|ORIGINAL RESEARCH REPORT
|Year : 2022 | Volume
| Issue : 1 | Page : 10-16
Perception of healthcare workers towards the government's Coronavirus disease 2019 pandemic response in Ekiti State, Nigeria: A cross sectional study
Adeyinka Adeniran1, Esther O Oluwole2, Florence C Chieme3, Babatunde Olujobi4, Marcus M Ilesanmi5, Omobola Y Ojo6, Modupe R Akinyinka1
1 Department of Community Health and Primary Health Care, Lagos State College of Medicine, Ikeja, Nigeria
2 Department of Community Health and Primary Care, College of Medicine, University of Lagos. P.M.B. 12003, Surulere, Lagos, Nigeria
3 Research Development Unit, Petra Global Consulting, Lagos, Nigeria
4 State Primary Health Care Development Agency, Ado Ekiti, Nigeria
5 Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada./ State Primary Health Care Development Agency, Ado Ekiti, Ekiti State, Nigeria
6 Department of Community Health and Primary Care, Federal Medical Center, Abeokuta, Nigeria
|Date of Submission||15-Apr-2021|
|Date of Acceptance||30-Nov-2021|
|Date of Web Publication||07-Mar-2022|
Dr. Esther O Oluwole
Department of Community Health and Primary Care, College of Medicine, University of Lagos, P.M.B. 12003, Surulere, Lagos
Source of Support: None, Conflict of Interest: None
Background: Globally, coronavirus 2019 pandemic has led to severe illnesses, loss of lives, and social disruption in Nigeria. Ekiti State government introduced different strategies, protocols, and standard operating procedures in the control of the pandemic. This study assessed the perception of primary healthcare workers (HCWs) to the measures introduced to combat the coronavirus disease 2019 (COVID-19) pandemic in Ekiti State, Nigeria. Methods: This study was a descriptive cross-sectional study conducted between August and September 2020 among primary HCWs in Ekiti State. A Google survey tool was used to create an online questionnaire which was administered to respondents on social media platform. Analysis was done using STATA SE 12. Descriptive and bivariate analysis were conducted with a level of significance set at P < 0.05. Results: The mean ± standard deviation age of the respondents was 44.2 ± 6.7 years. Almost all (99.4%) of respondents had heard of COVID-19 pandemic while less than three-quarter (67.7%) had been trained on COVID-19. About half (54.6%) and (50.0%), respectively had good knowledge and perception of COVID-19, while three-quarter (75%) had good practice. About half (50.4%) had good perception about government's response toward COVID-19 prevention and protocols. Social and news media and family and friends were significantly associated with respondents' perception toward government' response (P = 0.000; 0.006 and 0.011) respectively. Similarly, the level of perception and practice of respondents were found to be statistically significant with respondent's perception of government response to COVID-19 (P = 0.001 and 0.040) respectively. Conclusion: Only about half of the respondents had good knowledge of COVID-19 and positive perception toward government's response to COVID-19 pandemic. Intensification of government's efforts toward the pandemic control in Nigeria is recommended.
Keywords: Coronavirus disease 2019, Ekiti state, government's response, healthcare workers, Nigeria, perception
|How to cite this article:|
Adeniran A, Oluwole EO, Chieme FC, Olujobi B, Ilesanmi MM, Ojo OY, Akinyinka MR. Perception of healthcare workers towards the government's Coronavirus disease 2019 pandemic response in Ekiti State, Nigeria: A cross sectional study. J Clin Sci 2022;19:10-6
|How to cite this URL:|
Adeniran A, Oluwole EO, Chieme FC, Olujobi B, Ilesanmi MM, Ojo OY, Akinyinka MR. Perception of healthcare workers towards the government's Coronavirus disease 2019 pandemic response in Ekiti State, Nigeria: A cross sectional study. J Clin Sci [serial online] 2022 [cited 2023 Jun 2];19:10-6. Available from: https://www.jcsjournal.org/text.asp?2022/19/1/10/339145
| Introduction|| |
The World Health Organization (WHO) reported the occurrence of a strange deadly disease with an unknown etiology in December 2019. The virus was identified as the severe acute respiratory syndrome-coronavirus an enveloped single-stranded RNA virus belonging to the Coronaviridae family, the disease was later named coronavirus disease 2019 (COVID-19), WHO declared the outbreak a Public Health Emergency of International Concern on January 30, 2020 due to the rapid spread of the virus, and on March 11, 2020, it was announced a worldwide pandemic by WHO.
