An assessment of socio-cultural challenges of social distancing as a means of COVID-19 control in Lagos state, Nigeria

INTRODUCTION

An outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection occurred in Wuhan, Hubei Province, China in December 2019.^1-3 It is an acute respiratory disease that causes flu-like symptoms.^4,5 This infection spread across China to many countries of the world.^1-3 The common symptoms are fever, cough, breathlessness and myalgia or fatigue.^1-3,5 Complications may occur in older people and people with chronic disease.^1-3 The outbreak was declared a Public Health Emergency of International concern (PHEIC) by the World Health Organisation(WHO) on January 30, 2020.^6,7 This disease caused by the novel Coronavirus was officially named Coronavirus disease 2019 (COVID-19) by the WHO on February 12, 2020.^6,7 WHO declared COVID-19 a global pandemic on March 11, 2020.⁸ It has affected about 0.4% of the world’s population.⁹

The outbreak of COVID-19 was a challenging situation the world has to deal with.¹⁰ Even if there are currently vaccines for it, there was still a need to depend on classical public health measures to curb the pandemic of this respiratory disease.¹⁰ The main goal of such public health measures is to prevent person-to-person spread of disease by separating people to break the chain of transmission.¹⁰ One of the important public health measures is social distancing.¹¹ Social distancing is an action taken to reduce physical contact with other individuals.¹¹ Social distancing measures consists of one category of non-pharmaceutical countermeasures (NPCs) directed towards reducing disease transmission and thereby also decreasing pressure on health services.¹¹ Social distancing minimises physical contact among individuals thereby reducing social contact.¹¹

There are several different types of social distancing measures, and these can be classified in layers in ascending order.¹¹ Each progressive layer of measures includes all measures from the previous layers.¹¹ Individual social distancing measures include isolation of cases, quarantine of contacts, stay-at-home recommendations while social distancing measures including multiple persons are closures of educational institutions and workplaces, measures for special populations, mass gathering cancellations and mandatory quarantine of a building or residential area.¹¹ Community-level social distancing measures are used together with containment efforts like contact tracing whenever it is evident that containment alone cannot serve as a means of delaying the peak of the epidemic, decreasing the peak magnitude to what the health system can handle, or protecting vulnerable groups at risk of severe outcomes.¹¹

It should be recognised by public health authorities that there are extra-scientific factors affecting the implementation of social distancing.¹¹ These include: the feasibility of implementing it, socio-cultural factors, time pressure, socio-political factors, institutional factors, economic factors, pressure from neighbouring countries and so on.¹¹ There are some socio-cultural challenges to social distancing.¹² One of it is that citizens of a nation might view it as a violation of their human right which leads to social unrest and disorder.^12,13 There is usually need for enforcement to ensure compliance.¹² Religion was a hindrance to social distancing in Italy as the proposal to stop masses in Italy was initially turned down until there was escalation in the rate of infection.¹² This religious factor is in the socio-cultural domain and is applicable worldwide to all oppositions to cancellations of mass gatherings in places of worship in the world.⁸

Religion plays a big role to nonchalance to public health measures in Africa as Christianity and Islam have a stronghold in Africa.¹⁴ Many people in Africa strongly believe in their religious leaders and initially opposed cancellations of mass gatherings.¹⁴ Cancellation of public gatherings also affected various business and educational institutions in the world.¹² The different experiences of China and Italy highlight unsimilar socio-cultural understandings in the practice of social distancing.¹² These factors continued to have consequences as the pandemic expanded.¹²

In Africa, the high population density poses a challenge to social distancing.^8,14 Many African cities, towns and villages are more crowded than those in the developed countries.¹⁴ This is due to the high rate of poverty in Africa.⁸ The population density of Luanda is about 25,000 residents per square kilometre, while Lagos is about 6,000 residents per square kilometre.¹⁴ These densely populated areas in the region make implementation of social distancing measures difficult.¹⁴ There are lot of urban slums in Africa and they pose a challenge.⁸ Most residential areas and markets are usually chaotic in Africa.⁸ These conditions increased the likelihood of rapid transmission which caused problems in management of COVID-19.⁸

In addition, Africans like the communal way of living.¹⁴ It is embedded in our culture since time immemorial.¹⁴ It has persisted even till this age of globalisation.¹⁴ If the government controls movement, there is still the challenge of ensuring that precautions of social distancing are followed in households of more than ten people.¹⁴ Another challenge in Africa is the remoteness and lack of infrastructures of some villages and communities.¹⁴ For instance, Idjwi Island in the Democratic Republic of Congo, Samburu County in Kenya, and the village of Odeni-gida in Nasarawa State, Nigeria, are just a few of the many remote places of the continent that had little or no information on the pandemic.¹⁴ They had no access to the internet and little or no access to mass media therefore social distancing was not practised in these places.¹⁴ The objectives of this study was to assess the level of knowledge, attitude and pratice of residents of Lagos state on social distancing as a means of COVID-19 control, to determine the socio-cultural challenges and assess the coping mechanisms to the socio-cultural challenges to social distancing as a means of COVID-19 control in Lagos state, Nigeria.

