i SCHOOL OF PUBLIC HE ALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ` ASSESSMENT OF ADHERENCE TO COVID-19 PREVENTION PROTOCOLS IN SELECTED CHURCHES IN THE BOLGATANGA MUNICIPALITY BY SHEILA AKANTEELE AGANDAA 10876060 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE IN PUBLIC HEALTH MONITORING AND EVALUATION (MSC) DEGREE MARCH, 2022 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I declare that this thesis is an original report from my research work carried out as part of the requirements for the award of MSc Public Health Monitoring and Evaluation from the University Ghana, Legon. SIGNATURE …… …………………. DATE …15-11-2022…………………… SHEILA AKANTEELE AGANDAA (STUDENT) 15- 11-2022 SIGNATURE ………………………… DATE ……………………………. DR. BAATIAMA LEONARD (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh iii DEDICATION I dedicate this work to the Almighty God and my family, most especially my lovely husband Abaane Donatus Nbonibe, my children Abaane MacDonatus Ayinbono, Abaane Zephaniah Ayinemizaah, Abaane Evan Ayine-Ganebah and Abaane Evangeline Ayinpoka, my lovely mother Akuribire Juliana and my late father Agandaa Roland. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT With much gratitude, I sincerely express my earnest appreciation to Dr Baatiema Leonard my supervisor for all his support and mentorship throughout the entire study. It is my prayer that with each step you take you shall succeed. To the staff of the Department of Health Policy, Planning and Management especially the head of the department Dr Patricia Akweongo, Dr Paulina Tindaana and Dr Genevieve Aryeetey for their measureless support I appreciate. Also, to the authorities of the Catholic Church, the Church of Pentecost, the Assemblies of God Ghana, the Presbyterian Church of Ghana, the Anglican Church and the Ebenezer Methodist Church all in the Bolgatanga Municipality, I appreciate your support for the permission granted me to carry out the study. To the Nabdam District Director of Health Services, Mr Awuni Baba for his support during the study I say God richly bless him. With the support from family and friends, this work was possible, appreciation to you, Agandaa Clothilda, Agandaa Eugene and Atampugre Lawrencia. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT Background: Following the outbreak of the COVID-19 pandemic, the WHO recommended four key prevention protocols among several others: use of a face mask, physical/social distancing, use of hand sanitizer, and hand washing. Despite this, there were growing concerns about the lack of adherence to these recommended prevention protocols in public spaces and by individuals, leading to the significant spread of the virus. These recommended protocols are especially important for congregations such as churches where the risk of exposure is high. This study, therefore, aimed to assess adherence to the COVID-19 prevention protocols in selected churches in the Bolgatanga Municipality of the Upper East Region of Ghana. Method: This was a cross-sectional study conducted in selected churches and church members in the Bolgatanga Municipality of the Upper East Region of Ghana. Both an observational checklist and a structured questionnaire were used to collect data using stratified simple random sampling to recruit 438 church members into the study. Between August 2021 and October 2021, 33 churches were included in the study. Descriptive statistics were carried out with relative frequency analysis using SPSS version 25. Bloom’s Cut-off point of 80% and above was used to categorize Knowledge, Attitude and Practice (KAP) levels. The level of adherence was measured by the proportion of respondents who consistently observed all four protocols for the past five Sundays. Chi-square and binary logistics (both bivariate and multivariate) regression analysis were used to identify determinants and their level of influence on adherence. Result: It was observed that 97%, 69.7%, 69.7%, and 63.6% of the churches had hand sanitizers, handwashing facilities, face masks, and seats arranged a meter apart, respectively. Also, 96.9%, 86.6%, 82.6%, 64.8%, and 56.8% of the respondents reported having access to hand sanitizers, University of Ghana http://ugspace.ug.edu.gh vi handwashing facilities, face masks, and seats arranged a meter apart during worship sessions. Despite 65% of the respondents having good knowledge levels and 48% having a good attitude, 80.5% of the respondents had good practice of the protocol. The study revealed that only 26.8% of worshipers consistently adhered to all the recommended protocols for the past five worship sessions. The number of preventive facilities a respondent had access to, the denomination, attitude, age, place of residence, and occupation, consistently and statistically significantly determine adherence. Conclusion: Adherence to COVID-19 prevention protocols was low among worshipers thereby increasing the risk of infection should there be an exposure. Urgent efforts are needed by policymakers, law enforcement urgencies, church authorities and worshipers to improve the adherence to COVID-19 protocols in Ghana. University of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENT DECLARATION .......................................................................................................................................... ii DEDICATION ............................................................................................................................................. iii ACKNOWLEDGEMENT ........................................................................................................................... iv ABSTRACT .................................................................................................................................................. v TABLE OF CONTENT .............................................................................................................................. vii LIST OF ABBREVIATIONS ..................................................................................................................... xii CHAPTER ONE ......................................................................................................................................... 14 INTRODUCTION ...................................................................................................................................... 14 1.1. Background ............................................................................................................................... 14 1.2. Problem Statement .................................................................................................................... 18 1.3. Justification Of the Study ......................................................................................................... 20 1.4. Main Objective .......................................................................................................................... 21 1.5. Specific Objectives .................................................................................................................... 21 1.6. Research questions .................................................................................................................... 21 CHAPTER TWO ........................................................................................................................................ 22 LITERATURE REVIEW ........................................................................................................................... 22 2.1. Introduction ............................................................................................................................... 22 2.2. The epidemiological burden of COVID-19 ............................................................................. 22 2.3. The intervention of focus of the study ..................................................................................... 24 2.4. Equipment and infrastructure put in place to support the adherence to COVID-19 prevention protocols ............................................................................................................................. 25 2.5. Knowledge, Attitude, and Practices Towards COVID-19 Prevention Protocols ................ 27 2.6. Adherence to COVID-19 Prevention Protocols ...................................................................... 30 2.7. Determinants of Adherence to COVID-19 Prevention Protocols ......................................... 32 2.8. Methods in COVID-19 Implementation Research ................................................................. 34 CHAPTER THREE .................................................................................................................................... 36 METHODS ................................................................................................................................................. 36 3.1. Introduction ............................................................................................................................... 36 3.2. Research design ......................................................................................................................... 36 3.3. Study area .................................................................................................................................. 36 3.4. Study population ....................................................................................................................... 37 University of Ghana http://ugspace.ug.edu.gh viii 3.5. Inclusion and exclusion criteria ............................................................................................... 38 3.6. Definition of study variables .................................................................................................... 38 3.7. Sample size determination: ...................................................................................................... 41 3.8. Sampling methods and procedures ......................................................................................... 43 3.9. Data collection ........................................................................................................................... 43 3.10. Quality control....................................................................................................................... 45 3.11. Data processing and analysis ............................................................................................... 46 3.12. Ethical consideration ............................................................................................................ 46 CHAPTER FOUR ....................................................................................................................................... 48 MONITORING AND EVALUATION ISSUES OF THE STUDY ........................................................... 48 4.1. Introduction ............................................................................................................................... 48 4.2. The Goal of Covid-19 Prevention Protocols ........................................................................... 48 4.2.1. Face Mask Wearing .......................................................................................................... 49 4.2.2. Physical Distancing ........................................................................................................... 50 4.2.3. Hand Hygiene .................................................................................................................... 50 4.3. Practical Considerations and Recommendations for Religious Leaders and Faith-Based Communities in The Context of Covid-19 .......................................................................................... 