Introduction

The emerging novel coronavirus (COVID-19) disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was first seen in Wuhan, China, in early December 2019 and spread to other countries (WHO 2020a; PHEOC 2020; Bekele et al. 2020; Zhong et al. 2020; Sohail et al. 2020). The disease is highly infectious, and its main clinical symptoms include fever, dry cough, fatigue, myalgia, and dyspnea (Bekele et al. 2020). Evidence indicates that the human-to-human transmission of COVID-19 occurs through respiratory droplets (e.g., sneezing or coughing) and through contact with the secretions of infected people (Muslih et al. 2021). The ongoing coronavirus disease of 2019 (COVID-19) pandemic has spread very quickly (Zhong et al. 2020). According to official counts as of 14 May 2021 globally the virus has affected 161,214,600 people and caused over 3,343,500 deaths worldwide (WHO 2020b). The first COVID-19 case in Ethiopia was reported on March 13, 2020 (UNICEF 2020) and as of April 15, 2021, the Ethiopian Ministry of Health reported 236,554 people infected and 3285 deaths (UNHCR 2021). In the Tigray region, the first COVID-19 case was reported on May 7, 2020, and as of February 28, 2022; 12,129 total cases and 79 total deaths have been reported in the region (ODA 2021). Due to the ongoing war in Tigray, the people are under blockade and critical humanitarian crisis, most of the infrastructure and health facilities are destroyed and looted. Therefore, working on prevention of the viral spread should be a priority and feasible intervention. As a result, the Government of Tigray has declared a state of emergency to stop the spread of the disease. The measures taken by the government include school shut downs, closure of drinking spots and eateries, banning all gatherings and limiting the number of passengers per public transport vehicle, staying at home, kee** social and physical distances, putting hand washing basins in common spaces common (banks, churches/mosques, markets), wearing of face mask, etc., (PHEOC 2020). For successful implementation of these preventive measures, knowledge, attitude of the community about COVID-19 and their practices towards its preventive measures has to be optimum. However, the level of their knowledge, attitude and practices towards COVID-19 is not studied yet low and the practice of the people is not good, especially in the capital city of the region (Mekelle city) where people are in precarious living conditions such as overcrowding, shortage of food, poor sanitation, and disruption of healthcare service delivery and hosting large number of displaced people across the region due to the ongoing war (ODA 2021). Thus, this study was aimed at assessing the level of the knowledge, attitude, practice, and associated factors of COVID-19 and its prevention measures among residents of Mekelle city, Tigray.

Materials and methods

Study area

The study was conducted in Mekelle, which is the capital city of Tigray found around 780 km from Addis Ababa to north and has an area of 28 sq.km. Its altitude ranges from 2200 meters above sea level and has weyna-dega climatic conditions. According to the Central Statistical Agency of Tigray, a total population of Mekelle city is 537,822 (255,962 men, 281,860 women). Administratively, the city is structured into seven-sub cities and subdivided into 33 kebelles. These are Hawelti, Hadnet, Ayder, Semien, Kedamay Weyane, Adi-haki, and Quiha. Moreover the city owns one specialized hospital, two General hospitals, one primary hospital, and five health centers. The present study was conducted on residents of 33 kebelles (lowest administrative units in Ethiopia with approximately 1000 households) of Mekelle city, Tigray region.

Study design and period

This community-based cross sectional study was carried out using a quantitative method in Mekelle city, Tigray Region from April to October, 2021.

Source population

The source of population were all residents of Mekelle city, Tigray, Ethiopia.

Study population

All systematically selected residents of selected kebelles who resided in Mekelle city, Tigray region for 6 months.

Inclusion and exclusion criteria

Persons who were aged 18 years or more and agreed to participate in the study were included as study participants, whereas study participants who had lived in the city less than 6 months, with mental health disorders, or were seriously ill during data collection were excluded from the study.

Sample size determination

The sample size was calculated using a single population formula considering previous study prevalence of knowledge toward COVID-19 (43.9%) with 5% margin of error at 95% confidence level (Tadesse et al. 2021). By considering 10% non-response rate and the design effect of 1.5 (used to minimize sampling errors), the final sample size was 604 residents.

