A qualitative study of knowledge, beliefs and misinformation regarding COVID-19 in selected districts in Zimbabwe

Abstract

Background

Lack of appropriate knowledge, incorrect beliefs and misinformation misleads people about the risks they face and how best to protect themselves. A study was conducted to explore the knowledge, beliefs and misinformation regarding COVID-19 in Zimbabwe.

Methods

A qualitative study was conducted in September-October 2022 with a purposive sample of religious leaders, women leaders, youth leaders, health workers, village health workers, teachers, traditional healers, transporters, and the general population selected from ten sites across the country. In total there were 128 participants (30 key informants and 98 focus group discussion participants). At each site, 3 key informant interviews and one homogenous focus group discussion were conducted using semi-structured interviews and focus group discussion guides, respectively. The data were recorded on audiotapes, transcribed verbatim, and translated into English. Manual thematic analysis of the data was performed.

Findings

Three themes were identified in this study: (1) beliefs about COVID-19, (2) knowledge about COVID-19 (knowledge of origin, definition, transmission, signs and symptoms and recommended preventive measures), and (3) misinformation about COVID-19 (regarding its nature, existence and recommended preventive measures). There was awareness of the origin, transmission, signs and symptoms of COVID-19 among the participants. Participants reported that Zimbabwean communities were conversant with public health measures such as maintaining social distancing, wearing masks, and maintaining hand hygiene. However, misinformation was also observed to have circulated among the communities.

Conclusion

Participants demonstrated good knowledge of COVID-19. However, the misinformation circulating in the country calls for the government to establish structures to monitor the legitimacy of information coming through different sources and invest in providing information through trusted sources. In any disease outbreak, the government should engage its citizenry to understand their knowledge, beliefs and any misinformation that might influence adherence to disease preventive measures.

Introduction

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China, by the World Health Organization (WHO) China Office on December 31, 2019 [1]. The highly infectious disease went on to spread to other countries and was declared a pandemic on 11 March 2020, WHO [2]. Zimbabwe confirmed its first case of COVID-19 on 20 March 2020 [3]. Thereafter, Government of Zimbabwe vigilantly started implementing country-specific measures in line with the WHO guidelines on dealing with COVID-19 outbreak. The preventive measures implemented include hand hygiene, social distancing, quarantine, isolation, use of personal protective equipment, practicing cough etiquette, increased frequency of environmental cleaning, waste management in line with infection prevention and control guidelines [4], and later on vaccination after the approval of COVID-19 vaccines [5].

COVID-19, like other respiratory infections are known to pose a threat if the recommended preventive measures are not adhered to [6, 7]. Adherence to these measures may depend on factors such as knowledge and beliefs of the affected population and misinformation circulating in the community [8,9,10,11,12,13]. For instance, during the outbreak of severe acute respiratory syndrome in United States of America (USA) and China, the population’s practices were influenced by assumptions and emotions [14,15,16]. Positive correlations between knowledge, appropriate beliefs and practice of prevention and control methods were noted during the outbreak of Ebola in Nigeria [9], middle east respiratory syndrome in Korea [10], COVID-19 in Korea [8], and China [11]. In Ghana, those who had COVID-19 knowledge adhered to preventive measures. People were predisposed to infection by incorrect beliefs such as COVID-19 does not exist, temperatures in Africa are too hot for COVID-19 to survive and that the disease is a punishment from God [12]. In Uganda they believed mortality would be highest among white people from Europe and the USA [17].

Conspiracy beliefs and misinformation regarding COVID-19 spread globally at a rapid space through media [18,19,20,21], counteracting knowledge and reducing people’s intentions to protect themselves from the disease [22,23,24]. An abundance of misinformation makes people less likely to believe and trust scientific evidence and experts [25,26,27]. In United Kingdom, Ireland, USA, Spain and Mexico, willingness to be vaccinated and adherence to other preventive measures were affected by an increase in misinformation [27]. Misinformation and beliefs were associated with poorer COVID-19 knowledge and fewer preventive behaviours in South Korea [19]. In England, higher levels of COVID-19 conspiracy were related to less adherence to government COVID-19 guidelines [24].