METHODS

Study design

This was a descriptive cross-sectional study among adults aged 18 years old and above who have resided in Lagos state, Nigeria.

Eligibility criteria

Adult residents at least 18 years old who have resided in Lagos state for at least six months at the start time of the study were included in the study. While adult residents who have COVID-19 disease or are in isolation as suspected cases of COVID-19 were excluded.

Sample size

The Cochrane formula was used for determination of minimum sample size in this study.¹⁵

where, n is the desired sample size (where population≥10,000); z is the level of significance at 95% CI=1.96; p is the prevalence assumed to be 50%=0.5; d is the precision value set at 0.05; p=0.5; q=1-0.5=0.5.

To adjust for non-response and possible losses of questionnaire, sample size was increased by 10%.

n=384+38.4=422.4

Sampling technique

Multistage sampling technique was used. The first stage was quota sampling in which only residents who have lived for at least six months in Lagos state were selected. The second stage was also quota sampling in which residents of Lagos state which were 18 years and older were recruited. The third stage was by convenient sampling in which each eligible participant was recruited till a sample size of 500 was reached.

Methods and instruments of data collection

A semi-structured questionnaire was used. Some questions were adapted from some studies and some were developed.^16-22 The questionnaire was created using the free software-Google forms. The questionnaire contained questions covering socio-demographic data, knowledge on social distancing as a means of COVID-19 control, attitudes towards social distancing as a means of COVID-19 control, practice of social distancing as a means of COVID-19 control, socio-cultural challenges associated with social distancing and coping mechanisms to socio-cultural challenges of social distancing as means of COVID-19 control. Data were collected using an online questionnaire spread throughout the internet, using the social media platform from September 2020 till February 2021.

Techniques to minimise bias or errors

A thorough research plan was created. The hypothesis was also evaluated. Analytic duties were shared with the team. Research plan and data were reviewed. Detailed records of all research materials were kept.

Data analysis

Data were summarized on a spread-sheet and entered into the computer. SPSS (Statistical Products and Services Solutions) version 22 was used for analysis. Data was cleaned and stored on external disk drive for future reference. Categorical variables were analysed in frequencies and proportions. Knowledge score was between 1 and 7. A score of 1 was assigned to correct response and 0 to every wrong answer.²³ Scores range from a minimum of 0 to a maximum of 7. Poor knowledge ranges 0-3 and good knowledge ranges 4-7. The attitude towards social distancing was designed as a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1).²⁴ The lowest score from the scale was 8, whereas the highest score was 40. A high score indicated a positive attitude and a low score negative attitude because the attitudinal statements are positively framed.²⁴ The mean score of 24 points on this scale was taken as the cut-off point. A score below this represented a negative attitude and a score above represented a positive attitude.

Quantitative variables were summarised as means, medians and standard deviations. Inferential statistics was also conducted. Chi-square was used to determine the association between categorical variables. Student t-test was used to compute quantitative variables. The level of statistical significance was set at p<0.05.

RESULTS

Among 500 study participants, 51.8% were male, and the age range was between 18 and 65 years. The age group 26-35 years had the highest frequency having 58.8% of participants and age group 56-65 years had the lowest frequency with 0.8% of participants. The mean age was 33.25 ± 6.61 years. The majority were Christians (79%) with more than half (52%) of participants from the Yoruba tribe. With regards to their occupational status, 32.6%, 36.8%, 25%, 5%, and 0.6% were employees, self-employed, skilled worker, unemployed, and unskilled respectively. Sixty-nine-point-two percent lived in households with 1 to 5 persons, while the remaining (30.8%) lived in households with 6 to 10 persons. (Table 1). Majority (98.2%) agreed to have heard of COVID-19. With regards to the source of information on COVID-19, 41.5%, 36.9%, 90.9%, 89%, 79.3%, and 42.1% identified family, friends/neighbours, mass media (radio/TV), internet, health personnel, religious institution (Church/Mosque) as source of information on COVID-19 respectively. Majority (98.2%) agreed that social distancing measures are forms of public health measures to prevent the spread of COVID-19, 99.4% were positive that social distancing is an action taken to minimize contact with other individuals, 98.4% affirmed that social distancing measures means ensuring that people maintain social contact from a distance of at least 1m with friends, colleagues and people next to you, 98.6% believe that isolation of cases is a form of individual social distancing, 99.2% agreed that separation of travellers who have been exposed on a journey is a form of individual social distancing, while 98.6% affirmed that closure of educational institutions/workplace closures/mass gathering cancellations are all social distancing measures. Overall, 98.2% of participants had good knowledge of social distancing as a means of COVID-19 containment. (Table 2). With regards to how participants felt about Coronavirus, 2.6%, 37.4%, 12.6%, 46.1%, and 1.2% participants felt fearful, fearful but optimistic, no feelings, optimistic, and very fearful respectively (Figure 1).

