-19, their perceived chance of having
COVID-19 cured and that of survival if infected with COVID-19. By combining the two
dimensions, five items with five response options were asked to determine the respondents’
levels of risk perception [23].

Study variables
The outcome variable of this study was adherence towards COVID-19 mitigation measures,
while others like socio-demographic, information exposure related characteristics, risk percep-
tion of COVID-19, knowledge about COVID-19, and its mitigation strategies, mode of trans-
missions, attitude towards COVID-19 and its prevention measures were the explanatory
variables.

Data collection tools and procedures

Data regarding the socio-demographic, information exposure, risk perception of COVID-19,
and precaution measures adoption and community’s misconception about COVID-19 were
collected through face-to-face interview using a structured questionnaire adapted from different
literatures. Respondents were asked about the sources of information about COVID-19 and
how much they trust those sources. They were also asked about the types of information that
they wanted to receive. Participants were interviewed whether they performed precautionary
measures including avoiding handshaking, adopting hand washing, and practicing physical dis-
tancing. Data were collected by BSc nurses and strictly followed by supervisors who managed
the overall data collection process. A one-day training was given to the data collectors and
supervisors about the purpose of the study, data collection tools, collection techniques, and ethi-
cal issues during the selection of the study participants and collection of the data. All responses

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

to closed and open questions were written down manually by the interviewers. The supervisors
assessed the consistency and completeness of data on a daily basis (S1 Table).

Statistical analysis
The data entry was performed using the statistical program Epi-Data version 4.6 and then
exported into STATA version 14 for analysis. Descriptive statistics was carried out and pre-
sented with narration and tabulation. Binary logistic regression (Bivariable and multivariable)
was performed to identify statistically significant variables using a cut-off p-value < 0.2 in the
bivariable analysis to identify candidate variables for multivariable logistic regression. Adjusted
odds ratio with a 95% confidence interval was used to declare statistically significant variables
on the basis of p-value <0.05 in the multivariable binary logistic regression model. Hosmer
and Lemeshow goodness of fit test was performed and the decision was made at P>0.05.

Quality assurance mechanisms

To assure the quality of the data, the tool was prepared first in English and then translated into
the local language (Amharic) by language experts in English and Amharic languages. Data col-
lectors and supervisors were trained on the data collection process for one day. A pretest was
conducted from 5% of the total sample size in sub-city which is not selected for actual data col-
lection. Appropriate modifications such as wording, changing terms, rephrasing for better
understanding, deleting, and adding some information for clarity were made on the tool
accordingly. Data collection was closely monitored by investigators and supervisors. More-
over, the data quality was assured by using statistical parameters for assessing the validity of
the collected data.
Ethical clearance was obtained from the Institutional Review Board (IRB) of University
of Gondar and an official permission letter was gained from the city administrative office.
Written informed consent was obtained from each participant before conducting the actual
data collection process. Any identifiable issues were eliminated to ensure confidentiality.
Furthermore, appropriate infection prevention practices and principles related to COVID-
19 were considered during the data collection process. Data collectors provided health edu-
cation for the household after the interview has been completed based on the gaps identified
as appropriate.

Results
Respondents’ sociodemographic characteristics
Of the overall sample required (N = 635), 623 participants were included in the study, giving a
response rate of 98.1%. The mean (±SD) age of the respondents was 36.3 (= ±13.2) years, rang-
ing from 18 to 80 years. Above a quarter of the respondents, 27.9% were in the age group of
34–45 years. Around two-thirds of the study participants were married (373, 59.87%) and 402
(64.5%) were females. Four hundred thirty-three (69.5%) were orthodox by religion. Regard-
ing occupation, nearly three-fourth (448, 71.91%) of the participants were unemployed. Fur-
thermore, on average, 4 and above people lived in the same household at the time of the study
(SD = 2.04, min = 1, max = 14) (Table 1).