In Zimbabwe, low levels of COVID-19 knowledge but high positive attitudes were reported in Harare city in March 2020 [28]. In July 2020 it was noted that COVID-19 knowledge and positive attitudes were high but practices were poor in the same city [29]. In other Zimbabwean settings, poor adaptability and responsiveness to COVID-19 was attributed to lack of knowledge [30] while a positive correlation between knowledge and intention to vaccinate was observed [31, 32]. Zimbabweans were noted to have a high acceptance of COVID-19 misinformation [33]. Some of the misinformation included fake COVID-19 cure and preventive recipes, news that Zimbabweans were immune to the virus, and COVID-19 virus can’t survive in the Zimbabwean climate [33, 34]. These were compounded by misinformation on social media that Africans or black people were immune to the virus [34, 35]. This misinformation resulted in low vaccination rates and poor adherence to other preventive measures [33]. Fake news claiming that those who received the vaccines would die within 3 years or develop auto-immune diseases if they survive also contributed to vaccine hesitancy in Zimbabwe [36, 37]. Therefore, continued monitoring of COVID-19 knowledge, beliefs and misinformation remains crucial for addressing ongoing challenges associated with COVID-19, and help to shape public health communication strategies that strengthens population resilience to the disease. Thus, we conducted this study to explore the knowledge, beliefs and misinformation regarding COVID-19 in Zimbabwe.

Conceptual framework

We developed the conceptual framework of this study (Fig. 1) based on the health belief model (HBM). Health related knowledge, assist in establishing appropriate attitudes/perceptions towards preventive measures, thus, significantly affecting the practice of health behaviours [8,9,10,11,12]. Knowledge about the disease is shaped by the individual’s belief about the causes, symptoms, treatments, and prevention of the disease [38]. According to the HBM, individual health behaviours are determined by attitudes and beliefs of individuals resulting in readiness to act based on personal perceived susceptibility (which can be based on residential setting, nature of employment e.g. health workers, traditional healers, religious leaders, transporters and teachers perceiving to be highly susceptible), perceived seriousness of the health problem and perceived benefits of taking action and barriers to taking action. In addition, beliefs and a cue to action such as perception of bodily state, interpersonal interactions, media, and knowledge that someone else has been affected by the health condition or information from health workers may also instigate to set the process of adherence in motion [39, 40]. A positive correlation was noted between participation in influenza vaccination and the HBM constructs as the vaccination rates increased based on HBM applied to influenza [41, 42]. A COVID-19 study showed that education and higher COVID-19 health belief positively affected the practice of preventive behaviours [8].

Misinformation about COVID-19 include inaccurate information about its origins, transmission, prevention and control methods [20]. Belief in misinformation can result in less adherence to public health guidelines and engaging in transmission risk behaviour [19, 27, 33, 34, 37].

The HBM is relevant in the context of understanding COVID-19 knowledge, beliefs, and misinformation as it provide understanding of individuals’ perceptions of their susceptibility to the disease, disease severity, benefits of preventive behaviours, barriers to compliance and cues to action. Application of the HBM allows elucidation of how these aspects impact individuals’ responses to COVID-19 information, behaviours, and public health decision-making processes in Zimbabwe.

Fig. 1

Conceptual framework for the knowledge, beliefs and misinformation regarding COVID-19 study

Methodology

This is a sub-study of a WHO African Regional Office coordinated study that sought to understand the social-behavioural determinants of population compliance with public health and social measures (PHSM) and COVID-19 vaccine uptake in selected African countries. Data for the sub-study conducted in Zimbabwe is dually owned by the WHO African Regional Office and the collaborating institution that is the National Institute of Health Research, Ministry of Health and Child Care, Zimbabwe. This collaborative arrangement was made to ensure data access and utilization between both parties whilst leveraging on the resources and expertise of both parties.

Study design and population

We followed the design of WHO African Regional Office coordinated study. A qualitative descriptive design based on the ethnography of social groups using an emic and etic approach was followed. The emic approach in research involves understanding participant perspective and cultural context while the etic approach involves use of standard criteria to understand behaviours and perspectives across different cultures [43, 44].