Sampling techniques

A multi-stage sampling technique was used to select the study participants. There are seven sub cities and 33 kebelles in Mekelle city. The primary sampling units (12 kebelle) out of 33 kebelles of the city were selected by using lottery method and 604 households (HHs) from primary sampling unit were selected using systematic random sampling method from the selected kebelles. Proportional allocation was done and 38, 99, 89, 42, 43, 53, 29, 42, 27, 72, 29, and 41 study participants were recruited from selected kebelles of Mekelle city (Selam, Adi-shimdihun, Simret, Sertse, Adi-ha, Mesfin, Endustry, Walta, Zesilase, Amora, Hayelom, and Asmelash). The study units were randomly selected from the systematically selected HH members of each kebelle.

Data collection tools and procedures

Data was collected using a structured interviewer administered questioner by applying all the possible strict preventive measures of the pandemic. The tool was first prepared in English and then translated to Tigrigna (local language) for easy understanding and translated back to English for its consistency and analysis. The data collection tool was adapted from WHO guidelines and a previous study conducted on KAP towards covid-19 (WHO 2020a; Yoseph et al. 2021). The questionnaire includes five parts; the first part included socio-demographic characteristics of the study participants. The second part comprised 12 questions about the knowledge of COVID-19. Knowledge questions were both in the form of a multiple response or in the arrangement of yes, no, or I do not know. Yes responses were assigned 1 scores, whereas, no and I do not know responses were assigned 0 score. Finally, the overall knowledge point was extended from 12 to 16. The study participants who had scored greater than mean and above were considered as having good knowledge and below were considered as having poor knowledge. The third part contains 18 attitude questions. The responding and scoring systems were calculated by using a five-point Likert scale and based on the participants’ answer to each attitudinal statement (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). The overall attitude point was extended from 18 to 90. A score of mean and above was considered as having a positive attitude, whereas a score less than mean was considered as having a negative attitude toward COVID-19. The forth part included 08 questions regarding the practice toward COVID-19. The grading system was calculated by giving a value of 1 for yes regularly and 0 for sometimes and never practiced COVID-19 preventive measures. Study participants who had an overall score of mean and above were considered as having good practice while participants who answered below mean score were considered as having poor practice. The last part included an observational checklist to assess their actual practice towards COVID-19 prevention measures.

Data quality management

The data collection tool was pretested on 5% of the total sample size (30 participants) in Ayder sub city, Marta kebelle. During the pre-test, the questionnaire was assessed for its clarity, accuracy and comprehensiveness, readability and the optimal time for completing the interview. Then necessary adjustments and corrections such as wording, logical sequence, and skip patterns were made immediately. The data was collected and supervised by health professionals who had previous experience on data collection and supervision.

Data collectors and supervisors were trained for two days on the objective of the study, data collection process, confidentiality, and informed consent prior to data collection. The completeness and consistency of data were cross-checked, cleaned, and compiled on a daily basis by supervisors and the principal investigator.

Data processing and analysis

The data were cleaned, coded, and entered into Epi data version 3.1 software and exported to SPSS version 25.0 for analysis. Descriptive analysis was done and the results were presented using numerical summary measures, frequencies, and graphs to describe the study population in relation to relevant variables. Binary logistic regression analysis with odds ratio along with their 95% confidence interval were used to assess the degree of association between dependent and independent variables. The socio-demographic factors with knowledge, attitude, and practice of preventive measures against COVID-19 were the included factors in the bivariate analysis. The independent variables with p-value less than 0.25 were considered in the final model. The multivariate analysis model using adjusted odd ratio (AOR) was applied to identify the important determinant factors and used to control for possible confounding effects. The level of significance below 0.05 was considered to determine the association and Hosmer–Lemeshow goodness of fit was used to check the goodness of the applied models.

Operational definitions

Knowledge level

Participants who scored greater than or equal to the mean score were considered as having a good knowledge, whereas those who scored less than the mean score were labeled as having poor knowledge of COVID-19 and its prevention measures.

Attitude level

Participants who scored greater than or equal to the mean score were considered as having a positive attitude; otherwise, as a negative attitude toward COVID-19 and its prevention measures.

Practice level

Participants who scored greater than or equal to the mean score were considered as having a good practice of COVID-19 prevention measures, while those who scored less than the mean score were considered as having poor practice.