Knowledge, attitude, risk perception, and information exposure related

factors
Among all respondents, nearly half (49.3%) had poor knowledge about COVID-19 and only
57.5% and 52% of the respondents had a favorable attitude towards COVID-19 and its

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Table 1. Socio-demographic and personal characteristics of the study participants among Gondar City residents,
Northwest, Ethiopia, 2020 (n = 623).
Variables Frequency (n) Percent (%)
Age (in years)
18–26 163 26.2
27–33 150 24.1
34–45 174 27.9
>45 136 21.8
Sex
Male 221 35.5
Female 402 64.5
Current marital status
Unmarried 250 40.1
Married 373 59.9
Religion
Orthodox 433 69.5
Muslim 154 24.7
Protestant 27 4.3
Others 9 1.5
Educational status
No formal education 125 20.1
Primary education 101 16.2
Secondary education 195 31.3
College and above 202 32.4
Occupation
Unemployed 448 72
Employed 175 28
Household size
1–3 178 28.6
4–6 344 55.2
7 and above 101 16.2
Self-perceived health status
Good 564 90.5
Bad 59 9.5
Perceived dangerousness of COVID-19
Dangerous 570 91.5
Like the common cold/flu 53 8.5
Worry about COVID-19
Worried 444 71.3
Not worried 109 17.5
Worried as it is common cold/flu 70 11.2
https://doi.org/10.1371/journal.pone.0244265.t001

preventive measures, respectively. About 144 (23.11%) of the respondents had high risk per-
ception of coronavirus. Furthermore, only 29.05% of the participants had good exposure to
information about the various aspects of COVID-19. Of these, 84.75%, 84.59% and 43.18% of
the respondents heard about COVID-19 symptoms, mode of transmission, and distribution of
cases, respectively (Table 2).

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Table 2. Knowledge, attitude, risk perception, and information exposure of the study participants about COVID-
19 among Gondar City residents, Northwest, Ethiopia, 2020 (n = 623).
Variables Frequency Percent
Knowledge about COVID-19
Poor knowledge 307 49.3
Good knowledge 316 50.7
Attitude towards COVID-19
Unfavorable attitude 265 42.5
Favorable attitude 358 57.5
Attitude towards prevention measures of COVID-19
Unfavorable attitude 229 48
Favorable attitude 324 52
Risk perception of COVID-19
High risk 144 23.11
Low risk 479 76.89
Heard about COVID -19 complications
Yes 144 18.30
No 509 81.70
Heard about preventive measures taken by the government
Yes 248 39.81
No 375 60.19
Heard about COVID -symptoms
Yes 528 84.75
No 95 15.25
About COVID19 transmissions
Yes 527 84.59
No 96 15.41
About distribution of COVID -19 cases
Yes 296 43.18
No 354 56.82
Overall information exposure of the community
Good 181 29.05
Poor 442 70.95
Correctly know COVID-19 symptoms
Correct 378 60.67
Incorrect 245 39.30
Knows the COVID-19 mode of transmissions
Yes 361 57.94
No 262 42.05
https://doi.org/10.1371/journal.pone.0244265.t002

Adherence towards COVID-19 mitigation measures

The findings of this study indicated that nearly half of the study participants (48.96% (95% CI:
45.05%, 52.89%)) had poor adherence towards COVID-19 mitigationmeasures. Among the
mitigation strategies, hand washing was the commonest one practiced by the respondents
(73.84%), while most (67.58%) of the participants failed to use a face mask (Table 3).

Factors associated with adherence towards COVID-19 mitigation measures

The association between all potential independent variables and adherence towards COVID-
19 mitigation measures were analyzed using binary logistic regression. Accordingly, on

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Table 3. Proportions of community’s adherence towards specific mitigation measures of COVID-19 among Gon-
dar City residents.
Mitigation measures Category Proportion (95%CI)
Keeping physical distance 2 and above meters Yes 55.06 (51.12, 58.93)
No 44.94 (44.07, 48.88)
Use facemask when traveling out of home Yes 32.42 (28.85, 36.21)
No 67.58 (63.79, 71.15)
Travel to a crowed place Yes 59.55 (55.63, 63.35)
No 40.55 (36.65, 44.37)
Hand washing by soap and water in the past 2weeks Yes 73.84 (70.23, 77.15)
No 26.16 (22.85, 29.77)
Home stay Yes 59.23 (55.31, 63.03)
No 40.77 (36.96, 44.69)
Travel history in the past 2 weeks Yes 15.41 (12.78, 18.47)
No 84.59 (81.53, 87.22)
Overall adherence towards COVID_19 mitigation measures Poor 48.96 (45.05, 52.89).
Good 51.04 (47.11, 54.96)

Adherence towards COVID-19 mitigation measures was a composite variable generated from handwashing, using a
facemask, keeping physical distance, not travel to a crowded place, homestay, and not travel to anyplace out of the
city in the last 14 days. Hence, an individual was considered as having good adherence towards COVID-19
mitigation measures if he/she was able to answer ‘yes’ to the median and above of the aforementioned composite
variables.

https://doi.org/10.1371/journal.pone.0244265.t003

bivariable binary logistic regression analysis, predictor variables such as sex, household size,
level of information exposure, self-perceived health status, perceived dangerousness, knowl-
edge about COVID-19, attitude towards COVID-19 preventive measures, correctly know
COVID-19 symptoms, knows the COVID-19 mode of transmissions, risk perception of
COVID-19 were explored to significantly influenced the adherence of the community towards
mitigation measures against COVID-19. After controlling for confounders in a multivariable
binary logistic regression analysis, sex, level of information exposure, attitude towards
COVID-19 preventive measures, and risk perception of COVID-19 remained to significantly
influence the adherence of the community towards COVID-19 mitigation measures.
Hence, female respondents had 2.39 times better adherence than males towards COVID-19
mitigationmeasures [AOR: 2.39; 95%CI (1.66, 3.45)]. Respondents that had a good level of
information exposure about COVID-19 were 1.58 times more likely to have good adherence
towards COVID-19 mitigation measures than their counterparts [AOR: 1.58; 95%CI (1.03,
2.43)]. And also, study participants who had favorable attitude towards COVID-19 preventive
measures were 2.54 times more likely to adhere towards the mitigationmeasures against
COVID-19 than respondents who had an unfavorable attitude towards COVID-19 preventive
measures [AOR: 2.54; 95%CI (1.79,3.60)]. Furthermore, respondents who had high risk per-
ception of COVID-19 were 39% less likely to have good adherence towards mitigation mea-
sures against COVID-19 than their counterparts [AOR: 0.61; 95% CI (0.41, 0.92)] (Table 4).

Discussion
Since the emergence of COVID-19 pandemic, there is no definitive treatment found. There-
fore, the best alternative to control the spread of this pandemic is adherence towardsthe rec-
ommended mitigation startegies. This study assessed the adherence of the residents of Gondar

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Table 4. Factors associated with adherence towards COVID-19 mitigation measures among Gondar City residents.
Variable name Category Frequency COR (95%CI) AOR(95%CI) P_value
Sex Male 221 1 1
Female 402 2.02(1.45, 2.82) 2.39(1.66, 3.45)�� 0.001
Household size 1–3 178 1 1
4–6 344 1.89(0.82, 1.70) 0.98(0.66,1.45) 0.90
7 and above 101 1.67(1.02,2.75) 1.33(0.77, 2.29) 0.31
Self-perceived health status Good 564 1 1
Bad 59 0.63(0.37, 1.09) 0.96(0.53, 1.75) 0.91
Perceived dangerousness Dangerous 570 2.16(1.19, 3.90) 1.64(0.86, 3.11) 0.31
Like the common cold/flu 53 1 1
Level of information exposure Good 181 2.27(1.58, 3.24) 1.58(1.03, 2.43)� 0.04
Poor 442 1 1
Knowledge about COVID-19 Poor knowledge 307 0.41(0.30, 0.57) 0.79(0.46, 1.34) 0.38
Good knowledge 316 1 1
Attitude towards COVID-19 preventive measures Unfavorable attitude 229 1 1
Favorable attitude 324 2.68(1.94,3.71) 2.54(1.79,3.60)�� 0.001
Correctly know COVID-19 symptom Correct 378 1 1
Incorrect 245 0.44 (0.32, 0.61) 0.75 (0.45, 1.24) 0.26
Knows the COVID-19 mode of transmission Yes 361 1 1
No 262 0.41 (0.30, 0.58) 0.76(0.48, 1.19) 0.23
�
Risk perception of COVID-19 High risk 144 0.57(0.39,0.83) 0.61 (0.41, 0.92) 0.02
Low risk 479 1 1
�
shows significant at p<0.05;
��
implies significant at P<0.001
Hosmer and Lemeshow the goodness of fit test P = 0.134

