COVID-19-related testing, knowledge and behaviors among severe and chronic non-communicable disease patients in Neno District, Malawi: A prospective cohort study

Objective To assess changes over time in COVID-19 knowledge, risks, symptoms, testing, and infection prevention practices among patients with complex non-communicable disease (NCD) receiving care at Neno District and Lisungwi Community Hospitals, Malawi. Design and participants We conducted a prospective open cohort study using telephone-based data collection among patients enrolled in NCD clinics. We conducted four rounds of data collection between November 2020 and October 2021. Setting Rural southwestern Malawi in Neno District which has a population of 150, 211 persons. Primary and secondary outcome measures We used descriptive statistics to characterize the population and assess COVID-19-related knowledge and behaviors. Linear and logistic regression models were used to assess significant changes over time. Results Across four rounds of data collection, the most commonly reported COVID-19-related risks among patients included visiting health facilities (range: 35-49%), attending mass gatherings (range: 33-36%), and travelling outside the district (range: 14-19%). Patients reporting having ever experienced COVID-like symptoms increased from 30% in December 2020 to 41% in October 2021, however, as of the end of study period, only 13% of patients had ever received a COVID-19 test. Overall, respondents answered about two thirds (range: 67-70%) of the COVID-19 knowledge questions correctly with no significant changes over time. Hand washing, wearing of face masks and maintaining safe distance were the most frequently reported strategies used to prevent spreading of COVID-19. Wearing of facemask significantly improved from 63% to 96% over time (p<0.001). Conclusions Households of advanced chronic disease patients reported accurate knowledge about COVID-19 and improved adherence to wearing of face masks over time. However, patients commonly visit locations where they could be exposed to COVID-19 and often experience COVID-like symptoms but are rarely tested for COVID-19. We urge the government and other stakeholders to increase COVID-19 testing accessibility to primary facility and community levels. Strengths and limitations of this study 1. Assessed COVID-19-related outcomes among a highly vulnerable group of patients in a rural African setting 2. Longitudinal follow-up allowed us to assess changes over time from December 2020 to September 2021 3. Data can inform COVID-19 infection preventive measures in a setting with persistently poor access to COVID-19 vaccines 4. The telephone survey was conducted among severe and chronic NCD patients in rural Malawi and is not generalizable to urban areas or rural populations without cellular service 5. Data was self-reported data and vulnerable to social desirability bias ### Competing Interest Statement Moses Banda Aron, Revelation Nyirongo, Isaac Mphande, Bright Mailosi, Fabien Munyaneza, Emilia Connolly, Luckson Dullie, Dale A. Barnhart and Todd Ruderman are employees of Partners In Health, which implements the PEN-Plus Clinics in Neno District. The authors have no additional conflicts to declare. ### Funding Statement This study was supported by The Leona B. and Harry B. Helmsley Charitable Trust who supported with the funds for the data collectors and the purchase of CommCare tablets (Grant number: 2105-04638). DAB is supported by the Harvard Medical School Global Health Equity Research Fellowship, funded by Jonathan M. Goldstein and Kaia Miller Goldstein (N/A grant number for the award.). Funders had no role in the design, analysis, or reporting of the research ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: We obtained an ethical approval from Neno District Health Research Committee (NDHRC/2020/015) and Malawi National Health Sciences for Research Committee (NHSRC/20/08/2594). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors