Coronavirus Disease 2019 (COVID-19) is a rapidly expanding pandemic caused by a novel human coronavirus: severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (1). It was first reported in December 2019 among patients with viral pneumonia symptoms in Wuhan, China (2). As of 12 October 2020, there have been 37,423,660 confirmed cases of COVID-19, including 1,074,817 deaths, reported to WHO (3). To date, the African continent appears to be one of the least affected regions in the world with 1,594,750 cases and 38,570 deaths (4), but the numbers are increasing (5). Mozambique reported its first imported COVID-19 case on March 22, 2020 and has seen an increase in cases since then (6). As of 12 October there have been a total of 10,001 confirmed cases and 71 related deaths in the country (3).

COVID-19 is transmitted from person-to-person through inhalation of aerosols from an infected individual (7). Older adults and patients with pre-existing illnesses (like hypertension, cardiac disease, lung disease, cancer, or diabetes) have been identified as potential risk factors for severe disease and mortality (8). To date, there is no antiviral curative treatment or vaccine that has been recommended for COVID-19 (9). More information about its distribution, transmission, pathophysiology, treatment, and prevention are being studied. Infection by SARS-CoV-2 in humans occurs mainly through close contact through respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces (10). Primary preventive measures include frequent hand washing for a minimum of 20 seconds at a time, maintaining social distance, and respiratory hygiene (covering mouth and nose while coughing or sneezing) (11).

Healthcare workers (HCWs) are at the frontline of the COVID-19 pandemic response (12), yet there is a paucity of literature on their knowledge, attitudes and practices (KAP) in relation to the COVID-19 pandemic. One HCW KAP study, focused on Asian HCWs and medical students, revealed that a significant proportion (61 percent) had poor knowledge of its transmission (13). A study in Uganda, among hospital based HCWs, found that only 69 percent had sufficient knowledge of the disease, although a higher percentage (74 percent) reported practicing good prevention measures (14). One HCW study in Pakistan showed higher knowledge (93 percent) and good practice (89 percent) regarding COVID-19 (15). Findings from another HCW KAP study in Nepal found 82 percent of respondents had good to moderate knowledge of COVID-19 and 84 percent had good prevention practices (16). In a study among HCWs in China, 89 percent of HCWs had sufficient knowledge of COVID-19 and 90 percent followed correct practices regarding COVID-19 prevention, yet more than 85 percent feared self-infection with the virus (17).

Other KAP studies, in Nigeria and Tanzania, have focused on the KAP of COVID-19 among community residents. Residents from a study in Northern Nigeria showed high level of awareness of COVID-19 and prevention methods (99 percent and 95 percent, respectively). However, a lower percentage (80 percent) said they follow government guidelines for prevention (18). In the Tanzanian study, 84 percent of the participants had a good knowledge of COVID-19 (19). Similar community based KAP studies have been conducted in China, the Philippines and Malaysia. A Chinese residents’ KAP survey towards COVID-19, conducted during the rapid rise period of the outbreak, showed that COVID-19 knowledge was 90 percent and that nearly all of the participants (98 percent) wore masks when going out (20). In a survey among poor households in the Philippines, 94 percent of respondents were aware of COVID-19 and 82 percent were aware of appropriate preventive measures to protect people from infection (21). The Malaysia survey indicated that 81 percent had good knowledge of COVID-19, however, there was noticeable confusion among participants regarding transmission of the virus. Only 43 percent of participants answered correctly when asked if the virus was airborne and just 36 percent answered correctly when asked if eating and touching wild animals could result in infection (22). To our knowledge, there have been no published studies from sub-Saharan Africa to assess KAP toward COVID-19 specifically among community health workers (CHWs).

In Mozambique, CHWs, known locally as agentes polivalentes elementares (APEs), are community members who are trained to provide basic healthcare services and conduct health promotion activities in the remote areas in which they live. This includes providing integrated community case management (iCCM) for malaria, pneumonia and diarrhoea for children aged 2-59 months and, as of 2014, family planning, pregnancy tracking, antenatal and post-partum care. While technical guidance surrounding COVID-19 surveillance, case definitions and testing strategies are available to support APEs, communicating this information to the wider APE network has been a significant challenge. These have been largely due to restrictions on travel and face-to-face group meetings and training, which were in place from the beginning of April through to the beginning of August, when routine face-to-face activities were resumed. Other challenges include incorporating COVID-19 surveillance into existing surveillance networks and diagnosing COVID-19 within the community, due to the similarity of symptoms with other routinely presented diseases such as malaria and pneumonia. Furthermore, due to the novelty of COVID-19, the information available globally is constantly evolving and expanding, and this in turn requires continuous reflection and analysis in terms of the impact on country strategies and plans. This, combined with limited data on community-level caseload due to a lack of accessible and affordable tests, poses significant challenges in the APEs’ abilities to conduct their routine activities and support the COVID-19 response. There is need for a dynamic, rapid response model to effectively support APEs on COVID-19 management.

The upSCALE project, supported by UK AID (via UNICEF), is a continuation of the Bill and Melinda Gates Foundation supported inSCALE project. It consists of a smartphone app that guides APEs through patient registration, assists with diagnosis and advises on treatment and referrals (primarily related to iCCM), and a tablet-based app that allows supervisors to monitor CHW performance and stock levels. Data entered by APEs through the upSCALE app is visualised in the District Health Information System (DHIS2) at district, provincial and national levels of Mozambique’s health system. The app has the potential to analyse local disease-specific trends in near real-time, which will allow managers to improve their resource allocation. The programme is currently being implemented in three provinces (Inhambane, Cabo Delgado and Zambézia) with 1,213 APEs and 299 supervisors using the app. The MoH is planning to roll out the platform to 8,800 APES nationally by 2021.

Given the lack of sufficient accurate and up-to-date information on COVID-19, especially in rural communities, there is a risk of high levels of disinformation, and possible questionable practices. At the same time, the most up-to-date advice about COVID-19 symptoms (which is constantly changing as we learn more about the virus) and how to protect community members from getting infected and infecting others might not reach all community members timely and/or effectively. The use of the upSCALE app presents a dynamic solution for COVID-19 messaging and tracking, capable of adapting and expanding messages as new info/ practices arise, also allowing to capture how communities are adapting to living in a pandemic such as COVID-19. In this study, we investigate the KAP of APEs who use a digital health platform UpSCALE, in three provinces in Mozambique. This is the first report on the knowledge, attitude, and practices of these community health workers from Mozambique. Findings from this study should contribute to the global and local efforts to better control the COVID-19 pandemic.