51 4.4. The objective /Outcome Variables. .......................................................................................... 51 4.5. Output measurement ................................................................................................................ 52 4.6. Inputs ......................................................................................................................................... 52 4.7. Type of Evaluation .................................................................................................................... 52 4.8. Conceptual Framework and Logic Model .............................................................................. 54 CHAPTER FIVE ........................................................................................................................................ 57 RESULTS ................................................................................................................................................... 57 5.5. Introduction ............................................................................................................................... 57 5.6. Sociodemographic Characteristics of respondents ................................................................ 57 5.7. Availability of facilities and arrangements observed at churches ........................................ 59 5.4. Church members’ access to services and facilities to support adherence to COVID-19 prevention protocols during worship .................................................................................................. 61 5.5. Knowledge, attitude and practices of Church members towards adherence to COVID-19 prevention protocols ............................................................................................................................. 63 5.5.1. Knowledge .......................................................................................................................... 63 5.5.2. Attitude towards COVID-19 and its prevention activities .................................................. 67 5.5.3. Practices of Respondents towards COVID-19 prevention protocols .................................. 69 University of Ghana http://ugspace.ug.edu.gh ix 5.6. Levels of adherence of Church members to COVID-19 prevention protocols in Church . 71 5.7. Determinants of adherence to the COVID-19 prevention protocols among church members ................................................................................................................................................. 73 CHAPTER SIX ..................................................................................................................................... 84 DISCUSSION ............................................................................................................................................ 84 6.1. Introduction ............................................................................................................................... 84 6.2. Overview of Key Findings of the Study .................................................................................. 84 6.3. . Comparison of study findings with other previous studies ..................................................... 85 6.3.1. Availability of equipment and infrastructure to support adherence in churches ................. 85 6.3.2. Knowledge, Attitude and practices towards COVID-19 preventive protocols ................... 86 -Knowledge of COVID-19 and its preventive protocols .................................................................... 86 -Attitude of respondents towards COVID-19 and its preventive protocols ........................................ 88 -Practices of respondents of COVID-19 preventive protocols ........................................................... 89 6.3.3. Adherence to COVID-19 preventive protocols ................................................................... 91 6.3.4. Determinants of adherence to COVID-19 preventive protocols ......................................... 93 6.4. Relationship between framework, results and the literature review ...... Error! Bookmark not defined. 6.5. Implications for study findings ................................................................................................ 97 6.5.1. Implication for public health policy and practices .............................................................. 97 6.5.2. Monitoring and evaluation implications ............................................................................. 99 6.5.3. Implication for further research ........................................................................................ 100 6.6. Study limitations and strengths ............................................................................................. 100 CHAPTER 7 ............................................................................................................................................ 102 CONCLUSION AND RECOMMENDATIONS .................................................................................. 102 7.1. Conclusion of the study........................................................................................................... 102 7.2. Recommendations ................................................................................................................... 103 7.2.1. Recommendation for Public health policy and practice.................................................... 103 7.2.2. Recommendation for further research ............................................................................... 103 REFERENCE ............................................................................................................................................ 105 APPENDICES .......................................................................................................................................... 122 ETHICAL REVIEW APPROVAL ........................................................................................................... 129 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 1: Definition of variables used in this study ..................................................................................... 39 Table 2:Churches studies ............................................................................................................................ 44 Table 3:Definition of indicators .................................................................................................................. 52 Table 4:Demographic characteristics of respondents ................................................................................. 58 Table 5:Availability of COVID-19 preventive measures and facilities in churches(N=33) ....................... 60 Table 6: Distribution of church members based on their access to COVID-19 prevention facilities by denomination (N=426) ................................................................................................................................ 62 Table 7: Number of recommended facilities and arrangements respondents reported having access to during worship sessions by Denominations ........................................................................................ 62 Table 8:Distribution of Respondents by the number of COVID-19 prevention protocols and ways by which they can effectively be carried out respondents had knowledge on(N=426) ................................... 66 Table 9:Distribution of respondents’ attitudes towards COVID-19 and its prevention(N=426) ................ 67 Table 10: Knowledge, attitude and Practice Adequacy by Denominations ................................................ 70 Table 11:Number and percentage of Respondents who observed Recommended Protocols consistently for the last five worship sessions ...................................................................................................................... 71 Table 12: Correlation between knowledge, attitude and practice toward adherence .................................. 72 Table 13:T-test to ascertain relationship between knowledge, attitude and practice .................................. 72 Table 14:Determinants of adherence to the COVID-19 prevention protocols ............................................ 73 Table 15:Bivariate binary logistics regression between various factors and adherence to COVID-19 prevention protocols .................................................................................................................................... 76 Table 16:Multivariate logistics Regression between various factors and adherence .................................. 80 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 1:Conceptual Framework on adherence to COVID-19 prevention protocols ................... 55 Figure 2: Logic model on adherence to covid-19 prevention protocols among selected churches in Bolgatanga Municipality........................................................................................................... 56 Figure 3:Percentage of respondents with knowledge on preventive protocols and how effective they should be carried out ............................................................................................................. 65 Figure 4:Overall attitude of respondents toward COVID-19 preventive protocol ....................... 68 Figure 5:Percentage of respondents who practice COVID-19 preventive protocols and ensured effective practice ........................................................................................................................... 69 University of Ghana http://ugspace.ug.edu.gh file:///E:/current%20chapter%204,5,6/final%20results/dorcuments%20for%20department/THESIS_Sheila_10876060.docx%23_Toc97302259 file:///E:/current%20chapter%204,5,6/final%20results/dorcuments%20for%20department/THESIS_Sheila_10876060.docx%23_Toc97302259 xii LIST OF ABBREVIATIONS COVID-19 Coronavirus disease 2019 SARS-CoV-2 severe acute respiratory syndrome coronavirus 2 UER Upper East Region GDP Gross Domestic Product PPE Personal Protective Equipment WHO World Health Organization GHS Ghana Health Service MOH Ministry of Health PHEIC Public Health Emergency of International Concern KAP knowledge, attitude and practice IPC Infection Prevention and Control UNDP United Nations Development Programme UNICEF United Nations International Children’s Emergency Fund IMF International Monetary Fund USA United State of America University of Ghana http://ugspace.ug.edu.gh xiii DEFINITION OF TERMS Level of adherence: Respondent practicing all four recommended protocols (Hand washing, face mask-wearing, social distancing and hand sanitizing) consistently for five major worship sessions. (operational) Major worship session: Sunday worship session. Physical distancing: keeping at least a 1-meter distance Physical contact activities: activities that require body contact with objects in the church. Hand hygiene practices: both hand washing and hand sanitizing University of Ghana http://ugspace.ug.edu.gh 14 CHAPTER ONE INTRODUCTION 1.1. Background The coronavirus disease (COVID-19) caused by SARS-COV-2 (WHO b, 2020) is one of the emerging respiratory diseases and is believed to have originated from animals (WHO, 2020f). The elderly and immune-compromised persons are said to be most at risk of severe disease. Originally believed to be zoonotic, it has now spread from person to person, resulting in widespread community transmission. Its common signs and symptoms include fever, runny nose, cough, sore throat, and headache (Ghana Health Service, 2020). Transmission is particularly enhanced by congregations of people, especially in enclosed environments. In such an environment, there is an increased risk of coming into