key: cord-0892598-156xu060
authors: Ba, M. F.; Ridde, V.; Diallo, A. I.; Tine, J. A. D.; Kane, B.; Gaye, I.; Traore, Z.; Bonnet, E.; Faye, A.
title: Acceptability of contact management and care of simple cases of COVID-19 at home: a mixed-method study in Senegal
date: 2021-03-12
journal: nan
DOI: 10.1101/2021.03.10.21253266
sha: dba31c054eac17e25c70792711c81b9402993913
doc_id: 892598
cord_uid: 156xu060

Introduction: In mid-2020, due to the health system challenges from increased COVID-19 cases, the Ministry of Health and Social Action in Senegal opted for contact management and care of simple cases at home. The objective of the study was to determine the acceptability of contact management, home care of simple cases of COVID-19, and its associated factors. Method: This was a sequential mixed-method study. We collected data from June 11, 2020, to July 10, 2020, for the quantitative survey (N=813) and from August 24 to September 16, 2020, for the qualitative survey (N=30). We carried out a sampling strategy using marginal quotas at the national level. We collected data using a structured questionnaire in a telephone interview for the quantitative survey and using an interview guide formulated from the initial results of the quantitative survey for the qualitative data. We assessed acceptability using binomial logistic regression combined with content analysis. Results: The care of simple cases of COVID-19 at home was well accepted (78.5%). This result was justified for some (saturation of the health system) but not for others (risk of contamination). The use of home contact management was less accepted (51.4%), with risk limitation as the main reason given. The acceptability of home-based care for simple cases was positively associated with knowledge of the modes of transmission of the virus (ORaj: 1.55 [95%CI: 1.04,2.28]), regular research into COVID-19 (ORaj: 2.12 [95%CI: 1.45,3.12]), belief in the existence of treatment (ORaj: 1.82 [95%CI: 1.19,2.83]), and confidence in institutional information (ORaj: 2.10 [95%CI: 1.43,3.10]). The acceptability of home-based contact management was positively associated with knowledge of the modes of transmission of the virus (ORaj: 1.77 [95%CI: 1.27,2.48]), regular research for information on COVID-19 (ORaj: 2.39 [95%CI: 1.76,3.26]), and confidence in the government in the fight against the epidemic (ORaj: 1.51 [95%CI: 1.10,2.08]). Conclusion: Regular information on the disease, knowledge of its mode of transmission and trust in institutions are factors in accepting COVID-19 management at the community level. Authorities should take these factors into account for better communication to improve the acceptability of home-based care. Keywords: COVID-19, Acceptability, Simple cases, Contacts, Mixed method, Senegal

To break the chains of transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, case detection, case management in dedicated centres [1] , and screening and quarantine of contacts have been proposed as nonpharmaceutical interventions [2] . These measures aim to prevent the further transmission of secondary infections. They have been used successfully to prevent further outbreaks in South Korea [2] .

In Senegal, as soon as the first case of COVID-19 appeared on March 2, 2020, the authorities put a national multi-sectoral action plan in place for monitoring and response [3] . The government accompanied this plan with measures such as border closures, curfews, bans on movement between regions, closure of places of worship, and closure of markets [45] . They established epidemiological treatment centres (ETCs) in all regions to manage COVID cases [19] . On March 22, 2020, they began to isolate contacts in hotel facilities [4] .

Despite the unprecedented national measures taken, COVID-19 cases continued to increase ( Figure 1 ) [6, 7] leading to an increase in the number of contacts requiring follow-up. Faced with this increase in the number numbers and the over-saturation of the health and hotel systems, on May 15, 2020, the authorities decided to stop monitoring contacts in hotels and care of simple cases in the ETCs. For the care of simple cases of COVID-19, they first adopted an extra-hospital care (dedicated sites outside the ETCs) at the end of April 2020 [8] then a home care in July 2020 with protocol to be respected [9] . A simple case is defined as a patient confirmed at COVID-19 who presents signs of uncomplicated upper respiratory tract infection such as fatigue, cough (with or without phlegm), nausea or vomiting, muscle pain, sore throat, nasal congestion, headache, ageusia (loss of taste) and anosmia (loss of smell) [9] . A contact is defined as a person (including caregivers and health workers) who has been exposed to individuals with suspected COVID-19 disease; they are advised to monitor their health for 14 days from the last day of contact [10] .

The recent SARS and Ebola epidemics used home-based management approaches [11] . However, there are some risks associated with this strategy, including the spread of the virus within households and in the community [1] and social stigma [12] , which undermines these measures' potential effectiveness. Several countries and the World Health Organization (WHO) have developed guidelines for the home management of COVID cases [10, [13] [14] [15] . Indeed, the vast majority of patients infected with COVID-19 develop a benign disease [16] . A few studies have shown that the ideal way to control the COVID-19 pandemic is to isolate patients in health facilities with appropriate respiratory precautions, contact tracing, and barrier measures [17] [18] [19] . However, isolation in health facilities would result in a shortage of beds for other patients [15] . In this context, home-based management (a familiar environment with family support) is necessary and could help to overcome psychological problems [20] . However, to our knowledge, these guidelines and studies on the subject have not addressed the social acceptability of these measures. Thus, our objective was to determine the acceptability of contact and simple case management of COVID-19 at home and its associated factors in Senegal.

The study took place in the 14 regions of Senegal. The average age in Senegal is 19 years, and males make up 49.7% of the population [21] . The number of confirmed COVID-19 cases on the day the survey started (June 11, 2020) was 4759 [7] with 76.5% of cases in the Dakar region. The organisation of the socio-sanitary sector is pyramidal (central, intermediate and peripheral levels), based on administrative divisions [22] . There are twenty ETCs in all regions of Senegal [23] . They have a capacity of 800 inpatient beds [24] and 80 beds for resuscitation and respirators were available in May throughout the country [25] .

Research estimates, period and study population It was a mixed-method specification with a sequential explanatory design with a quantitative phase followed by a qualitative phase [26] . We collected quantitative data from June 11 to July 10, 2020, and qualitative data from August 24 to September 16, 2020. The study population consisted of people aged 18 and over in the general population with a mobile phone number.

The quantitative study used a marginal quota sampling strategy [27] . To have a representative sample of the population, we carried out stratification by population weight by region, gender and age group. We randomly generated a nine-digit telephone number list from mobile telephone numbers attributable to Senegal using the Random Digit Dialing (RDD) method. Each number had the same probability of being drawn at random. We integrated this list into a Reactive Auto Dialer (RAD) to trigger calls automatically and optimally. The respondents from the qualitative study were nested in the quantitative study. Their selection followed the same stratification as that of the quantitative sample in order to have a diversity of points of view. A total of 813 individuals took part in the quantitative survey, 30 of whom were in the qualitative survey.

Data collection Five interviewers speaking six languages (French, Diola, Wolof, Sérére, Pulaar, Soninké) collected the quantitative data using a structured and closed questionnaire. The interviewers . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; conducted the survey by telephone. They used tablets equipped with Open Data Kit (ODK) software to administer the questionnaire [28, 29] . We conceptualised the collected variables in accordance with Bruchon-Schweitzer's integrative and multifactorial model [30] . This model has good content validity for this study as it integrates most of the variables identified in the literature review. According to the model, we divided the factors in our study into three groups: situational, dispositional, and transactional. Situational factors are socio-demographic characteristics such as age, gender, region, education level, marital status and economic well-being score. Dispositional factors are knowledge about the cause of the disease, symptoms, modes of transmission and availability of treatment and other variables such as trust in government, information seeking and trust in different information sources (institutions, national media, social networks, health professionals and other applications). Transactional factors are concerns about the epidemic and psychosocial well-being [31] . The independent variables are defined in Appendix 1. We measured the acceptability (the dependent variable) using a 5-point Likert scale (Strongly agree = 5 not at all agree = 1). It was transformed into binary variables (Yes = Strongly agree and Agree) to determine acceptability levels and identify associated factors. The qualitative survey was guided by the results of the quantitative analyses. Using a guide formulated from the preliminary descriptive results, the average individual interview duration was 37 minutes. Of the 30 interviews, 28 were conducted in Wolof.