Due to logistical considerations and feasibility limitations, in Zimbabwe, eight out of ten provinces were included in the study. The selected provinces were Harare, Mashonaland Central, Mashonaland West, Mashonaland East, Matabeleland North, Matabeleland South, Masvingo and Midlands. Despite that the study was exploring a comprehensive array of COVID-19 factors beyond vaccination, within each province, districts were selected based on vaccine uptake as submitted to the District Health Information Software 2 (DHIS) database. The districts with the lowest vaccine uptake per province were selected for the study. While this approach may have introduced bias towards districts with lower vaccination rates, it strategically allowed a holistic understanding of multifaceted factors affecting community compliance to COVID-19 public health responses beyond vaccination alone. In Harare metropolitan province, districts were selected both in the capital city of Harare and its dormitory town Chitungwiza because these areas contain diverse communities from different cultural backgrounds and tribes. Within the districts, study sites were purposively selected based on the potential to get enough number of the study participants. Key informants (KIs) and focus group discussion (FGD) members aged ≥ 18 years, including religious leaders, women leaders, youth leaders, health workers, village health workers, teachers, traditional healers, transporters, and the general population residing in the study districts were selected for participation in the study (Fig. 2; Table 1). The participants were not selected based on vaccination status. These study groups were adapted from the WHO African Regional Office coordinated study and their selection was based on relevant COVID-19 behavioural and epidemiological patterns. For instance, religious leaders were selected for the study as they are influential in the community and may influence adherence to health guidelines. Women leaders may also influence household health practices and have an understanding of gender specific perspectives of COVID- as they may be involved in information dissemination and engagement of women. Youth leaders were responsible peer to peer COVID-19 communication, thus, they were considered to assess the role of youth behaviour in COVID-19 transmission dynamics in the community. Village health workers and health workers play a significant role in risk communication and community engagement to improve adherence to COVID-19 guidelines. Teachers are responsible for implementation of COVID-19 guidelines in schools and educate learners to prevent school related outbreaks and consequently education disruptions. Traditional healers have an impact on health care seeking behaviour and treatment outcomes. Thus, they were selected for their role in community education, perception on conventional health care and traditional healing practices for COVID-19. Transporters contribute to community spread of COVID-19 through their transport networks.

Fig. 2

Location of the study sites and classification of participants in the COVID-19 qualitative study in Zimbabwe. Adapted from Midzi et al. [45]

Table 1 Various social groups selected for participating in the study and their locations

The geographic locations of the study sites are shown in Fig. 2. The study sites have been described previously [45, 47, 48]. The study site in Mashonaland West province, Makonde district, was a growth point. The area was previously a farming compound and is surrounded by resettlement areas. Most of the households had a functional tippy tap popularly known as chigubhu gear among the locals. In Matabeleland North province, the study site was Binga district growth point, which, despite having a community of mixed culture, is mainly dominated by the Tonga people. Binga district is a resort business area attracting many tourists and fish traders due to the Zambezi River, which runs through it. Hand washing facilities or sanitizers were positioned at the entrances of most of the business buildings. In Matabeleland South province data collection was conducted at the Insiza district growth point and in one of the rural communities. At the rural clinic where the focus group discussion took place there was no sufficient water supply, no convenient hand washing facility at the point of entry. The Blair toilets were also dirty. In Mashonaland East province, data collection was conducted in Seke, a peri-urban district situated close to Harare.