https://doi.org/10.1371/journal.pone.0244265.t004

city towards COVID-19 mitigation measures since the beginning of the outbreak in Ethiopia
in March 13, 2020.
Accordingly, the study revealed that the overall adherence of the communitytowards
COVID-19 mitigation measures was 51.01%. Of the specific mitigation measures, 73.84% of
the respondents reported that they had been frequently washing their hands with water and
soap, which is comparable with the two studies conducted in Jimma, Ethiopia (76%) [24] and
(77.3%) [21]. However, the result of our study is lower than studies carried out in China
(79.44%) [25], Kansans, USA, (97%) [26], Egypt (87.6%) [27], and Malaysia (87.8%) [28]. The
possible explanation may be due to the differences in the study population, socio-demographic
characteristics and the measurement tools used across the studies. For instance, when we com-
pare our study participants with that of China, our study was conducted on a community
whereas the study conducted in China was on healthcare workers whom would have better
prior knowledge and experience about mitigationmeasures of COVID-19 than our study par-
ticipants. Additionally, the study participants of the study conducted in China had taken edu-
cation about hand hygiene and other infection control measures [25]. As a result, the
healthcare workers who have prior knowledge and experience as well as the training might
increase their adherence towards mitigation measures against COVID-19. Furthermore, there
is intermittent water supply in most parts of Ethiopia and limited hand washing facilities
which in turn negatively affected the adherence of the community towards hand hygiene in
our study.

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PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

The other specific mitigation measures were no travel to crowded places and staying at
home. As such, this study noted that 40.55% of the respondents reported that they hadn’t trav-
eled to crowded places that means they had good adherence towards the principle of avoiding
traveling to crowded places so as to prevent the spread of the pandemic. This finding is higher
than a study conducted in Jimma (33.2%) [21]. Nevertheless, this finding is lower than studies
done in Egypt (87.1%) [27] and Malaysia (83.4%) [28]. Regarding staying at home, 59.23% of
the respondents reported that they stayed at home. This finding is lower than a study con-
ducted in Egypt (96.1%) [27]. The possible explanation for the difference might be the living
conditions in our study setting, there is mostly high social and physical interaction leading to
overcrowding. There are also frequent religious activities in Gondar which forced the respon-
dents to go to religious places. Similarly, unemployment is common in the country, so most
people will go to crowded places, for they need to make money and satisfy their basic needs.
Moreover, the infection emerged earlier in Egypt than Ethiopia which forced the Egyptians to
stay at home and avoid traveling to crowded places. Hence, our study participants were nega-
tively influenced by the above conditions about the adherence of not traveling to crowded
places and staying at home.
This study found out that the adherence of the community towards wearing a facemask as
a mitigation measure was the least commonly used methods of mitigating the spread of
COVID-19 infection in the study area. In this regard, 67.58% of the study participants didn’t
use a face mask while going out of their home which is higher than studies conducted in USA
(23%) [26] and Egypt (43%) [27]. The possible reasons could be most of the residents might
not afford facemasks in order to use them on a daily basis when compared to residents of USA
and Egypt.
This study identified that sex, level of information exposure, attitude towards COVID-19
preventive measures and risk perception of COVID-19 had statistically significant association
with good adherence towards COVID-19 mitigation measures. Accordingly, female respon-
dents were 2.39 times more likely to have good adherence towards the mitigation measures of
COVID-19. This finding is in line with studies conducted in the Netherlands [29], Cyprus
[30], and United States [31]. The possible justification might be the majority of males work
outside their home by moving from one place to another place. As a result, mitigation mea-
sures might not be available and suitable for each place. In addition to this, because males
move from place to place more often, they use transportation services, which will be difficult
to comply with physical distancing. On the other hand, in our context, females bear a huge
burden of childcare, so they may fear transmitting the disease to their children if they didn’t
adhere towards the proper mitigation measures. Therefore, females might implement greater
adherence towards mitigation measures of COVID-19.
This study showed that the respondents whohad a good level of information exposure were
1.58 times more likely to have good adherence towards COVID-19 mitigation measures than
their counterparts. This finding is congruent with a study conducted in the Netherlands [29]
which revealed that low information seeking behavior was inversely associated with compli-
ance. This might be due to the fact that if the population had prior information about the utili-
zation and advantage of the mitigation measures, they might develop a good attitude towards
these preventive measures which in turn increase theiradherence.
The other significant factor affecting the adherence of the community towards COVID-19
mitigation measures in this study was attitude towards COVID-19 preventive measures. In
this regard, the respondents who had a favorable attitude towards COVID-19 preventive mea-
sures were 2.54 times more likely to adhere towardsthe mitigation measures than respondents
who had an unfavorable attitude towards COVID-19 preventive measures. This result is in
agreement with a study carried out in Jimma, Ethiopia [24]. The possible explanation might be