Globally, the coronavirus 2019 pandemic has led to loss of lives, social disruption, and severe illnesses. As of August 11, 2021, 13:46 Greenwich Mean Time + 1, WHO reported 204, 998, 198 confirmed cases and 4,331, 177 deaths due to COVID-19 worldwide. Furthermore, on the same day, it was reported that there were 179,118 confirmed cases, 2194 deaths, 166,131 discharged in Nigeria. Many governments, in response to the pandemic, have implemented policies and procedures including imposing temporary travel bans that resulted in a significant decrease in the number of travelers, as well as physical distancing, self-isolation, foreign travelers quarantine, frequent hand washing, and the use of face masks. These policies pose some economic consequences to both developed and developing countries.
In Nigeria, the government introduced different strategies, protocols, and standard operating procedures, as well as forming various committees, including the National Emergency Organizing Committee and the Presidential Task Force (PTF). The PTF was charged with collaborating with the Federal Ministry of Health and the Nigerian Center for Disease Control on COVID-19 containment measures and strategies. The federal government placed a lockdown on nonessential activities in the Federal Capital Territory, Abuja, Lagos, and Ogun states on March 30, 2020, and later to some other parts of the country.
Health care workers (HCWs) are at the forefront of the battle against COVID-19 and are subjected to a great deal of physical and emotional strain., Emotional exhaustion and stress can lead to mistakes, decreased efficiency, and an inability to provide the utmost care. Frontline HCWs (F-HCW) such as doctors, nurses, and paramedics, Doctors, nurses, and paramedics are vulnerable to the infection. According to a Pan American Health Organization study, by September 2, 2020, nearly 570,000 COVID-19 infections and at least 2500 deaths among FHCWs would have occurred across the area. Similarly, by August 29, 2020, India had recorded 87,176 F-HCW contaminations and 573 deaths. Nigeria was still leading in the African region as 606 HCW were reportedly infected with the virus in May 26, 2020.
Although other works have been published on public perception in Nigeria, Europe, and the United States, the perception, opinion, and attitude of health workers toward the various government social control measures implemented in the aftermath of the pandemic and now have not previously been evaluated in Nigeria. The information gathered could aid in the modification and implementation of a well-coordinated response.
Findings from a study conducted among 19 countries reported that the level at which the government's instructions are being interpreted and followed could have a significant effect on the pandemic. This study, which was conducted in Ekiti State while the nation was still observing lockdown, was designed to assess, document, and evaluate the perception of primary HCWs to the measures introduced to combat the COVID-19 pandemic in the State.
| Methods|| |
Ekiti State was created on October 1, 1996. It lies south of Kwara and Kogi States, east of Osun State and limited by the Ondo States in the east. Ekiti State has 16 LGAs with a population of 3,270,798 people (2016 estimates) with a 2.3% annual growth rate, and an area mass of 5,887.89sq km. The State is located in the southwestern part of Nigeria between longitudes 40°51′ and 50°451′ East of the Greenwich meridian and latitudes 70°151′ and 80°51′ north of the Equator. The capital is located at Ado-Ekiti. The state is mostly agrarian with small and medium scale enterprises in the urban and semi-urban areas. Health care is delivered through the public and private sectors. The Primary Health Care Development Agency is an umbrella body controlling all the Primary HCWs activities in Ekiti State. It currently has a total population of 4211 workers which comprise technical and support staff. In the respective Local Government Areas (LGAs), are different categories of workers with varying levels of authority and supervision.
Study population, study design, sample size determination, and selection of participants
This descriptive cross-sectional study design was conducted from August to September 2020 among Primary HCWs. The medical officer of health, assistant coordinators, program officers/ward focal persons, head of facilities, and other technical staff members were included. A Google survey tool (Google Forms) was used to create an online questionnaire which was administered to respondents on social media platform specifically the WhatsApp platform created for staff members. The link to the online survey questionnaire was sent to this platform which contained the informed consent forms. Respondents without smartphones were loaned devices by the LGA representative to fill the survey form.