Among the participants that have heard of COVID-19, 60.2% agreed that people should be willing to give up their daily activities to prevent the spread of coronavirus, 65.9% strongly agreed to support social distancing, 40.9% disagreed that law enforcement agencies are needed to carry out social distancing measures, 51.6% agreed that peoples’ rights as citizens cannot be infringed on by social distancing measures, 62% agreed that social distancing measures cannot lead to crisis in the society, 60% strongly disagreed that social distancing measures does not affect the economy, while 32.3% neither agreed nor disagreed that people will still be able to follow social distancing measures if it takes a long time. Overall, 51% of participants had positive attitude towards social distancing as a means of COVID-19 containment (Table 3). Among the participants that had heard of COIVD-19, 98.2% practiced social distancing. Majority (97.1%) of participants who practiced social distancing, practiced it two weeks prior to when responses were collated. Among the remaining 2.9% participants that did not practice social distancing two weeks prior; the reasons given were that: 50% were unable to fully socialise with others, 7.1% were living in a household of more than 10 persons, 35.7% had loss or decrease of wages, while 7.1% had poor living conditions and loss or decrease of wages.

Ninety-nine-point-two percent of participants were always in their house at curfew time (Table 4). The overall percentage of respondents with good knowledge of social distancing was 98.2% and those with poor knowledge of social distancing was 1.8%. The overall percentage of those with positive attitude towards social distancing was 51% while those with negative attitude towards social distancing was 49%. Ninety-eight-point-two percent practised social distancing while one-point-eight percent did not practise social distancing (Figure 2). Among the 492 participants that had heard of COVID-19, a large proportion 350 (71.1%) believed that social distancing is not a violation of your human rights, 349 (70.9%) affirmed that there has not been an increase in violence during the lockdown, 318 (64.6%) disagreed that social distancing serve as a barrier to religious practices, while 477 (97%) believed that social distancing affected education in school. Furthermore, 244 (45.5%) participants affirmed social distancing can be practiced in overcrowded areas in Lagos, 373 (75.8%) lived with extended family members in their household, while 490 (99.6%) have a source of access to mass media or the internet (Table 5). A large number of 470 participants (95.5%) were positive that internet-based communications were a key tool for ensuring a successful social distancing strategy, 454 (92.3%) affirmed that teleworking can be a good strategy to sustain businesses, while 491 (99.8%) agreed that financial compensation can be given to those with income loss as a coping mechanism. In the same vein, 453 (92.1%) participants agreed that support groups can help to overcome the socio-cultural challenges to social distancing, while 489 (99.4%) participants are of the opinion that health education can help to overcome the socio-cultural challenges to social distancing, and that special attention should be given to people who are vulnerable to COVID-19 infection (Table 6).

Note: *- Multiple responses.

DISCUSSION

Social distancing measures were implemented to control the spread of COVID-19 because there was no known cure or vaccination for the condition during the initial stage of the pandemic; understanding and adherence to social distancing rules were critical.²⁵ Awareness of COVID-19 was very high among respondents (98.2%). This is similar to that of a study conducted in North-Central Nigeria in which awareness of COVID-19 was among 99.5% of respondents.²⁶ The results went further to show that mass media (radio/TV) and the internet as major sources of information on social distancing. This implies that mass media and social media are very effective sources of spread of information on COVID-19 in recent times. However, there is the need to tread on caution because of the infodemic phenomenon.²⁴ Similarly, social media was the main source of information for young adults in a survey on COVID-19 carried out in Egypt.²⁷ Overall, most participants (98.2%) had good knowledge of social distancing as a means of COVID-19 containment. This showed that respondents had adequate knowledge. A scoping review done in Sub-Saharan Africa showed that participants from twenty-four studies had a good knowledge with only four studies reporting a low knowledge of COVID-19.²⁸