Results

Socio demographic characteristics of the study participants

Socio-demographic characteristics of the participants are summarized in Table 1. In this study, all (604) study participants completed the interviewer administered questionnaire making a response rate of 100%. Out of the total study participants (604), 318 (52.6%) were men and 286 (47.4%) were women. The age distribution of the respondents show that the majority of the study participants 266(4%), were between 31–40 years of age. The mean age of participants was 32±9.785 SD years, ranging from 18 to 67 years. Regarding marital status, more than half of the study participants 317 (52.5%) were married, while 214 (35.4%) were single, and 42 (7.0%) were divorced. Concerning their educational status, more than half of them 333 (55.1%) had diploma and above, whereas 171 (28.3%) and 63 (10.4%) of them complete secondary and primary school, respectively. Majority of the study participants 190(31.5%) were government employees, 139 (23%) were merchants, 109(18.0) were students, and 88 (14.6%) were housewives. Regarding family size, 275 (45.5%) and 248(41.1%) of the study participants were living with in 1–3 and 4–6 family members, respectively, while the remaining 81 (13.4%) study participants were living with >6 family members. Four hundred thirty two (71.5%) study participants had household monthly income below < 4120 Ethiopian birr.

Table 1 Socio-demographic characteristics of the study participants in Mekelle City, Tigray, 2021 (n = 604)
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Knowledge of study participants about COVID-19 and its prevention measures

This study identified that 448 (74.2%) of the study participants with mean score of 13.45 (±1.56) had a good level of knowledge about COVID-19 and its prevention measures (Fig. 1). Almost all participants 599 (99.2%) reported that they had heard about COVID-19 and its prevention measures. Among those participants who had heard about COVID-19, television 482 (79.8%), health professionals 395 (65.4%), radio 333 (55.1%), friends and relatives 251 (41.6%), and social media 21 (3.7%) were the main sources of information (Fig. 2).

Fig. 1
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Knowledge level of study participants toward COVID-19 in Mekelle city, Tigray, 2021

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Fig. 2
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Source of information of respondents regarding COVID-19 and its preventive measures in Mekelle city, Tigray, 2021

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As shown in Table 2, majority 514 (85%) of the study participants knew that the cause of COVID-19 is a virus, while 36(6.0%) & 24(4.0%) of the participants said that the cause of COVID-19 is God and bacteria, respectively. From the total respondents, majority 557 (92.2%) of the study participants knew that respiratory air droplets from the infected persons can transmit the infection of COVID-19 to healthy individuals. Similarly, 530 (87.7%), 459 (76%), and 516 (85.4%) of the study participants said that patients with COVID-19 had fever, dry cough & sore throat, and difficulty of breathing symptoms, respectively. Out of study participants 441 (73.0%) knew about the incubation period of COVID-19 (2–14 days). In addition to this, 386 (63.9%) of the study participants said that all people are susceptible to COVID-19 and 400 (66.2%) of the study participants mentioned that there is a vaccine for COVID-19. Moreover, majority 566 (93.7%) of the study participants answered that COVID-19 is a preventable disease. Regarding their knowledge towards the prevention measures, 542 (95.7%), 529 (93.5%), 526 (93.0%), 505 (89.3%) of the participants knew that regular hand washing with water and soap, maintaining social distance, wearing of mask, using of alcohol & sanitizer and others 50 (8.8%) can prevent COVID-19, respectively.

Table 2 Knowledge of study participants about COVID-19 in Mekelle city, Tigray, Ethiopia, 2021 (n = 604)
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Attitude of the study participants toward COVID-19 and its prevention measures

In this study, 355 (58.8%) of the study participants with mean score 76.17 (±7.497) had a positive attitude, whereas 249 (41.2%) of them had negative attitude toward COVID-19 and its prevention measures (see Fig. 3).

Fig. 3
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Attitude level of study participants toward COVID-19 in Mekelle city, Tigray, 2021

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As shown from Table 3, majority 544 (90%) of the study participants agreed with the idea that COVID-19 disease is dangerous. Five hundred fifty eight (92.4%) of the study participants worried that family members might become infected. The majority (95.3%) and 509 (84.3%) of study participants agreed with the statement that if they develop symptoms of COVID-19, they have to visit the health facility and they have to avoid normal activities, respectively. Most (567; 93.9%) of the study participants agreed that COVID-19 can be transmitted through coughing and sneezing and can be prevented by limiting movement (79.9%), maintaining social distance (93.2%), wearing masks (94.4%), washing hands (91.9%), isolation of COVID-19 infected patients (87.4%), avoiding touching nose, mouth and eyes (84.6%), and lockdown (64.4%). The majority (556; 92.1%) of the study participants said if there is a vaccine, they will use it. Moreover, 560 (92.7%) of the study participants reported that COVID-19 has a negative effect on Ethiopia’s economy. Only 120 (19.9%) of the study participants agreed that the government in our country has all the necessary healthcare facilities and are able to control the pandemic situation, while the majority (484; 80.1%) of the study did not.