The minimum sample size was determined using the Fisher's formula for population < 10, 0000, to be 352. Assuming a confidence level of 95%, the prevalence of 50% and an absolute precision of 5%. All the 16 LGAs of Ekiti State were included in the study; Ado Ekiti, Efon, Ekiti East, Ekiti South West, Ekiti West, Emure, Gbonyin, Ido/Osi, Ijero, Ikere, Ikole, Ilejemeje, Irepodun/Ifelodun, Ise/Orun, Moba, and Oye LGAs. 359 (8.5%) of 4211 PHC workers participated in the study. Each LGA had a WhatsApp platform of all staff in the respective LGA which is used to share information. The Google link to the survey instrument was sent to all workers through the existing WhatsApp platform the respective LGA had been using for their information dissemination. The research assistants were selected according to the following criteria: computer use proficiency, data collection, communication skills, previous survey experience, ability to use smartphone, and similar interface platform for data collection. One research assistant from each of the 16 LGAs was trained and equipped to follow-up with eligible respondents for them to properly complete the data collection Google form. The survey respondents reported back to the research assistant after completing the Google form. The use of the research assistants for the data collection was to assist in directing and resolving the would-be respondents with challenges during the process of responding to the forms.
Data collection was carried out using quantitative methods with the use of a self-administered Google form which consist of 5 sections: sociodemographic variables (age, level of education, gender, marital status, religion, occupation, designation, state of residence, and place of practice, etc.,); awareness and knowledge of COVID-19 (causes, mode of transmission, main symptoms, incubation period, complications of COVID-19, treatment, and prevention of COVID-19); perception of HCW toward COVID-19; and HCW perception toward government's response to COVID-19 pandemic (data collected on the perception of respondents toward: adequacy of laboratory testing to the people, adequacy of psychosocial support for HCWs, and adequacy of psychosocial support for the community people).
Fully completed questionnaires were extracted from Google forms and exported to Microsoft Excel 2016 for cleaning and coding. The cleaned data was exported to STATA SE 12 for analysis (STATA CORP LLC, College Station, Texas, USA). Numerical data were summarized as mean and standard deviations (SDs) or median and range as appropriate. The right answers to the questions in the knowledge section were selected by the researcher and the answers provided by the respondents were evaluated against these standard answers. Each correct answer was awarded a score of 1, while a wrong answer was awarded a score of 0. The total score was calculated by summing all the awarded scores, and these were converted to percentages Perception statements were scored using the 5-point Likert scale namely 1 = Strongly Agree, 2 = Agree, 3 = Indifferent, 4 = Disagree, and 5 = Strongly Disagree. Practice statements were scored using scale namely Always = 3, Sometimes = 2 = Rarely = 1 Not at all = 0. The knowledge, practice, and perception grade were assigned to each respondent based on their total percentage score. Poor knowledge of COVID-19 scores was rated as scores less than the mean score. Poor perception toward COVID-19 pandemic and negative perception to government response were rated < Median score, while poor practice to COVID-19 scores was rated as < mean score. The results were presented in the form of tables, figures, frequencies, and summary statistics such as mean, SD as appropriate. To identify associated factors, bivariate analysis was performed using demographic characteristics as an independent variable and perception toward government response to COVID-19 as the outcome variable. Variables with P < 0.05 were regarded as being statistically significant.
Every respondent gave an online informed consent before filling the study questionnaire after the provision of adequate information about the study. Serial numbers, not names of participants were used, to maintain confidentiality. The study was approved by the Lagos State University Teaching Hospital Health Research Ethics Committee (Ref No: LREC/06/10/1424).
The mode of data collection is internet-based and could be affected by erratic network connectivity for staff members located in remote communities with little or no access to the internet.
| Results|| |
Sociodemographic characteristics of respondents
[Table 1] shows that the respondent's age ranged from 30 to 65 years with a mean age of 44.2 ± 6.7 years. Most (87.2%) were female and almost all 349 (97.2%) were married. Most (90%) of the respondents had tertiary level of education, more than a quarter (28.7%) were Community Health Extension Workers.