contact with infected people and contaminated surfaces. In such a crowded congregation, the risk of transmission via droplet spray is high (WHO, 2020h, 2020o). To control this emerging pandemic, the WHO recommends the use of fabric face masks, physical distancing, cough etiquette, and hand hygiene for the general public (WHO, 2020h, 2020o, 2021c; WHOa, 2020). In particular, churches as gathering points are advised to adhere to these protocols (WHO, 2020k). COVID-19 since its emergence in Wuhan, China in December 2019 is now a pandemic with cases in every country except Turkmenistan and the People’s Republic of Korea as of March 12, 2021 (Deloitte, 2020; Kim et al., 2020; WHO, 2020p; WHO Coronavirus (COVID- 19) Dashboard | WHO Coronavirus Disease (COVID-19) Dashboard, 2021) with Ghana recording its first two cases of COVID-19 on March 12, 2020 (MOH, 2020). As of February 23, 2022, 426,624,859 people were infected with 1666103 active cases globally, 8303144 infected in University of Ghana http://ugspace.ug.edu.gh 15 Africa, and 159006 infected in Ghana with 968 active cases and corresponding 5899578 deaths globally, 169288 deaths in Africa, and 1442 deaths in Ghana (WHO, 2022). This pandemic comes with several consequences: the individual bears direct physical and psychological trauma, aftermath complications, the direct monetary cost of care and losses from time off work, social stigma, and loss of life. The impact of the pandemic can be felt in every aspect of human life. It has increased populations’ vulnerability to mental illness (Xiong et al., 2020), food and nutrition security (Carducci et al., 2021), and non-communicable diseases (Thakur et al., 2020). Healthcare systems have also been disrupted globally, leading to a reduced and widened equity gap in access to quality healthcare globally (Lynch & Pusey-Murray, 2021; Moynihan et al., 2021; WHO, 2020e; COVID-19 Continues to Disrupt Essential Health Services in 90% of Countries, 2021). The lockdown reduced financing, and the change in the mode of delivery of education has led to reduced access, equity, and quality of education (The Impact of COVID-19 on Education – Recommendations and Opportunities for Ukraine, 2021; Tuffour et al., 2021). Social consequences also resulted from the restriction of recreational and socio-cultural activities (Abid Haleem & Raju, 2020). At the upstream, the pandemic has caused micro and macroeconomic recession (Deloitte, 2020) resulting in inflation, low income and high cost of living (Asante & Mills, 2020; Diwambuena et al., 2020; Ebrahimy et al., 2020; The Economic Context of Ghana - Economic and Political Overview - Nordea Trade Portal, 2021; Rajeshni Naidu-Ghelani, 2020). According to Kaye and colleagues, it will cost the world 3 trillion and lead to negative growth of not less than 8% (Deloitte, 2020; Kaye et al., 2021). Even though Africa is one of the least affected continents in terms of prevalence and fatalities, it could be the biggest bearer of the economic impact (African Union, 2020; Grace, 2020; OECD, 2020). Ghana has received its share of the impact of COVID-19. University of Ghana http://ugspace.ug.edu.gh 16 Baffour and colleagues report of the severe impact of the pandemic on Ghana’s educational system (Tuffour et al., 2021). The Ghanaian economy has also been hit hard. Ghana’s estimated GDP growth target of 6.8% tumbled to 2.6% in 2020 (Deloitte, 2020). Aduhene & Osei-Assibey (2021) report that 42, 000 jobs were lost within a couple of months of the pandemic. This occurred amid rising food prices (Asante & Mills, 2020) leading to food insecurity (Bukari et al., 2021). The overall effect was increased poverty and a lower standard of living (Bukari et al., 2021). Since the insurgence of COVID-19, WHO and other global health stakeholders have taken steps to promote the observance of the COVID-19 prevention and control protocols. The preventive protocols were issued by WHO (WHO, 2020m, 2020j). The mobilization of other global organizations such as the International Monetary Fund(IMF), United Nations International Children’s Emergency Fund(UNICEF), United Nations Development Programme(UNDP), etc. and the distribution of both funds and resources to facilitate the observance of these protocols was critical (World Bank Group Supports Ghana To Boost Its COVID-19 Response, 2020; The Government of Ghana, the Embassy of Denmark and UNICEF Launch a Partnership to Support the COVID-19 Response; WHO Assures Government of Ghana of UN’s Continuous Collaboration in the Fight against COVID | WHO | Regional Office for Africa, 2021). These funds enabled poorer countries to provide water for WASH and purchase vaccines. It also enabled local production of sanitizers and face masks, and to carry out behaviour change communication (World Bank Group Supports Ghana To Boost Its COVID-19 Response, 2020; World Bank, 2021). Also, the strong fight against the infodemic by WHO (WHO, 2021a) facilitated public adoption of the preventive protocols. The Ghana government, following the Public Health Act, 2012 (Act 851) and the Ghana - Imposition of Restrictions Act, 2020 (Act 1012), made it mandatory for all churches to adhere to University of Ghana http://ugspace.ug.edu.gh 17 these protocols in their gatherings (MOH Ghana, 2020; President of Ghana, 2020a; Update No.10: President Akufo-Addo Addresses the Nation - YouTube, 2020). In Particular, the wearing of a face mask was declared mandatory (MOH Ghana, 2020; FULL TEXT: Akufo-Addo’s 11th Address to the Nation on Measures to Fight Coronavirus, 2020). There is currently no cure for the disease and vaccine penetration is still very low (Ghana Health Service, 2020). Even in the presence of a vaccine, adherence to the COVID-19 prevention protocols is unavoidable. This, therefore, calls for action both at the church as a collective unit and at the individual level as members of the unit. Cohen and Colleagues have argued that while legislation is a vital tool for the adoption and adherence to healthy behaviours, they require other complimentary actions to make them work effectively (Cohen et al., 2000). Models such as the knowledge, attitude, and practice model, a health behaviour change model which was introduced by Nancy Schwartz in her article published in the journal of nutrition education, stress the need for the nurse to have proper knowledge, attitude, and practice in order to provide better health care to their patients (Schwartz, 1976). It is presumed that knowledge, attitude, and practice influence each other and that knowledge and attitude have a direct effect on preventive practices (Rav-Marathe et al., 2016; Gimenez-Sanchez et al., 2001; Bansal et al., 2015). Poor health, inefficient use of health care, a decline in the disease screening rate, and maladaptive disease preventive behaviour are said to be due to lower KAP levels (C. et al., 2015). Therefore, KAP plays a key role in health prevention and promotion (Szymona-Pałkowska et al., 2016). Thus, the basic way to prevent COVID-19 infection is by improving the community’s knowledge, attitude, and practices toward COVID-19 prevention protocol (Olum et al., 2020). Also, one’s level of knowledge can affect one’s attitude (C, 2021). According to Mersha et al., (2021), shortage of PPE (face masks and gloves) and scarcity of hand cleaning facilities ( alcohol University of Ghana http://ugspace.ug.edu.gh 18 hand sanitizer) are the main barriers to healthcare workers not practicing preventive measures for COVID-19. 1.2. Problem Statement Since the inception of COVID-19, it has infected millions of humans and led to numerous mortalities. Ghana, after its first 2 cases recorded on the 12th of March 2020 (MOH, 2020), has since risen to 159,006 confirmed cases, with 968 active cases and 1442 deaths as of the 26th of February 2022 (WHO, 2022). The Upper East Region, as of December 26th 2021 had recorded 1531 confirmed cases, with 35 active cases and 56 deaths. The region, however, has a test positivity rate of 15.2% and a case fatality rate of 3.7% as of December 26th, 2021( Ghana Health Service Upper East Region, 2021). These suggest a higher infection, severity, and mortality rate in the region. Bolgatanga Municipality has the highest burden of COVID-19 cases in the Upper East Region compared to other districts in the region. The Municipality since the onset of the pandemic has recorded 605 confirmed cases, representing 39.51% of all cases in the region (Ghana Health Service upper East Region, 2021) as of December 26th, 2021, and also recorded 20 new cases, which is 60.71% of the total new cases in the Upper East Region as of December 26th, 2021. With the increasing number of cases, the Ghana Health Service adopted the WHO preventive measures and prevention protocols including hand hygiene, masking up (respiratory hygiene), and physical distancing, as the prevailing measures to combat the disease. In furtherance to this, the government implemented different interventions to promote adherence to these protocols, such as government absorption of water bills for all Ghanaians, purchase and distribution of hand sanitizers, liquid soap and other PPEs, e.g. face masks, closure of public gatherings such as funerals, festivals, and lockdown of schools, etc. (President of Ghana, 2020b; The President of Ghana, 2020a). Yet the adoption of these prevention and control protocols is said to be very low University of Ghana http://ugspace.ug.edu.gh 19 in some parts of the country (Bonful et al., 2020); Okyere et al., 2020) despite the emergence of a more rapid-spreading and virulent variant virus circulating in the Ghanaian community. However, people will not be able to adopt and adhere to these protocols if they do not have adequate knowledge to induce the positive attitude required for action (Green & Tones, 2010; Schwartz, 1976). Theoretically, these three constructs are in a logical relationship such that knowledge leads to a positive attitude which then leads to desired behaviour (Muleme et al., 2017; Rav-Marathe et al., 2016). Health education directly or indirectly via knowledge and attitudes contributes to enabling people to adopt and adhere to preventive behaviours (Rav-Marathe et al., 2016). Cultural norms and access to Personal Protective equipment can influence one’s practices toward COVID- 19 protocols (C, 2021). In Ghana, studies assessing KAP and adherence have been carried out in hospitality and shopping centres. Dabi et al (2021) reported 100% knowledge of prevention protocols, 95% availability of hand washing facilities, 95% availability of hand sanitizers, 90% availability of face masks and 90% wearing of face masks in local restaurants in the Ho Municipality. Fielmua et al (2021) study in shopping centres in Wa however, reported very poor adherence to COVID-19 prevention with only 8.7% of customers washing their hands and 15.8% wearing masks. However, the researcher could not find any study assessing KAP and adherence in religious settings, especially in churches where people congregate for longer times the Bolgatanga Municipal, a cosmopolitan, business and administrative centre of the Upper East Region of Northern Ghana and Ghana as a whole. Several questions need to be answered. Are equipment and infrastructure put in place to support the adherence to COVID-19 protocols among churches in the Bolgatanga Municipality available? What are the knowledge, attitude, and practices of church members towards COVID-19 prevention University of Ghana http://ugspace.ug.edu.gh 20 protocols? What is the level of adherence of church members towards COVID-19 prevention protocols? What are the determinants of adherence to the COVID-19 prevention protocols among church members? This study, therefore, seeks to assess the level of adherence to COVID-19 prevention protocols among selected churches in the Bolgatanga Municipality of the Upper East Region of Ghana. It is only through research that information of such nature can be ascertained, hence the need for the study. 