Table 3 Attitude of study participants toward COVID-19 in Mekelle city, Tigray, Ethiopia, 2021 (n = 604)
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Practice of study participants toward COVID-19 and its prevention measures

According to the present study, only 237 (39.2%) with mean score 3.15 (±1.334) of the study participants had good practice, while majority 367 (60.8%) of them had poor practice of COVID-19 prevention measures (see Fig. 4).

Fig. 4
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Study participants practice of COVID-19 preventive measures, in Mekelle city, Tigray, 2021

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Findings from the present study revealed that 53.1% of the study participants wash their hands regularly using hand soap or sanitizer and water, 57.0 % of the respondents avoid close contact with people having cough and flu-like symptoms, 42.1% of the respondents reported that they sneezed and cough between elbows and only 26.5%, 34.9%, 28.6%, 34.8%, and 37.9% of them wear mask regularly, maintain safe distance between each individual, avoid visiting crowded places, avoid shaking hands with their friends and avoid touching mouth or eyes or nose with un washed hands, respectively (Table 4). The observational study result shown in Table 6 revealed that 161 (53.7%) of the study participants’ had sufficient water supply. However, 133 (44.3%) and 104 (34.7%) of the study participants had a shortage of hand washing facilities and availability of soap and alcohol-based sanitizer, respectively (Table 5).

Table 4 Practice of study participants toward COVID-19 prevention measures in Mekelle city, Tigray, 2021 (n = 604)
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Table 5 Observational study result of the study participants practice toward COVID-19
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Factors associated with KAP of study participants toward COVID 19 and its prevention measures

Factors associated with knowledge of study participants about COVID 19

The summary of the association of socio-demographic characteristics with study participants’ knowledge on COVID-19 and its preventive measures is shown in Table 7. Results from the multivariate analysis showed that age, level of education, and family size were found to be significantly associated with knowledge of COVID-19 and its prevention measures. Participants who were aged >50 (AOR = 5.2, 95% CI = 1.572-17.26) were five times more likely to have good knowledge about COVID-19 and its prevention measures compared to the age group 18–30. Study participants who complete secondary education and diploma & above educational level were three times more likely to have good knowledge on COVID-19 and its preventive measures than those who cannot able to read and write (AOR = 3.157, 95% CI = 1.161–8.589); (AOR = 3.146, 95% CI = 1.137–8.702), respectively. Regarding family size, participants who were living within >6 family members were 67% less likely to be knowledgeable as compared to those living within small family members (1–3) (AOR = 0.33, 95% CI = 0.175–0.639). However; sex, marital status, occupation and family income were not associated with the knowledge of the study participants toward COVID-19 and its preventive measures (Table 6).

Table 6 Results of multivariate analysis on factors associated with knowledge of participants toward COVID-19 and its prevention measures
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Factors associated with attitude of study participants toward COVID-19

The multivariate analysis result showed that occupation, family size, income level, and having knowledge about COVID-19 and its prevention measures were associated with attitude of the study participants toward COVID-19 and its prevention measures and the results are summarized in Table 8. In this study, participants who were students (AOR = 2.584, 95% CI = 1.126–5.933) and government employees (AOR = 2.227, 95% CI = 0.959–4.985) were 2.6 and 2.2 times more likely to have a positive attitude toward COVID-19 and its preventive measures than participants who were housewives. Study participants living with >6 family members (AOR = 2.287, 95% CI = 1.217– 4.299) were two times more likely to have a positive attitude toward COVID-19 and its prevention measures compared with those who were living with fewer family members (1–3). Regarding the income level, participants having a monthly income of above 4120 Ethiopian Birr were two times more likely to have a positive attitude toward COVID-19 and its preventive measures than those who have the lowest monthly income (AOR = 1.951, 95% CI = 1.277–2.981). Moreover participants who had good knowledge on COVID-19 and its preventive measures were 1.6 times more likely to have a positive attitude than those who were not knowledgeable about it (AOR = 1.567, 95% CI = 1.052–2.337). The socio-demographic characteristics such as sex, age, marital status, and educational level were not associated with the attitude of participants toward COVID-19 and its preventive measures (Table 7).