Respondent's sources of information about coronavirus
[Figure 1] shows that 41% mostly use the news media as a reliable source of information. While 26% use social media more often, while 18% rely on information from family and friends and 15% from the government's website.
|Figure 1: Respondent's sources of information about coronavirus (N = 359)|
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Respondents' perception of government response to coronavirus disease 2019
[Table 2] shows that about one-third (34.3%) of them reported both strongly disagree and disagree to adequate laboratory testing of the people. Two-fifth (40.9%) of the respondents strongly disagreed and disagreed to ease of the lockdown. Twenty-nine percent of them strongly disagreed and disagreed that the government's response was well coordinated
|Table 2: Respondents' perception of government response to coronavirus disease 2019|
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Knowledge, perception and practice of respondents to coronavirus disease 2019 and government's response
[Table 3] shows that about half (54.6%; 50.1%) of the respondents had good knowledge and perception respectively to COVID-19, while most (74.7%) had good practice of COVID-19 prevention protocols. However, about half (50.4%) had good perception of government response to COVID-19.
|Table 3: Knowledge, perception and practice of respondents to coronavirus disease 2019 and government's response|
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Association between sociodemographic characteristics of respondents and their perception of government response to coronavirus disease 2019
[Table 4] shows that there was no statistical significance association between respondents' sociodemographic characteristics and their perception toward government response to COVID19. Although most respondents who were single had the highest level of positive perception (75.0%) to the government's response.
|Table 4: The association between sociodemographic characteristics of respondents and their perception of government response to coronavirus disease 2019|
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Association between respondent's preventive practices, perception and knowledge and perception of governments' response to coronavirus disease 2019
[Table 5] shows that two-third (66.0%) of respondents that had good preventive measures practice score, also had a good perception toward government's response to COVID-19 pandemic. Their level of practice and perception of COVID-19 were found to be statistically significantly associated with respondent's perception of government response to COVID-19.
|Table 5: Association between respondent's preventive practices, perception and knowledge and perception of governments' response to coronavirus disease 2019|
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| Discussion|| |
This study identified some noticeable in primary HCWs knowledge, perception of COVID-19, and government's response. It found that approximately 55% of respondents had good knowledge of COVID-19, which was lower than the finding of a bi-national survey conducted in Africa (62%). The reason for the higher knowledge score might be due to the different study areas. In this study, good knowledge was reported about the virus transmission through infected droplets (63.8%) which is low compared to a study conducted in Nepal (77.1%). Almost all (98%) the respondents knew that COVID-19 could be transmitted from person to person, this finding is higher than that of a study conducted in Iraq (87%). This is very beneficial in curbing the spread of the virus. This study found that a sufficient number (>90%) of respondents knew the complications of the virus. This may be due to the fact that most of them had undergone the COVID-19 training. The finding is high compared to a study conducted among HCW globally (78%). Moreover, around 98% were aware of the incubation period, which is higher than the finding from a study conducted in India (70.8%), the difference in outcome might the due to the fact that the India study was conducted among medical students. A vast portion of the respondents were aware of the preventive measures of COVID-19, which corresponds with a study conducted in India.
However, this study found that about half of the respondents had a positive perception toward COVID-19 pandemic, which is lower than that of a study conducted in Saudi-Arabia (69.2%). The variation in outcome could be due to the fact that the study was conducted among nurses and most of them possess at least a diploma in nursing. This can also be compared to findings from other studies., In this study, more than half of the respondents agreed that antibiotics would prevent COVID-19. One possible reason for this outcome could be due to the This is similar to a study conducted in India. In this study, more than 90% and approximately 87% strongly disagreed and disagreed that spraying chlorine or alcohol on your body will kill the virus and prevent the infection, which is in contrast with a study conducted in India (35% and 33.6% respectively). The different findings might be due to the difference in study population, the India study was conducted amongst medical students.