The quantitative analyses were carried out using R software version 4.0.2. The quantitative variables are described through the mean with its standard deviation and the qualitative variables through the frequencies. We used the Student's test to compare mean ages, and the Chi2 test to compare other characteristics with a 5% alpha risk. We used binomial logistic regression in the multivariate analysis. We ran two models to determine the factors associated with the acceptability of management of home contacts (model 1) and those associated with care of simple home cases (model 2). We included all variables with p-values below 0.25 in the original models [32] . We used the step-by-step top-down selection procedure in each model to construct the final model. We individually removed variables that did not improve the model. We used the likelihood ratio test compare nested models [33] . We used this multivariate analysis determine adjusted Odds Ratios (ORaj).

For the qualitative data, we transcribed the interviews in full in French and then conducted a manual content analysis [34] .

According to the mixed-method approach, divergences and convergences are taken into account in the presentation of the results, particularly concerning the percentages of acceptability of home care measures [35] .

The study was approved by the National Ethics Committee for Health Research in Senegal (SEN/20/23). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ;

The average age of the respondents was 34.70 ± 14.20 years. Males represented 54.6%. In our study, 64.3% of the respondents regularly sought information about COVID-19. The proportion of respondents who trusted institutional information was 56.7% (Appendix 2).

The proportion of participants who accepted care for simple COVID-19 cases at home was 78.5%. In the qualitative survey, some respondents thought that this high percentage was justified by the capacity of the hospitals: "We had said that the hospitals are full to bursting point, so those with simple cases of COVID, it is better to leave them in the homes and treat them from there and those who are serious cases are taken to hospital" (F, 20 years old, Kaolack). For others, this result was astonishing: "I'm not for that, it's not safe. Even if the individual has simple COVID-19, it is better to take him and take care of him, otherwise he can contaminate people" (F, 33, Fatick). Furthermore, 48.6% of the participants did not accept the management of COVID-19 contacts at home. The respondents explained this by a need for risk reduction: "If you are a contact and the disease is asymptomatic, if you are allowed to be in contact with other people, it can be a risk. So it is better to isolate the person until the incubation period passes. "(H, 40 years old, Thiès).

The proportion of acceptability of management for home contacts among participants with a good knowledge of the modes of transmission of the virus was 56.1% while those with poor knowledge were 39.0% (p<0.001). The proportion of acceptability of care of simple cases at home among participants who believed that treatment was available was 85.5%, while that of others was 74.8% (p=0.001) (Appendix 3). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

The study found that while respondents supported care for simple cases of COVID-19 at home, they were more cautious about management for home contacts. These results are interesting given the adoption of this strategy by MoHSA [36] . Highlighted by the qualitative survey, these results can be justified by the fact that the participants are concerned about health system overload, and accept their care at the community level. However, participants are more divided on the management of contacts. WHO recommends isolation of contacts for 14 days after the last exposure with a confirmed case [2] . During the Ebola epidemic, this isolation period was 21 days [37] . A British survey revealed that only 10.9% of contacts adhere to quarantine, and 18.2% adhere to self-isolation [38] . Some of the factors preventing adherence to the isolation may be related to social and financial charges [39] . The 14 days for COVID-19 are difficult to enforce as they take place in the home, and may expose the community to transmission of the virus if people do not isolate themselves. Thus, illustrated by the qualitative survey, these results can be explained by the unknown status of these contacts who may be asymptomatic and then transmit the disease. The experience of the Ebola epidemic in Senegal had shown a negative perception of risk around contacts because people considered them infected with the virus [37] . In addition to strengthening the monitoring of household contacts, efforts should be made to increase people's understanding of these measures through public health counselling, explaining the importance of ECP of household contacts to reduce transmission, and strong local and social support networks to raise awareness [40] .