1.3. Justification Of the Study COVID-19 remains a menace to the world, the nation, and Bolgatanga Municipality. The uniqueness of the disease, along with its uncertainties, makes it critical for health authorities to plan proper strategies to prepare and manage the public (C, 2021). Public adherence to COVID- 19 prevention protocols is key as a measure to control it (Ferdous et al., 2020). With the high number of cases, it is therefore important that the level of adherence be studied among the public to guide these efforts. Studies on adherence to COVID-19 prevention protocols are generally limited in the Ghanaian contexts, and this is more particular in public spaces such as churches which attract a mass gathering of the populace, predisposing them to COVID-19 infection if proper prevention measures and adherence to the protocols are not enforced. Therefore, I find it important to conduct this study, whose findings will add to the scientific knowledge of COVID-19, social and behavioural aspects, which will contribute to the efforts towards developing health promotion and public health interventions to improve adherence to COVID-19 prevention protocols, thus combating the disease in the Bolgatanga Municipality and the nation as a whole. University of Ghana http://ugspace.ug.edu.gh 21 1.4. Main Objective To assess adherence to COVID-19 prevention protocols in churches in the Bolgatanga Municipality. 1.5. Specific Objectives 1. To assess the availability and accessibility of equipment and infrastructure put in place to support adherence to COVID-19 prevention protocols in churches in the Bolgatanga Municipality. 2. To assess the knowledge, attitude, and practices of church members towards COVID-19 prevention protocols. 3. To determine the level of adherence of church members towards COVID-19 prevention protocols. 4. To examine the determinants of adherence to the COVID-19 prevention protocols among church members. 1.6. Research questions 1. What is the level of availability and access to equipment and infrastructure put in place to support adherence to COVID-19 prevention protocols in churches in the Bolgatanga Municipality? 2. What is the level of knowledge, attitude, and practices of church members towards COVID-19 prevention protocols? 3. What is the level of adherence of church members towards COVID-19 prevention protocols? 4. What are the determinants of adherence to the COVID-19 prevention protocols among church members? University of Ghana http://ugspace.ug.edu.gh 22 CHAPTER TWO LITERATURE REVIEW 2.1. Introduction This section presents previous works on adherence to COVID-19 prevention protocols in general and within the context of church environments. It covers the epidemiological burden of COVID- 19 globally, regionally, and within the study contexts. It also examines the literature on COVID- 19 prevention protocols, levels of adherence to the prevention protocols, and measures such as logistics, equipment, and infrastructure put in place to support adherence to COVID-19 prevention protocols. Work on people’s knowledge, attitude, and practices towards COVID-19 prevention protocols, adherence to COVID-19 prevention protocols, and determinants of adherence to COVID-19 prevention protocols were also explored. 2.2. The epidemiological burden of COVID-19 COVID-19, an emerging severe acute respiratory syndrome, is an infection that was first reported on December 31, 2019, in China and declared a public health emergency of international concern (PHEIC) on January 30, 2020 (WHO, 2020i). Mild conditions are commonly characterized by fever, cough, and fatigue, while common manifestations of severe disease are dyspnea, high temperature (38℃ or more), loss of appetite, pressure, pain in the chest, and confusion. Other less common symptoms of both mild and severe diseases have also been reported. From the emergence till May 11, 2021, about 158.6 million cases have been detected with over 3.3 million deaths (WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data, 2021) globally. However, some studies assert that the detected cases are just one-tenth of the prevailing seropositive (Havers et al., 2020; Stringhini et al., 2020). This fits well into the tip-of-iceberg phenomenon in epidemiology. All countries except University of Ghana http://ugspace.ug.edu.gh 23 Turkmenistan and the People’s Republic of Korea have officially recorded cases (WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data, 2021). The Americas, Europe, and Southeast Asia are the three WHO regions with the highest number of cases (WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus Disease (COVID-19) Dashboard, 2021). World Health Organization data analysis indicates that both men and women have about an equal risk with a ratio of 1.03:1, more males in 0-9, 60-69, and 70-79 year age bands are infected and more women in the 20-29 year and 80+ year age bands are also infected (WHO, 2020a). COVID-19 disease is caused by the SARS-Cov 2, a member of the coronaviruses responsible for earlier emerged acute respiratory syndromes, and the virus is postulated to have originated from bats, thereby making it a zoonosis (WHO, 2020f). Compared to the influenza virus, SARS-Cov-2 is said to be less transmissible and also causes less symptomatic and severe disease (WHO, 2020b). The disease has multiple modes of transmission, including direct and indirect contact with infectious secretions, airborne, especially in healthcare settings and fomites (WHO, 2020d), but the most common one is direct person-to-person (McIntosh et al., 2021). While all positive cases can transmit the virus, symptomatic cases are said to be the most infective source (McIntosh et al., 2021; WHO, 2020o). Direct person-to-person contact transmission is enhanced by closer proximity (less than 1 meter) to infectious people and in a crowded and enclosed environment(McIntosh et al., 2021). Churches as places of congregation have been identified as places where many have been infected (WHO, 2020k). As a communicable disease, the recommended measures for prevention and control follow the three key principles: elimination or removal of the source or cause of infection; breaking the chain of transmission; and protecting the susceptible (Merrill, 2017). The WHO recommends the early University of Ghana http://ugspace.ug.edu.gh 24 detection and isolation of cases, the identification, and quarantine of contacts, and most recently, vaccination to protect the general population from SARS-COV-2(WHO, 2020c, 2020o). Hand hygiene, respiratory etiquette, use of masks, social distancing within the community, and effective infection control. Prevention and control measures in healthcare settings constitute measures to break the chain of transmission (WHO, 2020c, 2020o). Last but not least, environmental control measures include cleaning and disinfecting surfaces likely to be contaminated with viruses and ensuring effective ventilation of enclosed places used for gatherings (WHO, 2020c, 2020o). In addition, modification of religious observance such as avoidance of physical contact with religious objects, laying of hands, etc., is recommended (WHO, 2020k). 2.3. The intervention of focus of the study The COVID-19 prevention and control measures of focus in this study included hygiene (i.e hand washing and use of hand sanitizers), social distancing (i.e. maintaining at least a meter away from other people during sitting and processing for church activities) and wearing a mask during church services. With no treatment at hand, these measures were very crucial in rolling back the pandemic. These measures have been assessed to offer protection about 40% - 60% protection(Gozdzielewska et al., 2022). Wearing of mask reduced the risk of falling sick with COVID-19 by 60% and observing physical distancing mitigated the risk by 25% (Talic et al., 2021). The mandatory masking-up policy also reduced hospitalization in young adults by 5.9% and slowed case growth by 1% among early adopters and 0.44% among late adopters. They have also been reported to be cost-effective with incremental cost-effectiveness ratios (ICERs) of 83.32 ($1.13) for a combined effect of masking and hand hygiene, 8.07($0.77) for hand hygiene only, and, 76.36 ($1.03) for Masking only (Bagepally et al., 2021). Therefore, adherence to these University of Ghana http://ugspace.ug.edu.gh 25 protocols in congregations will contribute to curbing COVID-19. The benefits of these measures may have been already harvested in Ghana since no cluster of cases nor sub-outbreak was associated with the religious congregations. 2.4. Equipment and infrastructure put in place to support the adherence to COVID-19 prevention protocols The availability of essential infection prevention control(IPC) logistics together with targeted behaviour change communication is vital to reducing the risk of COVID-19 transmission in the treatment centres (Ashinyo et al., 2021). In Ghana, there have been legal instructions and repeated calls by the president to managers of public places to ensure the provision of facilities to enable public adherence to hand hygiene and social distancing and to also ensure that all accessing their services are in face masks (Update No.10: President Akufo-Addo Addresses the Nation - YouTube, 2020; FULL TEXT: Akufo-Addo’s 11th Address to the Nation on Measures to Fight Coronavirus, 2020; Address To The Nation By The President Of The Republic, Nana Addo Dankwa Akufo- Addo, On Updates To Ghana’s Enhanced Response To The Coronavirus Pandemic, On Sunday, 3rd January 2021, 2020). To support adherence to the COVID-19 prevention protocols, Ghana’s President, in one of his addresses on COVID-19, instructed public establishments to ensure the supply of necessary resources and enforce the observance of these protocols by persons accessing the premises (The President of Ghana, 2020). These places include recreational centres, entities of the hospitality industry, marketplaces, and banks. They should observe enhanced hygiene procedures by providing, among others, hand sanitizers, running water, and soap for handwashing. Also, the Ministry of Transport should work with the transport unions and private and public transport University of Ghana http://ugspace.ug.edu.gh 26 operators to ensure enhanced hygienic conditions in all vehicles and terminals by providing, amongst others, hand sanitizers, running water, and soap for handwashing (President of Ghana, 2020b). Indeed, the condition for the reopening of religious gatherings was for them to ensure an adequate supply of logistics and ensure strict compliance with the COVID-19 protocols (Address To The Nation By The President Of The Republic, Nana Addo Dankwa Akufo-Addo, On Updates To Ghana’s Enhanced Response To The Coronavirus Pandemic, On Sunday, 3rd January 2021, 2020). A study by Dabi et al. (2021) revealed a 95% availability of handwashing apparatuses at entrances or receptions at hotels in the HO municipality and a provision of hand sanitizers at 95%. While the provision of handwashing apparatus had 100% compliance at local restaurants, with a 95% provision of hand sanitizers. But the provision of handwashing apparatus (80%), provision of sanitizers at vantage points (80%), at drinking bars. A study by Bonful et al. (2020) to assess compliance with the COVID-19 infection prevention recommendation in selected transport stations in Ghana revealed the majority (80%) of 36 stations in Accra have at least one veronica bucket with flowing water and soap, but the number of washing places at each station was not adequate, while almost all stations (93%) did not have alcohol-based hand sanitizers for public use. The