Table 7 Results of multivariate analysis of factors associated with attitude of participants toward COVID-19 and prevention measures
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Factors associated with practice of study participants toward COVID-19

Study results from multivariate analysis revealed that socio-demographic characteristics such as educational level, occupational status, income level, and having a positive attitude about practicing COVID-19 prevention measures were not associated with practice of study participants toward COVID-19 and its preventive measures, whereas sex, age, marital status, family size, and knowledge of study participants do not (Table 8). Study participants who had secondary and diploma and above education levels (AOR = 4.453, 95% CI = 1.296–15.301) & (AOR = 8.578, 95% CI = 2.445–30.094) were four times and eight times more likely to practicing COVID-19 prevention measures than those who were not able to read and write. Regarding occupational status, government employees (AOR = 0.390, 95% CI = 0.171–0.891) and taxi drivers (AOR = 0.257, 95% CI = 0.093–0.707) were 44.2% and 27% less likely to have good practice toward COVID-19 and its prevention measures compared to those who were housewives. The odds of practicing COVID-19 prevention and control were higher (42.3%) for study participants who had highest family income compared with their counterpart (AOR = 0.505, 95% CI = 0.287–0.890). Moreover, participants who have a positive attitude toward COVID-19 and its preventive measures were 1.734 times more likely to have a better practice of COVID-19 prevention measures than those who have a negative attitude AOR = 1.734, 95% CI = 1.195–2.515).

Table 8 Results of multivariate analysis of factors associated with the practice of COVID-19 prevention measures
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Discussions

In this study, the overall good knowledge, positive attitude, and good practice toward preventive measures of COVID 19 among students were 74.2%, 58.8%, and 39.2%, respectively. This study showed that 74.2 % of the study participants had a good level of knowledge about COVID-19 and its prevention measures. This finding is higher than studies conducted in Jimma Ethiopia (41.3%) (Kebede et al. 2020), Debretabor, Ethiopia (52.2%) (Emiru et al. 2020), Sidama, Ethiopia (43.9%) (Yoseph et al. 2021), Gonder, Ethiopia (51.85%) (Tadesse et al. 2021), Egypt (13.39%) (Kasemy et al. 2020), and the Syrian population (60%) (Sanaa 2021). The discrepancy might be due to differences in cut-off values used to categorize the knowledge levels (this study used the mean knowledge score as the cutoff value to dichotomize poor and good knowledge), data collection period, and socio-demographic characteristics of the study participants. For instance, in this study, 55% of the study participants had a diploma and above, which was higher than the comparable studies. It might also be due to the efforts made in disseminating COVID-19 related messages by government & non-government organizations before the conflict or war in the region happened. However, the present study result is lower than the previous studies done in Iran (90%) (Erfani et al. 2020), Pakistan (93.2%) (Sohail et al. 2020), and China (90%) (Zhong et al. 2020). The discrepancy may be due to differences in socio-demographic characteristics and socioeconomic status of study participants and the cut-off values to categorize the knowledge level of participants, study setting, and health care system of the region to create awareness regarding the pandemic. In these studies, more than 70% of the study participants were educated, the data were collected during the main phase of the outbreak when most populations were exposed to a lot of information about COVID-19 and they have better health care system as compared to the Tigray region (present study area) where its health care system is impaired and not able to create awareness among residents about the disease due to the ongoing war and siege. Moreover, due to the ongoing war in the region there is no access to the internet and electricity in the present study area to disseminate COVID-19 related information. This contributes in lowering the study participants’ knowledge toward COVID-19 as compared to the above mentioned studies. The present study also showed that almost all (99.2%) of the participants had heard about COVID-19. This finding is in agreement with a study done in Debretabor (among pregnant women), Ethiopia (100%) (Alemu et al. 2021), Debretabor, Ethiopia (97.1%) (Emiru et al. 2020), and Ethiopian residents (91.2%) (Bekele et al. 2020). In this study, television (80%) and health professionals (65.4%) were the most likely sources of information. However, this finding is contradicted with studies done in Ethiopia (Bekele et al. 2020), Egypt (Kasemy et al. 2020), China (Zhong et al. 2020), and Pakistan (Sohail et al.2020) in which the main source of information was reported as social media. The difference may be due to socioeconomic status of the study participants and the absence of social media, as there is no internet and electricity in the region including Mekelle city due to the ongoing war. The majority (516; 85.4%) of the study participants knew that the cause of COVID-19 is a virus. This study finding is in line with studies done in Awi-zone, Ethiopia, and Aseer region Saudi Arabia where the majority of their study participants knew that COVID-19 is caused by a virus (Adane et al. 2021; Arwa et al. 2020). Moreover, 533 (92.2%) of the study participants knew that respiratory air droplets from the infected persons can transmit the infection of COVID-19 to healthy individuals. This finding is in agreement with a study done in Saudi Arabia (Al-Hanawi et al. 2020). In addition to this, the majority (81.2%) of the study participants knew the main clinical symptoms of the disease. Similarly, study findings from Sidama, Ethiopia, indicated that the study participants knew the main symptoms of the disease (Yoseph et al. 2021). Moreover, 93.7% of the study participants knew the preventive measures of COVID-19. This finding is consistent with study done in Sidama, Ethiopia (Yoseph et al. 2021). More than half (63.9% and 66.2%) of study participants said that all people are susceptible to COVID-19 and there is a vaccine for COVID-19. This result is consistent with the previous study findings from Cameroon (Akomoneh et al. 2020) and Pakistan (Sohail et al. 2020).