The study in Senegal found that individuals who trusted institutional sources were more likely to accept care from simple cases at home. Similarly, trust in government in the fight against the epidemic was positively associated with the acceptability of management for home-based contacts. This finding is similar to the study in Israel and China [41] which showed that trust in institutions represented a 'reservoir of favourable attitudes and good will' during the COVID epidemic [42] .

Good knowledge of the modes of transmission of the virus was positively associated with the acceptability of contact management and care of simple cases at home. Since the beginning of the pandemic, the MoHSA has been explaining to the population the importance of respecting collective and individual prevention measures [8]. These prevention measures have been defined as necessary to curb the spread of the virus [43] . Two studies conducted on HIV have shown that individuals with a good knowledge of the modes of transmission of the virus have a better knowledge of the modes of prevention [44, 45] . A study conducted in Senegal in April 2020 showed that barrier gestures seemed to be well followed [46] . Compliance with these measures, together with knowledge of how the virus is transmitted, may explain the good acceptability of management among populations.

The regular search for information on COVID-19 was positively associated with the acceptability of contact management and care of simple cases at home. The information provides knowledge that the recipient did not possess or could not foresee [47] . This definition recognises that information as an element of knowledge reduces ignorance about COVID-19. This knowledge will enable the community to consider the extent of the current context and adhere to public health measures. A systematic review showed that the provision of information is an important factor in influencing public acceptability of the authorities' measures [48] . This leads to a better understanding of the disease and autonomous decision-making in the light of the evolution of the pandemic. This finding seems consistent because people know better what is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253266 doi: medRxiv preprint is good for them and are therefore reluctant to accept an intervention that interferes with their own decisions [48] .

Belief in the existence of treatment is positively associated with the acceptability of care in simple cases at home. To date, no specific medication is recommended to prevent or treat infection of the new coronavirus [49] . At the beginning of the epidemic, Senegal adopted a treatment protocol based on the treatment of patients with hydroxychloroquine [50] and later with a combination of hydroxychloroquine and azithromycin [51] . This perception of the population in Senegal can be explained by the national communication on the "encouraging" results of this protocol [51] , which has become a source of hope in the event of contamination despite the risks involved in its acceptability.

Concern about the epidemic is negatively associated with the acceptability of management for home contacts. Health risks or threats, such as crises, involve emotional connotations and uncertainty about their health and economic implications [52] . These risks would lead to concern about the pandemic which may be due to the prospect of undesirable future consequences [53] and may explain this attitude.

Our study has certain limitations. It only involved people who had a mobile phone, thus excluding marginalised populations. In addition, the cross-sectional nature of the data limits our ability to draw conclusions about causality. However, the sample is representative of the Senegalese population and the use of mixed methods allowed for a better understanding of the results.

This study shows that being regularly informed about the disease, knowing how it is transmitted, and trusting institutions are important factors in the acceptance of COVID-19 management at the community level. It will be important for the authorities to consider and integrate these aspects for a more effective strategy. However, it is also necessary to have messages that are adapted and targeted according to the categories of the population. Emergency Health Operations Centre. The World Health Organization's 5-item index of wellbeing is a subjective measure of the positive dimensions of mental health. It is derived from the field of quality of life research. The 5 items ask about how people felt in the last two weeks and included: "I felt good and in good spirits", "I felt calm and quiet", "I felt energetic and vigorous", "I woke up feeling fresh and refreshed" and "My daily life was full of interesting things". Six response modalities: all the time rated 5, most of the time 4, more than half of the time 3, less than half of the time 2, occasionally 1 and never 0. An overall score is obtained by adding up the responses to the 5 items and ranges from 0 to 25. Well-being was considered good when the respondent had a score of 13 or more.