functioning of these hand washing stations will demand increased volumes of water usage(Rahman Zuthi et al., 2022). The free supply of water to the populace by the state, even though it was largely geared towards economic mitigation, was timely and should have an impact on hand hygiene(Address To The Nation By President Akufo-Addo On Updates To Ghana’s Enhanced Response To The Coronavirus Pandemic - The Presidency, Republic of Ghana, 2020). University of Ghana http://ugspace.ug.edu.gh 27 2.5. Knowledge, Attitude, and Practices Towards COVID-19 Prevention Protocols The KAP model has remained one of the key theories in health-related behaviour research in several fields (Green et al., 2015). It has been built on the assertion that knowledge alone is not enough to cause the desired behaviour and will require tailored communication that registers positive perceptions in the minds of the target group compelling enough to elicit the desired behaviour (Ashinyo et al., 2021; Green et al., 2015). According to Szymona-Pałkowska et al. (2016) adequate and appropriate knowledge, attitude, and practice are key in public health regarding health prevention and promotion. Improving the community’s knowledge and positive attitude toward COVID-19 prevention protocols to help them adopt them is therefore the basic way to prevent COVID-19 infection (Olum et al., 2020). Knowing the knowledge level of a target group on COVID-19 is crucial as it enables the identification and subsequent addressing of knowledge gaps to elicit positive attitudes (Ashinyo et al., 2021; Bakanauskas et al., 2020). According to Iqbal and Younas, one’s perception can influence one’s knowledge (Iqbal & Younas, 2021) while according to Haftom et al (2020) and Zhu and Colleagues (2015), one’s knowledge can be influenced by misinformation and beliefs(Haftom et al., 2020; Zhu & Xie, 2015), while Ferdous et al. (2020) say knowledge is influenced by access to information and health education. The outbreak itself, perhaps by its weight on human life, was also found to motivate knowledge gain(Rahman Zuthi et al., 2022). A study by P & J (2020) evaluating factors influencing adherence to recommended COVID-19 prevention measures in Siaga, Kenya among small-scale retailers revealed low levels of KAP where only 12.2% had good knowledge, only 7% had a good attitude, and 14.4% had the desired practices towards the fight against COVID-19. However, there was appreciable knowledge of COVID-19 protocols (100%) at hotels, local restaurants, and drinking bars according to a study by University of Ghana http://ugspace.ug.edu.gh 28 Dabi et al (2021), and 83.2% of knowledge according to Tawiah et al (2021) in a study on socio- demographic factors associated with people’s knowledge, their attitude, as well as their practices for the prevention of COVID-19 among Ghanaians, with 88.2% of positive attitude and 69.2% of good preventive practices. Also, a study by Iqbal & Younas (2021) evaluating the level of knowledge of the general public, their attitude, as well as their practices towards COVID-19 in Pakistan revealed an overall knowledge score of 73.7% whiles 74.5%, 68.8%, and 71% practiced social distance, mask-wearing, and hand sanitizer use, respectively. Another study by Zhong et al. (2020) on COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey reported high KAP levels with an overall correct rate of 90% knowledge, 96.4%, and 98.3% practicing social distance and mask-wearing respectively. A study by Azene et al. (2020) which evaluated adherence levels and factors influencing them among Gondar city residents in North West Ethiopia towards COVID-19 mitigation measures reported an adequate knowledge prevalence of 50.7%, 57.5% favourable attitude toward COVID- 19, and 52.2% favourable practices toward preventive measures similar to a study on knowledge, attitude and practices of healthcare workers regarding the use of face masks to limit the spread of the new coronavirus disease, which reported 56.4% knowledge on the wearing of a mask (Kumar et al., 2020). There was, however, a better level of knowledge, attitude, and practice reported in a study among university students in Vietnam in which health faculties had a majority of respondents reporting a higher (89.7%) level of good knowledge on face mask use, 72.8%, and 76.5% of positive attitude and good practice respectively (Duong et al., 2021). The difference seen here could be a result of the type of respondents, as university students are more likely to have access University of Ghana http://ugspace.ug.edu.gh 29 to information compared to residents of a city, but for the healthcare workers, their failure to pay attention to prevailing information could be the reason. Another study by Gao et al. (2020) revealed high KAP levels, knowledge of 91.2%, 98.0% positive attitude, and 96.8% good practice, and another study focusing on physical distancing behaviour among Africans also reported high knowledge of 85% (Bicalho et al., 2021). However, Okello et al. (2020) in their cross-sectional survey in Uganda, even though they also reported very high (93.9%) levels, revealed a low positive attitude prevalence of 51.3% and lower adherence of 48.3%. On the other hand, Natnael et al. (2021) reported a lower adequate knowledge prevalence of 69.8% compared to Okello et al. (2020). Their positive attitude and good practices on frequent hand hygiene among taxi drivers were better at 67.6% and 66.4%, respectively. An online study in China revealed 85.2%, 92.9% and 84.4% prevalence for good knowledge, good attitude and appropriate practices respectively(Yang et al., 2021), which reported better KAP levels compared to a study to assess knowledge, attitude and practices towards COVID-19 among adults in Bangladesh which revealed that overall, 61.2% had adequate knowledge, 78.9% had a positive attitude towards COVID-19 and only 51.6% had a good practice (Banik et al., 2020) likewise a study by Ferdous et al. (2020) on the COVID-19 outbreak in Bangladesh reported 48.3%, 62.3%, and 55.1% knowledge, positive attitude, and more frequent practices regarding COVID-19 prevention, respectively. However, there were equally good levels reported in a study by Azlan et al. (2020) on public knowledge, attitude, and practices towards COVID-19: A cross-sectional study in Malaysia which reported an 80.5%, 83.1%, 83.4%, and 87.8% overall correct rate of knowledge, positive attitude, social distance practice, and hand hygiene, respectively. The Practice of face mask wearing was, however, low (51.2%). University of Ghana http://ugspace.ug.edu.gh 30 2.6. Adherence to COVID-19 Prevention Protocols Understanding the level of adherence to and satisfaction with personal preventive measures is essential for the containment of the COVID-19 epidemic in the long term (Amodan et al., 2020). Adherence to public health instructions for COVID-19 is important for controlling the transmission and the pandemic’s health and economic impact. Understanding the characteristics of people who do not comply with COVID-19-related public health measures is essential for developing effective public health campaigns in the current and future pandemics (Nzaji et al., 2020). A cross-sectional study evaluating the effectiveness of these preventive measures found adherence to these measures to offer protection(Talic et al., 2021; Youssef et al., 2022). Hand hygiene is considered an effective measure to prevent and control the spread of diseases (WHO, 2009; Assab & Temime, 2016). Both alcohol-based hand rubs and handwashing with soap and water are critical approaches to preventing and controlling healthcare-associated infections that are effective in combating enveloped viruses like Ebola and coronaviruses (Adhikari et al., 2020). Hand hygiene seems to have risen as the pandemic progressed where early studies reported lower adherence compared to later studies even though the settings of the studies brought a lot of variances. Some studies reported a universal (95% or more) prevalence of handwashing (Amodan et al., 2020; Faria de Moura Villela et al., 2021; Shewale et al., 2021), and one reported 93% (Afful et al., 2020). One study assessing non-adherence reported as high as 91.3% non- adherence(Fielmua et al., 2021). A lower adherence level has been reported in previous studies for hand sanitization. 94.8% of people use alcohol-based hand sanitizers in a study in Ghana (Afful et University of Ghana http://ugspace.ug.edu.gh 31 al., 2020), 77% adherence was reported in a study in India (Shewale et al., 2021), and 74.5% was reported by Saab and colleagues (Saab & Domiati, 2021). Apanga & Kumbeni (2021) reported hand washing /sanitization rates of 31.7%. Enforcement of preventive measures, such as wearing a mask, prevents the spraying of droplets and their inhalation, thereby reducing transmission. In the United State of America( USA), enforcement of mask use and other preventive measures reduced cases by 75% in about a month (CDC, 2021; Gandhi & Marr, 2021). Studies assessing mask use reported mixed results. While some studies reported good adherence levels of more than 80% (Afful et al., 2020; Dabi et al., 2021; Tong et al., 2020), Block et al.(2020) reported an intermediate level of 65% and others reported poor adherence of less than 50% (Amodan et al., 2020; Apanga & Kumbeni, 2021; Faria de Moura Villela et al., 2021). According to Durante et al. (2021), observing physical distancing has the potential to reduce COVID-19 cases by 60%. A physical distance of not less than 1 meter apart is recommended (Jones et al., 2020). However, Tan et al. (2021) assert that social or physical distancing is a costly activity for Christians, which might be a stumbling block to it being adhered to in churches. Previous studies reported varying adherence levels, with Shewale et al.(2021) reporting good coverage of 81%. Block et al. (2020) reported an intermediary coverage of 67%, while other studies reported poor coverage ranging from 22%- 49.2% (Afful et al., 2020; Apanga & Kumbeni, 2021). Studies that assessed overall adherence to the recommended protocols among the general public also reported varying results. Azene et al. (2020) reported the highest adherence of 51%, Yehualashet et al. (2021) reported 44.1%, and Abeya et al. (2021) reported as low as 8.3%. University of Ghana http://ugspace.ug.edu.gh 32 2.7. Determinants of Adherence to COVID-19 Prevention Protocols Public adherence to COVID-19, prevention protocols is key as a measure to control it and adherence is affected by one’s knowledge, attitude, and practice toward COVID-19 (Ferdous et al., 2020). Public knowledge, attitude and practices toward a disease are likely to influence adherence, and public knowledge is important in tackling pandemics (Chirwa, 2020). Also, assessing people’s knowledge, attitudes, and practices towards the COVID-19 virus deepens insights into determinants of adherence to COVID-19 prevention and control guidelines (P & J, 2020). According to Amodan et al. ( 2020), those who obtained COVID-19 information from healthcare workers and from village leaders or those who were worried about their health were likely to adhere to the preventive measures positively, while staying with siblings reduced the odds of high adherence. Satisfaction with preventive measures was also associated with increased adherence. Also, many Africans did not wear masks because it was uncomfortable or because they did not even think that it was necessary (Ahmed et al., 2020). However, more sensitization regarding the importance of face mask use in containing the COVID-19 pandemic is needed, as well as subsidies and free masks for those who may not be able to afford them (Amodan et al., 2020). According to a study by Apanga & Kumbeni(2021), knowledge of COVID-19 symptoms and transmission via contaminated surfaces and