PLOS ONE | https://doi.org/10.1371/journal.pone.0244265 December 30, 2020 11 / 15

PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

that the respondents who had a favorable attitude towards COVID-19 preventive measures
might trust the science of mitigation measures and comply with the instructions of these
guidelines.
Lastly, respondents who had a high risk perception of COVID-19 were 39% less likely to
have good adherence towards COVID-19 mitigation measures than their counterparts. The
plausible explanation might be due to the link between the high risk perception of COVID-19
and anxiety. As a result, this anxiety might lead to unnecessary behaviors associated with an
increased level of impairment within the individual and the community at large [32]. Thus, the
community’s adherence towards mitigation measures would be negatively affected by high
risk perception of COVID-19. This finding is in contrast with a study conducted in United
States [33] which revealed that as individual’s perception of risk increases, they highly engage
in risk prevention behaviors. Additionally, this finding is also in contrast with a study done in
United Kingdom [34] and Slovenia [35] which showed that desensitization to risk or genuine
reductions in risk might lead to reduction in mitigation measures utilization.

Limitations of the study

This study acknowledged some important possible limitations that should be considered when
interpreting the results. First, the study was cross-sectional, a design that does not permit
establishing cause-effect relationships. Second, social desirability bias might be introduced.

Strength of the study

Through this community based survey, it was possible to conduct a face-to-face interview and
observation with maximum precaution than a simple telephone survey to evaluate the real
response and adherence of the community towards mitigation measures against the pandemic
despite the lockdown effect where many people were confined at home.

Conclusions
Our findings have indicated that nearly half of the study participants had poor adherence
towards COVID-19 mitigation measures. Sex, level of information exposure, attitude towards
COVID-19 preventive measures, and risk perception of COVID-19 were factors, which signifi-
cantly influenced the adherence of the community towards COVID-19 mitigation measures.
Therefore, it is crucial to track adherence responses to the COVID19 measures, scale up the
community’s awareness of COVID-19 prevention and mitigation strategies through appropri-
ate information outlets such as mainstream media on prevention strategies of COVID-19, and
rely on updating information from TV, radio, and healthcare workers about COVID-19.

Supporting information
S1 Table. English version questionnaire.
(DOCX)
S1 Dataset.
(XLS)

Acknowledgments
We are very indebted to Gondar city health office for permitting to conduct the study and
providing the necessary preliminary information while conducting this study. We do wish
to extend our gratitude to the study participants, supervisors and data collectors.

PLOS ONE | https://doi.org/10.1371/journal.pone.0244265 December 30, 2020 12 / 15

PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Author Contributions
Conceptualization: Zelalem Nigussie Azene.
Data curation: Melaku Kindie Yenit, Abere Woretaw Azagew.
Formal analysis: Zelalem Nigussie Azene, Mehari Woldemariam Merid, Atalay Goshu Mulu-
neh, Demiss Mulatu Geberu, Getahun Molla Kassa, Melaku Kindie Yenit, Sewbesew
Yitayih Tilahun, Kassahun Alemu Gelaye, Habtamu Sewunet Mekonnen, Abere Woretaw
Azagew, Chalachew Adugna Wubneh, Getaneh Mulualem Belay, Nega Tezera Asmamaw,
Chilot Desta Agegnehu, Telake Azale, Animut Tagele Tamiru, Bayew Kelkay Rade, Eden
Bishaw Taye, Asefa Adimasu Taddese, Zewudu Andualem, Henok Dagne, Kiros Terefe
Gashaye, Gebisa Guyasa Kabito, Tesfaye Hambisa Mekonnen, Sintayehu Daba, Jember
Azanaw, Tsegaye Adane, Mekuriaw Alemayeyu.
Funding acquisition: Zelalem Nigussie Azene.
Investigation: Zelalem Nigussie Azene.
Methodology: Zelalem Nigussie Azene, Mehari Woldemariam Merid, Atalay Goshu Muluneh,
Demiss Mulatu Geberu, Getahun Molla Kassa, Sewbesew Yitayih Tilahun, Kassahun
Alemu Gelaye, Habtamu Sewunet Mekonnen, Abere Woretaw Azagew, Chalachew Adugna
Wubneh, Getaneh Mulualem Belay, Nega Tezera Asmamaw, Chilot Desta Agegnehu, Tel-
ake Azale, Animut Tagele Tamiru, Bayew Kelkay Rade, Eden Bishaw Taye, Zewudu Andua-
lem, Henok Dagne, Kiros Terefe Gashaye, Gebisa Guyasa Kabito, Sintayehu Daba, Jember
Azanaw, Tsegaye Adane, Mekuriaw Alemayeyu.
Resources: Zelalem Nigussie Azene.
Software: Zelalem Nigussie Azene, Mehari Woldemariam Merid, Atalay Goshu Muluneh,
Demiss Mulatu Geberu, Getahun Molla Kassa, Melaku Kindie Yenit, Sewbesew Yitayih
Tilahun, Kassahun Alemu Gelaye, Habtamu Sewunet Mekonnen, Abere Woretaw Azagew,
Chalachew Adugna Wubneh, Getaneh Mulualem Belay, Nega Tezera Asmamaw, Telake
Azale, Asefa Adimasu Taddese, Henok Dagne, Tesfaye Hambisa Mekonnen, Jember
Azanaw.
Supervision: Zelalem Nigussie Azene, Atalay Goshu Muluneh, Getahun Molla Kassa, Hab-
tamu Sewunet Mekonnen, Animut Tagele Tamiru, Zewudu Andualem, Gebisa Guyasa
Kabito.
Validation: Zelalem Nigussie Azene, Atalay Goshu Muluneh, Demiss Mulatu Geberu, Melaku
Kindie Yenit, Kassahun Alemu Gelaye, Getaneh Mulualem Belay.
Visualization: Zelalem Nigussie Azene, Atalay Goshu Muluneh, Demiss Mulatu Geberu.
Writing – original draft: Zelalem Nigussie Azene, Mehari Woldemariam Merid, Atalay
Goshu Muluneh, Demiss Mulatu Geberu, Getahun Molla Kassa, Melaku Kindie Yenit, Sew-
besew Yitayih Tilahun, Kassahun Alemu Gelaye, Habtamu Sewunet Mekonnen, Abere
Woretaw Azagew, Chalachew Adugna Wubneh, Getaneh Mulualem Belay, Nega Tezera
Asmamaw, Chilot Desta Agegnehu, Telake Azale, Animut Tagele Tamiru, Bayew Kelkay
Rade, Eden Bishaw Taye, Asefa Adimasu Taddese, Zewudu Andualem, Henok Dagne,
Kiros Terefe Gashaye, Gebisa Guyasa Kabito, Tesfaye Hambisa Mekonnen, Sintayehu
Daba, Jember Azanaw, Tsegaye Adane, Mekuriaw Alemayeyu.
Writing – review & editing: Zelalem Nigussie Azene, Mehari Woldemariam Merid, Atalay
Goshu Muluneh, Demiss Mulatu Geberu, Getahun Molla Kassa, Melaku Kindie Yenit, Sew-
besew Yitayih Tilahun, Kassahun Alemu Gelaye, Habtamu Sewunet Mekonnen, Abere

PLOS ONE | https://doi.org/10.1371/journal.pone.0244265 December 30, 2020 13 / 15

PLOS ONE Adherence towards COVID-19 mitigation measures and its associated factors

Woretaw Azagew, Chalachew Adugna Wubneh, Getaneh Mulualem Belay, Nega Tezera
Asmamaw, Chilot Desta Agegnehu, Telake Azale, Animut Tagele Tamiru, Bayew Kelkay
Rade, Eden Bishaw Taye, Asefa Adimasu Taddese, Zewudu Andualem, Henok Dagne,
Kiros Terefe Gashaye, Gebisa Guyasa Kabito, Tesfaye Hambisa Mekonnen, Sintayehu
Daba, Jember Azanaw, Tsegaye Adane, Mekuriaw Alemayeyu.

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