Attitudes had a significant impact on practising preventive behaviours, implying that promoting preventive behaviours toward COVID-19 would require promoting both knowledge and efficacy beliefs among the public.²⁴ Adequate information about a subject has been identified as a prerequisite for excellent attitude and practice.²⁹ Overall, 51% of participants had positive attitude towards social distancing as a means of COVID-19 containment. This was relatively low, and showed the need for more efforts to persuade individuals into appropriate conduct. However, a study done in South Korea showed more favourable attitude (69.53%).²³ A scoping review conducted in Sub-Saharan Africa showed participants in fifteen studies had a good attitude, average in five studies, and low in four studies.²⁸

Findings obtained from this study revealed that the practice of social distancing was common among respondents, and most participants were always in their house at curfew time. In an attempt to slow down the spread of an infectious disease, several social distancing practices could be observed.²⁹ An overview of certain social distancing measures that could be observed to slow the spread of an infectious disease include the closure of schools and workplaces, self-isolation, self-quarantine, imposing restrictions on people's movements, and prohibiting large gatherings, are beneficial social distancing practices that could aid in the containment of an infectious disease's spread.²⁹

The study findings also revealed socio-cultural challenges to social distancing. About 64.6% of the participants disagreed that social distancing serves as a barrier to religious practices. Previous research has found disparities in attachment styles between religions and ethnicities, as well as links between cultural identification and attachment.³⁰ Religious and cultural similarities foster a common objective as well as the opportunity to congregate, share, and receive information. It provides emotional and social support and is said to encourage healing.³⁰ Many people believed that the in-person collective experience typified by these gatherings is essential for people's religiosity, social identity, and well-being.³⁰ Ninety-seven percent of the participants believed that social distancing affected education in school. Similarly, in a Nigerian study, one of the disadvantages of online teaching mentioned by both students and teachers was the little engagement they had with one another; this restricted interaction and had a significant negative impact on student satisfaction.³¹ A good number of participants believed that social distancing is not a violation of your human rights, and that there has not been an increase in violence during the lockdown. On the other hand, another study found that significant violations of people's fundamental rights occurred during the implementation of the COVID-19 lockdowns and curfews, particularly within the first month of its implementation in twelve countries, resulting in police-related deaths in two countries and prison-congestion deaths in three countries.³² Nigeria tops the list among the twelve countries.³²

A large number of participants (95.5%) were positive that internet-based communications were a key tool for ensuring a successful social distancing strategy. This result supports findings from another study where teenagers expanded their use of social media interaction across the globe, with many teens reporting usage of social media (Instagram, Snapchat, and TikTok) to remain in touch with their classmates.³³ Similarly, majority of the respondents (92.3%) affirmed that teleworking can be a good strategy to sustain businesses. The ability of many employees to telework has mitigated the resulting economic crisis of the COVID-19 pandemic.³⁴ Teleworking became a critical technique for both the business and public sectors in preserving and sustaining the economy and work operations throughout the COVID-19 pandemic's lockdown period.³⁵ Participants also agreed that financial compensation can be given to those with income loss as a coping mechanism. Findings from a United Nations High Commissioner for Refugees (UNHCR) study posits that COVID-19 impacted various persons of concerns (PoCs), with the majority of them reporting lower income as a result of government restrictions implemented at both the state and federal levels.³⁶ The policy was enacted in order to slow the spread of the disease.³⁶ The circumstance must have compelled the majority of PoCs to rely completely on remittances given by UNHCR and other humanitarian players.³⁶ Also, 92.1% of participants agreed that support groups can help to overcome the socio-cultural challenges to social distancing, while 99.4% of participants were of the opinion that health education can help to overcome the socio-cultural challenges to social distancing, and that special attention should be given to people who are vulnerable to COVID-19 infection. If all these coping strategies are implemented, the socio-cultural challenges associated with social distancing will be surmounted.

A limitation that occurred in this study was that sampling was not done among the study population as the questionnaires were administered via online means using social media platforms.

Tackling the socio-cultural challenges to social distancing would need a comprehensive approach comprising a nonpartisan and well-coordinated national response from the stakeholders. The government need to step up its efforts in educating its population about the significance of social distancing, conduct mass health education at the grassroots level, and provide social and economic support systems that will help mitigate socio-cultural challenges associated with social distancing.