objects was associated with wearing a face mask. Pregnant women who knew that avoiding the touching of eyes, nose, and mouth could prevent COVID-19 and knowledge of the virus being transmitted via contaminated objects and surfaces were associated with handwashing and hand sanitizing, whiles knowledge of COVID-19 transmission via contaminated surfaces and objects was also associated with social distancing. University of Ghana http://ugspace.ug.edu.gh 33 They stated that knowledge of COVID-19 symptoms, transmission, and preventive measures may play an important role in the practice of preventive measures against COVID-19 among pregnant women. Other studies find that people with adequate knowledge are more likely to adhere than those with poor knowledge (Nzaji et al., 2020; Yehualashet et al., 2021). However, other studies did not find an association between knowledge and adherence (Bante et al., 2021). This could be due to dilution by the infodemics of COVID-19 (García-saisó et al., 2021; Global Infectious Hazard Preparedness & WHO, 2021). A study by Nzaji and colleagues outlined that non-respect of public health measures for COVID- 19 can be predicted by never studied, primary education level, unemployed status, female gender of head of households, not attending lectures/discussions about COVID-19, not being satisfied with the measures taken by the ministry of health, not being regularly informed about the pandemic, and bad knowledge about COVID-19 (Nzaji et al., 2020). But Faria de Moura Villela et al (2021) revealed older age, being female, having at least an undergraduate degree, being a health worker, having comorbidities, not living in a rural area/village, not being a student, not working in the private sector, and not smoking as factors independently associated with higher overall adherence. Whereas other studies suggest that sex, level of information exposure, attitude towards COVID-19 preventive measures, and risk perception of COVID-19 were risk factors which significantly influenced the adherence of the community towards COVID-19 mitigation measures. Some studies also reported that people’s occupations or employment status influenced their adherence (Abeya et al., 2021). University of Ghana http://ugspace.ug.edu.gh 34 2.8. Methods in COVID-19 Implementation Research Amidst the pandemic, the Government of Ghana following the recommendations from the World Health Organization decreed that all churches are required to fully implement the preventive and control measures to be able to operate(WHO, 2020k). Each of these preventive control measures had standards to follow to ensure efficiency and effectiveness(WHO, 2021c). This study sought to assess compliance with the President of Ghana directive which demanded that, churches should ensure the availability and access to needed resources for congregants to support adherence, the proportion of congregants adopting it and dose practice measured by adherence to these measures. By measuring the fidelity, reach and dose recommended practices, this could be viewed as a process evaluation(Dixon & Bamberger, 2022), but, can also fit into implementation research. KAP studies formed part of the WHO-recommended process evaluation(WHO, 2021b). While a mix of both qualitative and quantitative method are usually recommended for these type of studies(Limbani et al., 2019; MEASURE Evaluation, 2012; Schneider et al., 2009), it is not uncommon to see one of them being used(Scott et al., 2019). A review of studies reveals that while few studies employed mixed methods(Supriyati et al., 2022), the majority of studies assessing KAP on COVID-19 prevention and control measures employed quantitative methods (Abd Elhameed Ali et al., 2021; Abeya et al., 2021; Ahmadi et al., 2022; Ahmed et al., 2020; Apanga & Kumbeni, 2021; Bante et al., 2021; Kanligi et al., 2022). While the reason for the over preference for quantitative is not immediately known, the ease associated with the analysis, questionnaire administration, possibility of self-administration and above all the objectivity of their findings as well as the ability to obtain representative findings for generalization could be accounting for this. All the studies reviewed used a cross-sectional study design with either a structured questionnaire or interview guide(Abd Elhameed Ali et al., 2021; Abeya et al., 2021; University of Ghana http://ugspace.ug.edu.gh 35 Ahmadi et al., 2022; Ahmed et al., 2020; Apanga & Kumbeni, 2021; Bante et al., 2021; Datta, 2004; Herbert et al., 2022; Kanligi et al., 2022; Kasemy et al., 2020). According to USAID, the KAP surveys are methodological quantitative but relevant questions could be (USAID, 2011). University of Ghana http://ugspace.ug.edu.gh 36 CHAPTER THREE METHODS 3.1. Introduction This section describes how the research was conducted from start to finish. It defined the target population, the sampling process, the sample size, the variables, the indicators of the research, the instrument for data collection, data management and evaluation, and ethical issues. 3.2. Research design This is a cross-sectional study involving quantitative methods to evaluate adherence to COVID- 19 prevention protocols and the factors associated with adherence among church members in Bolgatanga Municipality. A cross-sectional study design was used because it is most appropriate in addressing the study objectives. The study was carried out in churches through face-to-face interviews led by the researcher using a structured questionnaire and personal observation using an observational checklist at the Bolgatanga Municipality. 3.3. Study area The study was carried out in selected churches in the Bolgatanga municipality. The municipality is the capital of 15 districts of the Upper East region. It can be found between latitudes 10°30' and 10°50' North and longitudes 0°30' and 1°00' West with an area of 326 km². It is one of the most densely populated districts in the region with a population density of 394.2/km²(City Population, 2020). According to the Municipal Health Directorate, the municipality had a population of 130,091 based on the 2021 projected population. Also, according to the 2010 population and housing census, Christianity formed the dominant religion (57.6%) of all religious affiliations in the municipality, with 35.2%, 13.8%, and 5.3% being the Catholic population, Pentecostal/Charismatic population, and Protestant population, respectively, representing a total University of Ghana http://ugspace.ug.edu.gh 37 percentage of 54.4% of the three denominations. Based on 57.6% of the 2021 population, the Christian population is 74933. The people are mainly peasant farmers, with few farming vegetables like tomatoes in commercial quantities during the tomato farming season. A handful of the women also deal in basketry, and this accounts for as much as 57% of the labour force; trade and commerce account for 19%, manufacturing (mainly handicrafts) 11.92%, community and social services 7.4%, and others like mining, construction, and utility services. Bolgatanga Municipality has the second highest burden of COVID-19 cases in the Upper East Region. The municipality since the onset of the pandemic has recorded 605 confirmed cases, representing 39.51% of all cases in the region (Ghana Health Service Upper East Region, 2021) as at December 26, 2021, and also recorded 20 new cases, which is about 60.71% of the total new cases in the Upper East Region. 3.4. Study population The study had two categories of population: church members and churches in the Bolgatanga municipal. The study population included people aged 18 and above, both sexes, worshipping in the following denominations in the Bolgatanga Municipality: The St. Cyprian’s Anglican Church, The Church of Pentecost, Ebenezer Methodist Church, Assemblies of God Ghana, Presbyterian Church of Ghana, and the Catholic Church. The churches were chosen because most people within the region tend to congregate more in higher numbers and for longer hours, a situation which exposes them to the risk of COVID-19. University of Ghana http://ugspace.ug.edu.gh 38 3.5. Inclusion and exclusion criteria The following inclusion criteria were used: 1. Only individuals attending the selected churches within the Municipality were included in the study. 2. Church attendees 18 years and above who were of sound mind were included in the study. 3. Those who did not consent to the study were excluded 4. Churches within the Bolgatanga Municipality that were initially selected but permission was not granted were excluded. 3.6. Definition of study variables According to Vitolins and colleagues, gold standards for defining adherence do not exist, but what will be termed satisfactory or appropriate adherence depends on the situation (Vitolins et al., 2000). Most studies assessing adherence to COVID-19 among the general public employed Likert scales with either 4 or 5 ranked options ("never," "..., always"), with the last two options often used as points for defining adherence (Amodan et al., 2020; van Loenhout et al., 2021). The main dependent variable used in this study was adherence to COVID-19, which was uniquely defined and measured in this study. A worshipper was classified as having adhered if he/she consistently observed all four recommended protocols for the past five (5) major worship sessions, and this is an operational definition for this study. Emphasis was placed on observing all four (4) protocols based on the fact that masking and physical/social distancing were mandatory per both the WHO recommendations and Ghana government directives for the resumption of religious activities and the fact that higher benefits would be derived if handwashing and use of hand sanitizers were complementary rather than substitutionary. Consistency was also emphasized here because any breakage in observation of any of the protocols could expose the entire congregation University of Ghana http://ugspace.ug.edu.gh 39 to the SARS-CoV-2 infection. A major worship session was defined as Saturday worship for those whose Sabbath fell on that day, and Sunday worship for everyone else. According to Kjellsson et al.