In terms of COVID-19 preventive measures, about three-quarter of the respondents practiced these measures. This is similar to a study conducted in Uganda. It is also consistent with findings from other studies conducted in Ethiopia and Nepal., More so, almost all the respondents had good knowledge of COVID-19 preventive measures and most of them put these into practice. Hence, the higher the knowledge, the higher the COVID-19 preventive measure practices. This corresponds to the findings from a previous study conducted in Ethiopia.
In assessing respondents' perception to government response, this study found that half of the respondents had a positive perception; which is lower than that of a study conducted in Nepal (62.8%). The difference in the findings might be because the study was conducted amongst residents of Nepal. The current study is also in contrast with that of a study conducted in Ghana which reported that more than half of respondents felt that the government hasn't done enough. However, this outcome was reportedly linked to high rate of misconception. In this study, about 56% strongly agreed and agreed to the lockdown measures by the government in this study, which is lower than that of the study conducted in Egypt and Nigeria (81%). The possible reason for the difference might be due to the difference in study population, the study was conducted among the general public and it's a bi-national study. In this study, the perception of government response to Covid-19 was statistically significant with respondent's good preventive measures practices. Hence, the importance of modifying behaviors such as wearing masks, excellent hygiene, social distancing, or compulsory quarantine was heavily influenced by the government's response measures as well as transparency in epidemic information and widespread of media coverage. A study carried out in the UK reported that the majority of respondents positively changed their behavior in response to government guidance.
| Conclusion and Recommendation|| |
About half of the respondents had good knowledge of COVID 19 and had positive perception toward government's response to COVID 19 pandemic. Hence, we recommend intensification of efforts by the government in the control of Covid 19.
The authors would like to acknowledge the support of the Chairman and the Permanent Secretary, State PHC board, Ekiti State, and appreciate all research assistants for their commitments during the collection of research data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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;395:497-506.
Abdel Wahed WY, Hefzy EM, Ahmed MI, Hamed NS. Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. J Community Health 2020;45:1242-51.
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;382:727-33.
Ogolodom M, Mbaba A, Alazigha N, Erondu O, Egbe N, Golden I, et al
. Knowledge, attitudes and fears of healthcare workers towards the corona virus disease (COVID 19) pandemic in south south, Nigeria. Health Sci J 2020; Iss 1:002.
Al Ghafri T, Al Ajmi F, Anwar H, Al Balushi L, Al Balushi Z, Al Fahdi F, et al.
The experiences and perceptions of health-care workers during the COVID-19 pandemic in Muscat, Oman: A qualitative study. J Prim Care Community Health 2020;11:2150132720967514.
Nigeria Centre for Disease Control, 2020. About the NCDC. Available from: https://Ncdc.Gov.Ng/Ncdc
. [Last accessed on 2021 Aug 11].
Oleribe O, Ezechi O, Osita-Oleribe P, Olawepo O, Musa AZ, Omoluabi A, et al.
Public perception of COVID-19 management and response in Nigeria: A cross-sectional survey. BMJ Open 2020;10:e041936.
Adesegun OA, Binuyo T, Adeyemi O, Ehioghae O, Rabor DF, Amusan O, et al.
The COVID-19 crisis in Sub-Saharan Africa: Knowledge, attitudes, and practices of the Nigerian public. Am J Trop Med Hyg 2020;103:1997-2004.
Ejeh FE, Saidu AS, Owoicho S, Maurice NA, Jauro S, Madukaji L, et al.
Knowledge, attitude, and practice among healthcare workers towards COVID-19 outbreak in Nigeria. Heliyon 2020;6:e05557.
Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, et al.
Risk of COVID-19 among front-line health-care workers and the general community: A prospective cohort study. Lancet Public Health 2020;5:e475-83.
Bol D, Giani M, Blais A, Loewen PJ. The effect of COVID 19 lockdowns on political support: Some good news for democracy? Eur J Polit Res 2020;60:497-505.
Gollust SE, Nagler RH, Fowler EF. The emergence of COVID-19 in the US: A public health and political communication crisis. J Health Polit Policy Law 2020;45:967-81.
Lazarus JV, Ratzan S, Palayew A, Billari FC, Binagwaho A, Kimball S, et al.