The current study also reported that 58.8% of study participants had a positive attitude toward the COVID-19 pandemic and it prevention measures and the study result indicates that it needs an intervention to improve the study participants’ attitude toward COVID-19. However the study finding is higher than a study conducted in Sidama, Ethiopia (37.5%) (Yoseph et al. 2021), Gonder, Ethiopia (53.13%) (Tadesse et al. 2021), and Cameroon (28%) (Akomoneh et al.2020). This variation might be caused by differences in the study area and population, cut-off values to classify positive or negative attitude, knowledge level, and socio-demographic characteristics of study participants. For instance, in the present study, 55% of the study participants had diploma and above, whereas in these studies only 16.7%, 32.4%, and 46% of study participants had diploma and above, respectively. Moreover, the cut-off values to classify positive or negative attitude of participants might be the other reason for variation, i.e, most of the above mentioned studies have used percent (%) to classify positive attitude, while the current study has used mean and above to categorize study participants with a positive attitude. The knowledge level of the study participants could be the other reason for study result variation since knowledgeable participants might have an opportunity to obtain information that can increase their knowledge regarding COVID-19 which is associated with boosting positive attitude. However, the present study result is lower than a study done in Uganda (72.4%) (Ssebuufu et al. 2020), Egypt (75.9%) (Kasemy et al. 2020), China (90.8%) (Zhong et al. 2020), Iran (89%) (Erfani et al. 2020), and Pakistan (91%) (Kebede et al. 2020). The discrepancy may be due to differences in socio-demographic characteristics, educational level of study participants, socioeconomic status (economic crisis due to the war), the cut-off values to categorize the attitude and knowledge level of the study participants. Moreover, it may also be due to the blockade and ongoing war, which impairs health care systems in the region. Based on this study results, the majority (90%, 92.4%, 84.3%) of the study participants agreed that COVID-19 is dangerous, worried about the risk of infection for their family members, and to avoid normal activities if they have one of the symptom of COVID-19, respectively. In addition, 85.5% of the study participants agreed that the transmission of COVID-19 could be prevented by using standard and isolation precautions provided by the WHO. Moreover, 92.1% of the study participants are willing to take the vaccine once it becomes available, and more than half (57.8%) of them believed that available information about COVID-19 in Ethiopia is sufficient. This result is consistent with the study findings of Sidama, Ethiopia (Yoseph et al. 2021), Aseer region, Saudi Arabia (Arwa et al. 2020), and China (Zhong et al. 2020). However, the majority (80.1%) of the study participants did not agree with the idea that the government has all the necessary healthcare facilities and is able to control the epidemic situation. This finding is in line with studies done in Egypt and among Bangladeshi Internet Users (Kasemy et al. 2020; Rahman and Sathi 2020). This negative attitude could be attributed to the frequent news received from all over the world about the seriousness and rapid speed of the disease and the increase in the number of patients and deaths in many countries. It could also be due to the poor capacity of the health care system of the region to create awareness regarding the pandemic since there was no medication supply and the health care facilities were destroyed due to the ongoing war in Tigray (Regional Health Bureau of Tigray Region 2020). However, this result contrasts with findings of a study done in Saudi Arabia where 97% of the study participants were convinced that the Saudi government will control the pandemic (Kassie et al. 2020). Positive attitudes and high confidence in the control of COVID-19 can be explained by the government’s unprecedented actions and prompt response in taking stringent control and precautionary measures against COVID-19, to safeguard citizens and ensure their well-being. Moreover, the majority (560; 92.7%) of the study participants reported that COVID-19 has a negative effect on Ethiopia’s economy, whereas the remaining 7.3% of the study participants reported that COVID-19 has no effect on the Ethiopian economy. This finding is in line with a study conducted in Sidama, Ethiopia (Yoseph et al. 2021).