(2014), five (5) major worship sessions implied a recall period of 35 days, yielding a recall accuracy of 98.4%. This was preferable since it provokes thorough reflection than just seeking simple rank orders like never, sometimes, often, as used in other studies etc. All other variables used in this study are defined in table 3.1 below. Table 1: Definition of variables used in this study VARIABLE NAME TYPE OF VARIABLE OPERATIONAL DEFINITION SCALE OF MEASUREMENT Age groups Independent Age into 10 years at the time of data collection Ordinal Sex Independent Sex of the respondent Binary District of residence Independent District of residence of the respondent Nominal Type of residence Independent Type of residence of the respondent Nominal Educational status Independent Having formal education Ordinal Employment status Independent Whether the respondent is employed Binary Type of employment Independent The type of employment of the respondent Nominal Denomination Independent The category of the church that each respondent attends, catholic church, protestant, Pentecostal and others Nominal University of Ghana http://ugspace.ug.edu.gh 40 Level of adherence Dependent A number of times out of 5 previous worship sessions a respondent observed the protocols; hand washing, use of hand sanitizers, wearing of face mask and observing physical distance Continuous, ordinal Level of knowledge Independent Knowledge of respondents on COVID-19 prevention protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance Ordinal (quintiles) Level of attitude Independent The respondent stands/thought on adherence to the recommended protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance Ordinal Practice of COVID- 19 protocols Independent At least one-time practice of the protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance Binary Availability of equipment and infrastructure needed to practice the protocols Independent Availability of water and soap, hand sanitizer, face mask, health education and sitting arrangement in the church to ensure physical distance is observed Ordinal Access to equipment and infrastructure needed to practice the protocols Independent Access water and soap, hand sanitizer, face mask, health education and sitting arrangement in the church to ensure physical distance is observed Ordinal University of Ghana http://ugspace.ug.edu.gh 41 Knowledge on computer Independent able to use a computer including a smartphone to search for information online Binary English literacy Independent Ability to speak and understand English Binary 3.7. Sample size determination: A. Determination of the Sample Size of Christians was calculated using Taro Yamane’s 1967 formula as; 𝑛 = 𝑁 (1+𝑁𝑒2) Where, n=sample size (Christians) N= Total population of Christians under study =74933 E= Margin of error = 0.05 𝑛 = 74933 (1 + 74933(0.052) n=398 But allowing for a 10% loss and rounding up lower decimals to obtain full human beings after distribution for each denomination, the sample increased to 439. University of Ghana http://ugspace.ug.edu.gh 42 B. Determination of the number of churches to use In all, the researcher was able to identify 36 churches based on available information and approached the leadership for permission to conduct the study. The leadership of 33 churches granted the researcher permission and were included, while the leadership of the remaining three (3) churches refused and were excluded. C. Determination of the sample size of church members under each category (denomination) The sample size of 438 was distributed to the denominations by proportion to size based on the 2010 denomination distribution of these three denominations. This was also to ensure a fair representation of the entire Christian population. Catholics Sample size for catholic = 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 𝑐𝑎𝑡ℎ𝑜𝑙𝑖𝑐𝑠 𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 3 𝑑𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑖𝑜𝑛𝑠 × 𝑠𝑎𝑚𝑝𝑙𝑒 𝑠𝑖𝑧𝑒 = 35.2 54.3 × 438 = 284 After cleaning sample size =271 Protestants Sample size for protestant = 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 𝑃𝑟𝑜𝑡𝑒𝑠𝑡𝑎𝑛𝑡𝑠 𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 3 𝑑𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑖𝑜𝑛𝑠 × 𝑠𝑎𝑚𝑝𝑙𝑒 𝑠𝑖𝑧𝑒 = 5.3 54.3 × 438 = 43 Pentecostals/Charismatics Sample size for Pentecostal = 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 𝑃𝑒𝑛𝑡𝑒𝑐𝑜𝑠𝑡𝑎𝑙/𝑐ℎ𝑎𝑟𝑖𝑠𝑚𝑎𝑡𝑖𝑐𝑠 𝑡𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑜𝑓 3 𝑑𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑖𝑜𝑛𝑠 × 𝑠𝑎𝑚𝑝𝑙𝑒 𝑠𝑖𝑧𝑒 = 13.8 54.3 × 438 = 112 University of Ghana http://ugspace.ug.edu.gh 43 3.8. Sampling methods and procedures Stratified Simple random sampling was deployed in this study. Firstly, churches were grouped according to denominations: Catholic, Pentecostal/charismatic, and Protestant, which formed the first strata, as categorized in the 2010 population and housing census. Using the numerical strength of each denomination as a basis, the sample for the study (number of church members) of 439 was distributed proportionately among the denominations (stratum) as follows: Catholic = 284; Pentecostal/charismatic = 112; protestant = 43. The number of respondents assigned to each denomination (stratum) was also distributed proportionately to size among the churches selected from that stratum. In each church, the list of members was obtained, and church members' names were then extracted from the list of inclusion and assigned a number. Simple random sampling was used to select respondents in each church until the number required in each church was obtained by generating random numbers within the size of each congregation using the "RANDBETWEEN" formulae in excel. Based on the generated numbers, the respondents who were assigned similar numbers to the computer-generated numbers were selected for the study. 3.9. Data collection Data were collected via face-to-face administration of a structured questionnaire based on self- report by the respondent, and observation of the availability of basic facilities for implementation of COVID-19 protocols was done using an observational checklist. Six(6) field assistants supported the face-to-face administration of the questionnaires. Both the checklist and the structured questionnaire were designed with the Kobocollect application installed on android phones. The questionnaire had five (5) sections. Section 1 consisted of socio-demographic characteristics; section 2 on accessibility to available equipment and infrastructure necessary for University of Ghana http://ugspace.ug.edu.gh 44 protocol implementation; section 3 on the KAP on prevention protocol; section 4 on level of adherence to COVID-19 prevention protocols; and section 5 on determinants of adherence to the protocols. The questionnaire was administered in English and Gurune. Data were collected from all 439 respondents, giving a response rate of 100%, of which 13 respondents' data sets which had irreparable missing data were deleted, leaving 426 cases for analysis. Also, out of an estimated number of 36 churches, only 33 granted permission for the study. Below is a table with details of the churches used for the study Table 2:Churches studies CHURCHES DENOMINATION CATEGORY Sacred Heart Cathederal Parish Catholic Yikene outstation Our Lady of Africa parish Kalbeo outstation Sherigu outstation Holy Spirit Outstation St. Kizito Outstation Christ The King outstation ST. Joseph parish Yebongo outstation Sumbrungu outstation Yariga-Akasore outstation Yorobiisi outstation Miracle centre (kugadone) congregation Pentecostal /Charismatic (Assemblies of God Ghana Victory (Pubaka) Congregation Revelation (Sangardens congregation Centuory of Glory (Kalbeo) congregation Holy ghost temple congregation Redemption centre congregation University of Ghana http://ugspace.ug.edu.gh 45 Madanator(Anatim-Tankwidi) congregation Bolga District congregation Pentecostal /Charismatic (Church of Pentcost) Estate District congregation Pentecost internation Worship centre congregation Bukere congregation Sumbrungu congregation Dorungu congregation The St. Cyprian’s Anglican Church Protestant (The St. Cyprian’s Anglican Church) Ebenezer Methodist Church Bolga congregation Protestant (Methodist Churches) Nyorkoko congregation Yikene NO.1 congregation Presbyterian church Bolga congregation Protestant (Presbyterian Church of Ghana) Yorogo congregation Yipaala(Famous) congregation 3.10. Quality control To ensure quality, only six(6) people who were well-versed in Kobocollect and had knowledge of the use of Android phones were hired, trained, and supported in collecting the data. After designing the data collection tool, it was pretested at Bolga East District, a district that was carved out of Bolgatanga Municipality and shares boundaries with the study area (Bolgatanga Municipality) and all necessary corrections were made before the real data collection process began. Data debriefing sessions were held regularly with data collectors to ensure quality and sufficient data were collected and analyzed. University of Ghana http://ugspace.ug.edu.gh 46 3.11. Data processing and analysis Data were first downloaded into Microsoft Excel and the necessary cleaning was done using Excel. SPSS version 25 software was used for the analysis. Descriptive statistics were carried out on the socio-demographic data and also used to measure objectives one (1), two (2), and three. Relative frequency analysis was carried out throughout to describe the size of each category or choice or option of variable after categorizing all continuous variables. The proportions of churches observed as well as the proportion of respondents who reported having access to recommended resources were used to assess the availability of recommended resources. KAP was measured by the proportion of respondents with knowledge of COVID-19 prevention protocols, falling into each category of personal feeling or opinion about the protocols and having carried out the protocols. Bloom’s cut-off point of 80% and above was used to categorize the KAP level as "good”(Faria de Moura Villela et al., 2021; Kaliyaperumal, 2004; Jones et al., 2020). The level of adherence was measured by the proportion of respondents who consistently observed all the protocols for the past five Sundays. Chi-square and binary logistics (both bivariate and multivariate) regression analysis were used to identify determinants and their level of influence on adherence. 3.12. Ethical consideration Ethical clearance was sought from the Ghana Health Service Ethics Review committee with approval number GHS-ERS 033/06/21 and based on their approval, the researcher proceeded with the study. -Inform consent Formal permission was obtained from the heads of the various churches before the study started. Informed consent was also obtained from the participants. Each participant was made to read or University of Ghana http://ugspace.ug.edu.gh 47 read and interpreted in language that they understand the information sheet. Participants were then allowed to ask for clarification. They were then made to sign or thumbprint a consent form indicating their willingness to participate in the study. -Privacy and confidentiality Data collected from the study were used for the purpose for which it was collected. To ensure confidentiality, codes were used to identify participants instead of names. Data were also kept under lock and key to avoid access by unauthorized people. Members of the research team were also trained properly and advised to be responsive and respect all participants that were included in the study. University of Ghana http://ugspace.ug.edu.gh 48 CHAPTER FOUR MONITORING AND EVALUATION ISSUES OF THE STUDY 4.1. Introduction Monitoring and evaluation are essential in guiding the implementation of any health intervention to achieve its aims or objective and consequently its goal. The three types of evaluation are the process, outcome or impact. Effective Monitoring and evaluation recommend the used of an appropriate approach or model. One of the popular models in health intervention evaluation is the logic model. The logic model and conceptual framework were used in this study. The element of the logic model includes the inputs, activities, output, outcome and goal. In this study inputs were assessed by the Availability of infrastructure needed to adhere to COVID-19 prevention protocols, outputs were assessed by access to these resources or infrastructure, outcome by the KAP as well as adherence to these protocols. 