CONCLUSION

Knowledge and practice of social distancing as a COVID-19 mitigating measure were found to be very high, however, attitude towards social distancing was moderately good among the participants. Major socio-cultural challenges found in implementing social distancing were its negative effect on education in schools and difficulty in practicing it in overcrowded areas in Lagos state, Nigeria. Other socio-cultural challenges were not found to have major impact in the practice of social distancing as a COVID-19 mitigating measure. It is therefore pertinent that health education, interventions in information technology, socio-cultural and socio-economic support are given to people in communities during pandemics.

ACKNOWLEDGEMENTS

The authors are thankful to all those who contributed immensely to the success of this research. We are indeed grateful for your contributions.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
2. 2. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-33.
3. 3. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020;382(13):1199-207.
4. 4. Guo YR, Cao QD, Hong ZS, Tan Y, Chen S, Jin H, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res. 2020;7(1):11.
5. 5. Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health. 2020;25(3):278-80.
6. 6. WHO. Statement on the second meeting of the International Health Regulations. Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV), 2020. Available at: https://www.who.int/newsroom/detail/3001coronavirus-(2019-ncov). Accessed on 29 April 2024.
7. 7. WHO. WHO Director-General's remarks at the media briefing on 2019-nCoV, 2020. Available at: https://www.who.int/dg/speeches/detail/whodirector2019ncov-on-11-february-2020.Accessed on 29 April 2024.
8. 8. Gadabu A. Malawi’s Response, Risk Factors, and Preparedness for COVID-19. North American Acad Res. 2020;3(04):44-66.
9. 9. World meters. Coronavirus Update, 2020. Available at: https://www.worldometers.info. Accessed on 30 April 2024.
10. 10. Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med. 2020;27(2):taaa020.
11. 11. European Centre for Disease Prevention and Control. Considerations relating to social distancing measures in response to COVID-19 – second update. Stockholm: ECDC, 2020. Available at: https://www.ecdc.europa.eu/en/publicationsdata/considerationsmeasuresresponse-covid-19-s. Accessed on 30 April 2024.
12. 12. Ferguson N, Laydon D, Nedjati Gilani G, Imai N, Ainslie K, Baguelin M, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College COVID-19 Response Team. J Adv Bio Biotech. 2016;7(2):1-10.
13. 13. NCDC. Updates on COVID-19, 2020. Available at: http://Covid19.ncdc.gov.ng. Accessed on 25 April 2024.
14. 14. Iroulo LC, Boateng O. African States Must Localise Coronavirus Response, 2020. Available at: https://www.ssoar.info/ssoar/bitstream/handle/document/67242iroulo_et_alAfrican_States_Must_Localise_Must_Localise_Coronavirus. Accessed on 01 June 2024.
15. 15. Charan J, Biswas T. How to calculate sample size for different study designs in medical research?. Indian J Psychol Med. 2013;35(2):121-6.
16. 16. European Centre for Disease Prevention and Control. Outbreak of novel coronavirus disease 2019 (COVID19): increased transmission globally – fifth update. Stockholm: ECDC, 2020. Available at: https://www.ecdc.europa.eu/sites/default/files/dments/RRA-outbreakcoronavirudisease19. Accessed on 03 June 2024.
17. 17. European Centre for Disease Prevention and Control. Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – sixth update, Stockholm: ECDC, 2020. Available at: https://www.ecdc.europa.eu/en/publicationsdata/rapidriskassessmentnoveldisease2019covid19pandemic-increased. Accessed on 03 June 2024.
18. 18. Public Health England. Guidance on social distancing for everyone in the UK – 20 March 2020. London: PHE, 2020. Available at:https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancingvulnerableadults. Accessed on 23 March 2024.
19. 19. European Centre for Disease Prevention and Control. Guidance on community engagement for public health events caused by communicable disease threats in the EU/EEA. Stockholm: ECDC, 2020. Available at: URL:https://www.ecdc.europa.eu/sites/default/files/documents/Guidance%20on%20community%20engagement-FINAL. Accessed on 04 June 2024.
20. 20. Austrian K. COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya, 2020. Available at: https://ssrn.com/abstract=3576785. Accessed on 11 May 2024.
21. 21. Survey. Knowledge, attitude and practice Survey (Round 2) on COVID-19 response 2020. Available at: https://www.surveymonkey.com/r/KAP_GY. Accessed on 01 April 2024.
22. 22. Amin S, Rob U, Billah M, Aniul S, Hossain I, Noor FH, et al. COVID-19 related knowledge, attitude and practices among adolescent girls in Bangladesh. Population council, 2020. Available at: https://www.popcouncil.org/research/practicesamongadolescent-girls-i. Accessed on 02 April 2024.