With regard to COVID-19 preventive practice, only 39.2% of the study participants had a good level of practice toward COVID-19 and its prevention measures, and the result is low compared to good knowledge and positive attitude of the residents toward COVID-19. This study finding is lower than the study conducted in Southwest Ethiopia (59.4%) (Abdelrahim et al. 2021), Debretabor, Ethiopia (54.2 %) (Emiru et al. 2020), Iran (71%) (Erfani et al. 2020), Cameroon (51.6%) (Akomoneh et al. 2020), Egypt (49.2%) (Kasemy et al. 2020), and China (90%) (Zhong et al. 2020). The reason for the discrepancy might be related to the impaired health system of the region by the ongoing war and siege, lack of access to COVID-19 preventive measures such as overcrowding in transportation due to increasing cost of fuel, unavailability of hand washing facilities, unavailability and increased cost of face mask, socio-demographic characteristics of study participants, cut-off values to classify good or poor practice. Although the result indicates that it needs serious intervention, this research finding is slightly higher than the study done in Sidama (Ethiopia) 24.4% (Yoseph et al. 2021) and Awi Zone, Ethiopia (29%)( Adane et al. 2021). Based the study results, only 53.1% of participants were washing their hands regularly using soap and sanitizer, 57% avoided close contact with people having symptoms and 49.5% of the respondents cover their mouth and nose when coughing or sneezing. Moreover, the study participants poorly practice COVID-19 preventive measures such as maintaiing social distance (34.9%), avoiding shaking hands (34.8%), avoiding touching mouth & eye with unwashed hands (37.9%), using mask regularly (26.5%), and avoid going to crowded places (28.6%). These figures are very low as compared to the study results from Debre Tabor, Ethiopia (Emiru et al. 2020); Sidama, Ethiopia (Yoseph et al. 2021); Ethiopian residents (Bekele et al. 2020); China (Zhong et al. 2020); Egypt (Kasemy et al. 2020), and Iran (Erfani et al. 2020), and it is also against the WHO recommendations to defeat the COVID-19 pandemic (Sanaa, 2021). The poor practice of study participants toward COVID-19 prevention measures was confirmed during observation where only 247 (41%), 199 (33%), and 163 (27%) of the study participants’ were observed to have sufficient water supply, hand washing facilities, and availability of soap and alcohol-based sanitizer, respectively. The reasons mentioned by the study participants were blockade and ongoing war in the region, which affects the overall socio-economic status of the community.

The multivariate analyses result revealed that the socio-demographic variables age, education level, and family size were associated with good knowledge of the study participants toward COVID-19 and its preventive measures. In this study, age of study participants >50 years was significantly associated with good knowledge.

This finding is consistent with the study done in China which showed that study participants aged ≥50 years had a good level of knowledge (Zhong et al. 2020). It was also supported by research works done in Sudan and Malaysia, which showed that older persons had better knowledge about COVID-19 (Abdelrahim et al. 2021, Azlan et al. 2020). Moreover, study participants who attended higher levels of education were three times more likely to have good knowledge compared to those respondents who were not able to read and write. The finding of this study is supported by various studies (Zhong et al. 2020; Kasemy et al. 2020; Abay et al. 2020). The reason for this might be highly educated people would have a better opportunity to use different mass media to obtain relevant information about COVID 19 compared with less educated people. Family size was another predictor associated with good knowledge, i.e, study participants with greater than six family members in the same home were 63% more likely to have good knowledge than those who had 1–3 family members in the current study. The possible reason for this could be people living with several family members might have an opportunity to discuss COVID-19 and would share information on how to care about each other during the pandemic. This would in turn enable them to have good knowledge on COVID-19 compared to those who live with only a few family members. This figure is in line with previous studies done in Amhara, Ethiopia, and Gonder, Ethiopia (Abay et al. 2020, Tadesse et al. 2021).