4.2. The Goal of Covid-19 Prevention Protocols Target 3.4 of the Sustainable Development Goals demands the World authorities to act to protect lives and health in other to ensure the wellbeing of people amid pandemics(United Nations, 2019). The declaration of COVID-19 as a disease of public health concern meant the world needed to identify and implement all appropriate response measures in attempts to combat the pandemic (WHO, 2020l, 2020g). In the absence of a vaccine, the WHO, as an immediate effort, recommended hand hygiene, physical distancing, cough etiquette, avoidance of touching one’s face, and the rational use of personal protective equipment in community settings (WHO, 2020m, 2020j). These protocols, even though WHO was hesitant with some of them, evidence later backed them, therefore, compliance to was crucial in the prevention and control of the pandemic. University of Ghana http://ugspace.ug.edu.gh 49 4.2.1. Face Mask Wearing Despite the WHO's initial reluctance to endorse the use of face masks, the world health organization eventually issued a directive for the rational use of masking-up in community settings (WHO, 2020m). evidence later backed the effectiveness of masking up in the prevention and control of the pandemic(Talic et al., 2021; Wang et al., 2021)Food vendors and sellers at markets, commercial vehicle drivers and attendants, commuters on public transportation, and people in public and commercial centres, facilities, and buildings, including but not limited to offices, bars, workshops, restaurants, sports arenas, salons, shopping malls, churches, clinics, and hospitals, and all facilities accessible to the public, whether private or public, were initially targeted in Ghana (MOH Ghana, 2020). Procedures for wearing and removing a mask include ▪ Carry out effective hand hygiene before donning the mask. ▪ A donned mask must cover one’s mouth and nose and chin. ▪ Desist from touching the donned mask to avoid contaminating your hands. ▪ Efforts should be made not to touch the front part of the mask during removal. How to change and dispose of a mask, • A mask must not be worn for more than 12 hours. • A damp or soiled mask should be changed immediately. • Re-useable masks should be shocked in soap or bleach-lathered water immediately after removal for at least 5 minutes before washing and drying for reuse. • A mask meant for single use should never be re-used. Also, N95 masks should not be used more than 3 times. University of Ghana http://ugspace.ug.edu.gh 50 ▪ All used masks should be disposed of in a closed bin for onward processing or be burnt in a safe environment. Hands must also be washed immediately after disposal of the mask(MOH Ghana, 2020). 4.2.2. Physical Distancing This refers to all measures aimed at keeping infectious and susceptible people at least 1 meter apart to reduce the risk of transmission of COVID-19 (WHO, 2020c). Since it is difficult to differentiate between the infectious and the susceptible, it is required that everyone maintain a 1-meter distance in all instances, most especially in public spaces. Measures are usually implemented to promote the observance of this protocol, including lockdowns, proscription of mass gatherings, including religious ones, work from home, and takeaway transactions in the food industry, among others (Bicalho et al., 2021; Jones et al., 2020; WHO, 2020c). 4.2.3. Hand Hygiene This includes all measures that prevent the picking of germs, including the COVID virus from all contaminated surfaces and the transfer of them to the mucous membranes of susceptible hosts for the prevention and control of infectious diseases (WHO/UNICEF, 2021). This can be achieved by regular washing of hands and /or regular use of hand sanitizers containing at least 70% alcohol- based (WHO/UNICEF, 2021). Hand hygiene is so critical in the fight against COVID-19 that the Ghana government issued a directive requiring public places and service providers such as financial institutions, recreational centres, shopping centres, transport providers, and hospitality facilities to provide logistics and ensure hand hygiene observance during their usage. The Ministry of Local Government and Rural Development and its decentralized establishments were mandated to also enforce this directive at marketplaces (Address To The Nation By The President Of The University of Ghana http://ugspace.ug.edu.gh 51 Republic, Nana Addo Dankwa Akufo-Addo, On Updates To Ghana’s Enhanced Response To The Coronavirus Pandemic, On Sunday, 3rd January 2021, 2020). 4.3. Practical Considerations and Recommendations for Religious Leaders and Faith- Based Communities in The Context of Covid-19 Leaders of religious bodies and faith-based organizations should only hold gatherings after paying attention to the following conditions: ▪ Participants at such gatherings should maintain at least a meter distance apart throughout the meeting period. ▪ Participants can avoid physical contact with possible contaminated religious objects during the performance of rites. ▪ Ensure hygiene practice, especially regular hand hygiene, among participants throughout the gathering period. This can be achieved by providing hygiene facilities and logistics as well as enforcing their usage. ▪ Carry out regular disinfection of the church, including all surfaces of the worship (WHO, 2020k). 4.4. The objective /Outcome Variables. The directive by the President of the republic of Ghana demanded strict adherence to these preventive protocols before the resumption of church services. This implied 100% adherence in both numbers and recommended steps to the protocols(President of Ghana, 2020a). Despite this directive by the president being a decree and therefore punishable, adequate knowledge and information that brought about a positive attitude was necessary for practice and possibly University of Ghana http://ugspace.ug.edu.gh 52 adhering to these protocols. The KAP was therefore seen as preceding outcomes to the ultimate outcome measured by adherence. 4.5. Output measurement In this study, the output variable measured was access to recommended facilities and logistics necessary for the adoption and adherence to the recommended protocols during worship. This was measured by asking respondents to report on whether they have access to these facilities and logistics or not. 4.6. Inputs The president of Ghana particularly demanded the religious authorities to ensure the continuous supply of resources to enable congregants to comply with protocols. The availability of these recommended facilities during worship was measured as an input variable by observing them. 4.7. Type of Evaluation The study is a process evaluation of the implementation of COVID-19 prevention protocols in the quest to curb the COVID-19 pandemic. It seeks to assess if church members adhere to the COVID- 19 prevention protocols during worship sessions. Table 3:Definition of indicators Indicators Numerator Denominator Indicator description Proportion of churches with hand sanitizers available Number of churches with hand sanitizer Total number of churches assessed Churches with hand sanitizers available to aid in adherence to COVID-19 prevention protocols out of a lot of churches assessed Proportion of churches with available facilities to support Number of churches with facilities to support physical distance Total number of churches assessed churches with siting arrangements to aid in the physical distance out of a lot of churches assessed University of Ghana http://ugspace.ug.edu.gh 53 physical distance Proportion of churches with available hand washing facilities Number of churches with available hand washing facilities Total number of churches assessed churches with water and soap to aid in hand washing out of a lot of churches assessed Proportion of churches with face masks available Number of churches with face mask Total number of churches assessed churches with face masks available to aid members in wearing masks out of a lot of churches assessed Proportion of respondents who had access to face masks Number of church members(respondents) who had access to face mask The total number of church members assessed Church members who had access to face masks out of a lot of church members interviewed Proportion of respondents who had access to a hand washing facility Number of respondents who had access to hand washing facility The total number of church members assessed Church members who had access to a hand-washing facility out of a lot of church members interviewed Proportion of respondents who had access to hand sanitizers Number of respondents who had access to hand sanitizers The total number of church members assessed Church members who had access to hand sanitizers, out of a lot of church members interviewed Proportion of respondents who had access to facilities to support physical distance Number of respondents who had access to facilities to support physical distance The total number of church members assessed Church members who had access to facilities to support physical distance out of a lot of church members interviewed Proportion of respondents who had good knowledge of the COVID- Number of respondents who had good knowledge of the COVID-19 prevention protocols The total number of church members assessed Church members who had Knowledge of COVID-19 prevention protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance out University of Ghana http://ugspace.ug.edu.gh 54 19 prevention protocols of a lot of church members interviewed Proportion of respondents who had a good attitude towards COVID-19 prevention protocols Number of respondents who had a good attitude towards the COVID- 19 prevention protocols The total number of church members assessed Church members’ stands/thoughts on adherence to the recommended protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance out of a lot of church members interviewed Proportion of respondents who practiced COVID-19 prevention protocols Number of respondents who practiced the COVID- 19 prevention protocols The total number of church members assessed Church members with at least one-time practice of the protocols: hand washing, use of hand sanitizers, wearing of face mask and observing physical distance out of a lot of church members interviewed Proportion of respondents who adhered to COVID-19 prevention protocols Number of respondents who adhered to the COVID-19 prevention protocols The total number of church members assessed Church members who practiced all, four protocols; hand washing, use of hand sanitizers, wearing of face mask and observing physical distance for all five past worship sessions out of a lot of church members interviewed 4.8. Conceptual Framework and Logic Model The conceptual framework below is based on the KAP model, which was introduced by Nancy Schwartz in her article. Schwartz emphasized the importance of nurses having the necessary knowledge, attitude, and practice to provide better health care to their clients (Schwartz, 1976). Thus, KAP can also influence adherence to COVID-19 prevention protocols. One’s knowledge of the COVID-19 prevention protocols can influence one’s attitude, and attitude can influence practices towards the protocols. Also knowledge can influence adherence and one’s attitude can University of Ghana http://ugspace.ug.edu.gh 55 also influence adherence. The availability and access to equipment and infrastructure needed to adhere to the COVID-19 prevention protocols can also influence one getting access to the prevention protocols and access to the prevention protocols can influence one’s adherence to the COVID-19 prevention protocols. The level of adherence to the protocols can affect the prevalence of COVID-19 and, subsequently, mortalities, but the researcher does not intend to measure that. Figure 1:Conceptual Framework on adherence to COVID-19 prevention protocols Disease prevalence, disability, mortality, economic impact, development indices COVID 19 Preventive Practices Knowledge on COVID 19 preventive protocols Attitude towards COVID 19 and its Preventive Protocols Outcome: Adherence to COVID 19 prevention protocols Availability of infrastructure needed to adhere to COVID 19 prevention protocols • Hand washing facilities, • Hand sanitizers • Face masks • Physical distancing arrangements in churches Input factors Access to infrastructure needed to adhere to COVID 19 prevention protocols Output factors Outcome factors Impact University of Ghana http://ugspace.ug.edu.gh 56 LOGIC MODEL ON ADHERENCE TO COVID-19 PREVENTION PROTOCOLS AMONG SELECTED CHURCHES IN BOLGATANGA MUNICIPALITY Figure 2: Logic model on adherence to covid-19 prevention protocols among selected churches in Bolgatanga Municipality University of Ghana http://ugspace.ug