COVID-SCORE: A global survey to assess public perceptions of government responses to COVID-19 (COVID-SCORE-10). PLoS One 2020;15:e0240011.
Ahmed AM, Ojo OY, Imhonopi GB, Oladeji FO, Oyesola OA, Alausa OK. Knowledge, perceptions and safety practices of COVID-19 infection among healthcare workers in a tertiary health institution, Southwest, Nigeria. Int J Community Med Public Health 2020;7:4697-705.
Jemal B, Aweke Z, Mola S, Hailu S, Abiy S, Dendir G, et al.
Knowledge, attitude and practice of healthcare workers towards COVID 19 and its prevention in Ethiopia: A multicenter study. SAGE Open Medicine 2021; 9: 1 10. [doi: 10.1177/20503121211034389.
Hager E, Odetokun IA, Bolarinwa O, Zainab A, Okechukwu O, Al-Mustapha AI. Knowledge, attitude, and perceptions towards the 2019 coronavirus pandemic: A bi-national survey in Africa. J Pone 2020;15:1-28.
Karn A, Karn M, Agrawal A, Giri P, Bohara G, Sharma R, et al.
Knowledge and perception on corona virus disease 2019 (COVID-19) among the general public in Nepal. Int J Soc Sci Manag 2020;7:183-90.
Al-Kaabi HJ, Mohammed HA, Kumait A. Assessing knowledge and perceptions of health care workers toward novel coronavirus (COVID-19). Med Legal Update 2020;20:2023-30.
Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: Cross-sectional study. JMIR Public Health Surveill 2020;6:e19160.
Gohel KH, Patel PB, Shah PM, Patel JR, Pandit N, Raut A. Knowledge and perceptions about COVID 19 among the medical and allied health science students in India: An online cross sectional survey. Clin Epidemiol Glob Health 2021;9:104-9. [doi: 10.1016/j.cegh. 2020.07.008].
Narayana G, Pradeepkumar B, Ramaiah JD, Jayasree T, Yadav DL, Kumar BK. Knowledge, perception, and practices towards COVID-19 pandemic among general public of India: A cross-sectional online survey. Curr Med Res Pract 2020;10:153-9.
Al-Dossary R, Alamri M, Albaqawi H, Al Hosis K, Aljeldah M, Aljohan M, et al.
Awareness, attitudes, prevention, and perceptions of COVID-19 outbreak among nurses in Saudi Arabia. Int J Environ Res Public Health 2020;17:8269.
Paul G, Sharma S, Singh G, Singh G, Sharma S, Birinder P. Assessment of knowledge gaps and perceptions about COVID-19 among health care workers and general public- national crosssectional study. Anaesthesiol Clin Pharmacol 2020;36:337-44.
Kumar H, Khurana MS, Charan GS, Sharma NK. Knowledge and perception of health professionals towards COVID-19. Int J Heal Sci Res 2020;10:123.
Olum R, Chekwech G, Wekha G, Nassozi DR, Bongomin F. Coronavirus disease-2019: Knowledge, attitude, and practices of health care workers at Makerere university teaching hospitals, Uganda. Front Public Health 2020;8:181.
Limbu DK, Piryani RM, Sunny AK. Healthcare workers' knowledge, attitude and practices during the COVID-19 pandemic response in a tertiary care hospital of Nepal. J Pone 2020;12:7-13.
Bondah EK, Agyemang DO. Factors predicting knowledge on COVID-19 misconceptions and perception of government efforts in Ghana: A cross-sectional study. Int J Sci Rep 2020;6:340.
Nguyen TT, Nguyen LH, Le HT, Vu GT, Hoang MT, Nguyen DN, et al.
Perceptions and attitudes toward COVID-19-related national response measures of Vietnamese: Implications for pandemic prevention and control. Front Public Health 2020;8:589053.
Atchison C, Bowman L, Eaton JW, Imai N, Redd R, Pristera P, et al
. Report 10: Public response to UK Government recommendations on COVID 19: Population survey; 2020. [doi: https://doi.org/10.25561/77581]. Available from: http://hdl.handle.net/10044/1/7758
. [Last accessed on 2021 Mar 26].
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]