The results of this study also showed that socio-demographic variables (occupation, family size, income) and knowledge of the respondents were statistically associated with the attitude of study participants toward COVID-19. Regarding occupation, students and government employees were found to have a positive attitude compared to participants who were housewives. This was supported by previous studies (Zhong et al. 2020; Akomoneh et al. 2020) where students and government employees had a more positive attitude compared with housewives. The underlined reason might be students and government employees had better academic exposure, which makes have a better understanding of COVID-19 and its preventive measures. This also confirms that education is an influential determining factor of healthy behavior. Family size was another factor associated with positive attitude and study participants living with more than six family members were two times more likely to have a positive attitude than those who live within 1–3 family members. This finding is in agreement with a former study (Tadesse et al. 2021). The possible reason for this might be study participants living with several family members might have a good opportunity to discuss and share ideas about COVID-19 that would help them to avoid a misconception and understand the severity of the pandemic. This will improve their positive attitude toward COVID 19. Moreover, study participants with better income level have a more positive attitude toward COVID-19 than those who have low income. This study finding was supported by various studies (Sohail et al. 2020; Yoseph et al. 2021; Kassie et al. 2020) which showed that a study participant who earns high income are more knowledgeable and had positive attitude toward COVID-19 compared with these who had low monthly income. The reason could be study participants who had high income would have a better opportunity to get access to credible and timely information about COVID 19 which will improve their level of knowledge and in turn increase the positive attitude toward the COVID 19 pandemic and its prevention measures.

In regard to factors affecting practice, education level, occupation, monthly income level, and attitude of participants were associated with good practice of participants toward COVID-19 and its prevention measures. The present study findings demonstrate that respondents with higher education level had a good practice toward COVID-19 prevention measures compared with others having low education level and this was parallel with the studies which found statistical association between knowledge of study participants toward COVID-19 and their level of education (Zhong et al. 2020; Erfani et al. 2020). This reason might be due to educated study participants would have better access to information and understanding about COVID-19, which would improve their practice toward COVID-19 prevention measures compared to less educated people. The study also revealed that monthly income level of study participants was associated with their practice of COVID-19 prevention measures, which showed that study participants with higher monthly income had good practice toward COVID-19 compared with others having low income level. A study done in Malaysia revealed that study participants with lower income level had good practice and better compliance toward COVID-19 and preventive measures, which is contrary to the present study finding (Chang et al. 2021). Moreover the present study finding also demonstrates that good practice of study participants was significantly associated with their positive attitude. This is in agreement with other study reports (Zhong et al. 2020; Kasemy et al. 2020).

Conclusions

In conclusion the present study was able to assess the level of knowledge, attitudes, and practices of residents in Mekelle city, Tigray toward COVID-19 and its prevention measures. The present study showed that the majority of study participants had good knowledge and a positive attitude regarding COVID-19 and its prevention measures. However, their practice toward COVID-19 and its prevention measures was poor. Higher age, level of education, and family size were significantly associated with study participants’ knowledge about COVID-19. Whereas occupation, family size, income level, and having knowledge about COVID-19 were significant factors associated with the attitude of the study participants toward COVID-19. Moreover, the practice of study participants to prevent COVID-19 was also significantly associated with educational status, occupation status, income level, and having a positive attitude about the practice of COVID-19 prevention. Therefore, continuous and effective public health education programs, community mobilization, law enforcements, and breaking siege and allowing all types of humanitarian aid into the region are urgently needed to improve knowledge, encourage an optimistic attitude, and maintain safe practices toward COVID-19 and its preventive measures among the residents of Mekelle city.

Limitations

Since this study was conducted among residents of Mekelle city only, the results of this study may not be generalizable to other cities or rural areas of the region. Therefore, upcoming studies should assess the level of knowledge, attitude, and practice of the population on a larger scale to be able to design proper interventions on a country or regional level.