To deal with the pandemic, the Senegalese government had taken measures against the population, including curfews, travel bans and the closure of markets and places of worship. Each of these measures was measured by 7 items which gave us a score ranging from 0 to 7. In our framework, a measure was considered to be respected when the respondent had a score of 6 or more. Compliance with a measure was coded as 1 and non-compliance as 0. A respondent was considered to accept all 4 measures when he or she scored 1 in all 4 measures. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253266 doi: medRxiv preprint

Institutional versus home isolation to curb the COVID-19 outbreak -Authors' reply

Quarantine and testing strategies in contact tracing for SARS-CoV-2: a modelling study

Council of Ministers of 04

Home isolation guidance when unwell (suspected or confirmed cases

19-information-about-home-isolation-when-unwell-suspected-or-confirmedcases.pdf 14. Canadian government

Out-patient management of patients with COVID-19 on home isolation

Institutional, not home-based, isolation could contain the COVID-19 outbreak

Effectiveness of isolation, testing, contact tracing, and physical distancing on reducing transmission of SARS-CoV-2 in different settings: a mathematical modelling study

Case isolation, contact tracing, and physical distancing are pillars of COVID-19 pandemic control, not optional choices

Home care for patients with suspected or confirmed COVID-19 and management of their contacts

World Health Organization

Ministry of Health and Social Action. Senegal: Plan National de Développement Sanitaire et Social ( PNDSS )

Covid-19: The number of beds increased as a matter of urgency in the face of the worrying development of the pandemic

Number of resuscitation beds and respirateurs : What is the status of Afrique ?

Toward a methodology of mixed methods social inquiry

A theory of quota surveys.pdf. Survey Tech, Stat Canada

An exploratory study assessing psychological distress of indigents in Burkina Faso: a step forward in understanding mental health needs in West Africa

Characterisation of the rural indigent population in Burkina Faso: A screening tool for setting priority healthcare services in sub-Saharan Africa

Acceptability of the main types of serious adverse events associated with care in the general population and among doctors

Wellbeing Measures in Primary Health Care/ The Depcare Project

Applied Logistic Regression

Model building strategy for logistic regression: Purposeful selection

Qualitative Data Analysis. Second Edition

Understanding divergence of quantitative and qualitative data (or results) in mixed methods studies

Accepted monitoring or endured quarantine? Ebola contacts' perceptions in Senegal

Adherence to the test, trace and isolate system: results from a time series of 21 nationally representative surveys in the UK (the COVID-19 Rapid Survey of Adherence to Interventions and Responses

How to improve adherence with quarantine: rapid review of the evidence. Public Health

How to improve adherence with quarantine: rapid review of the evidence. Public Health

The adoption of preventive behaviors during the COVID-19 pandemic in China and Israel

Public acceptability of containment measures during the COVID-19 pandemic in Italy: how institutional confidence and specific political support matter

World Health Organization. COVID-19 Strategy Update

Knowledge , counseling and test acceptability regarding AIDS among Knowledge , counseling and test acceptability regarding AIDS among secondary school students

Knowledge about the transmission of the AIDS virus

Telephone survey on the Covid crisis in Senegal

Information needs in companies

Public acceptability of government intervention to change health-related behaviours: A systematic review and narrative synthesis

COVID-19 : What you need to know [Internet]. World Health Organization

Les chloroquine results are absolutely encourageants

Chloroquine & Azythromicine : Prof. Seydi revalidates the "Raoult protocol

The Senegalese Government's communication to the COVID-19 test

Adaptation strategies in consumption during the COVID crisis-19 : what hope for consumption responsable ?

We would like to thank the five interviewers who participated in the data collection: Tabaski Diouf, Coumba Sow, Fatoumata Dieme, Rokhaya Gueye and Mafoudya Camara. To our technical partner Cloudlyyours, who have been able to put in place all the necessary tools for data collection. This research was conducted as part of the ARIACOV programme (Appui à la Riposte Africaine à l'épidémie de , which receives funding from the French Development Agency through the "COVID-19 -Santé en commun" initiative.