In the Harare metropolitan province, three districts, Mbare, Epworth and Zengeza were chosen for the study. Zengeza is a high density area found in Chitungwiza, a dormitory town for the Harare metropolitan city. The district has water shortages which result in many people converging at boreholes for water collection. Mbare district is an over populated high-density suburb close to Harare central business district. Residents in the district have mixed backgrounds and the main activities in the area include vending and trading. Mbare district also houses the central bus park station for transport connecting to different areas locally and crossing the borders of Zimbabwe. Epworth is a peri-urban densely populated district with a mixture of cultures and ethnic backgrounds. Most of the housing structures in this district have limited water supply and compromised ablution facilities. Hand washing facilities were scarce in the district. Gokwe South growth point was chosen as the study site in Midlands province. The population including the school children, was not observing physical distancing, not wearing face masks and there were no visible hand washing facilities at the entry points. The study site in Mashonaland Central province was Rushinga district growth point. The district which is made up of people from different cultural backgrounds also borders with Mozambique. Most of the shops were observed to have hand washing. In Masvingo province, Chiredzi district, the study was conducted in town. The town is densely populated, and has a mixed cultural background. The town also experiences intermittent water supply. It supports a lot of trading between Harare, Chiredzi, Masvingo and South Africa.

In these study sites we have previously reported sociocultural and religious practices hindering adherence to COVID-19 preventive measures such as stigmatization of wearing of face masks at public gatherings such as churches, funerals or centralized water collection points, no face masking for the traditional healers during consultations [47], prohibition of vaccinations by some religious Sect. [48], hand laying during spiritual practices, and handshaking or hugging during consolations at funerals [45].

Community entry and engagement

After obtaining ethical approval, approval to collect data was sought from the Permanent Secretary (PS) of Health and Child Care. Following this, permissions for community entry were sought from provincial medical directors (PMDs). The PMDs gave approval and informed the District Medical Officers (DMOs) about the study and requested them to nominate environmental health personnel (EHP) to assist the research team in study implementation. The selected EHP were trained for community engagement and selection of participants. After training, the EHP sensitized community leaders about the study. They also requested the community leaders to assist in selection of prospective participants as KIs or FGD participants based on their knowledge of their community members. The EHPs approached the prospective participants with the assistance of the community leaders for sensitisation, mobilization and recruitment. The process of community engagement, sensitization, mobilization and recruitment was conducted within a week.

Sampling and sample size

Sampling strategy and Sample size has been described previously [45, 47, 48]. Briefly, at each site, participants who shared the same characteristics and with potential to provide relevant, rich and diverse data pertinent to the research question were purposively selected. Participants were considered for the study based on the feasibility of accessing them and recruiting them, their willingness to provide written consent and participate in the study. We chose individuals in the community to be KIs if (i) they had first-hand knowledge about their community, insights from their fellow residence and issues related to COVID-19 based on their experience due to current or previous participation in COVID-19 activities in the area, professional expertise, or special social role, (ii) they were known to be sensitive to differences among the community members and non-judgmental. Those who could express themselves in a group setting to provide different perspectives and experiences related to COVID-19 were selected for the FGDs. The sample size for the study was based on set standards of qualitative studies for homogeneity and data saturation, that is, 10 FGDs and 30 Key informant interviews (KIIs) as the minimum threshold to reach saturation. In general, each FGD should have 4–12 participants [49]. At each site, a homogeneous sample of 3 KIs and 10 FGD individuals were recruited to respond to the semi-structured interviews and to be part of the FGDs, respectively, as outlined in Table 1.Thus, the expected sample size for the 10 sites was 130 participants (30 KIs and 100 FGD participants).

Study guides and data collection

The study guides developed by the WHO were conceptualized in the Zimbabwean setting by local researchers. Local researchers included PhD experts in grounding theory studies, ethnography and community health, and individuals with master’s degrees in public health and research assistants with at least a degree in social sciences. A systematic approach informed by both existing literature and conceptual framework was employed to develop the topic guides. Initially a thorough review of relevant literature on COVID-19 was conducted to identify key themes, research questions, and potential areas of interest for exploring community perspectives of COVID-19. Further to that, the HBM [39, 40] was integrated to understand the complex interplay of cognitive process and individual perceptions regarding COVID-19. The focus group discussion guide and key informant interview guide were collated in the form of open-ended and semi-structured interview guide questions. In our study, knowledge was conceptualized as the understanding of COVID-19 basic science and aetiology, mode of transmission, signs and symptoms, and preventive measures based on previous studies [50, 51]. The guides included knowledge related questions adopted from previous studies such as: What do you think COVID-19 is? According to your own experiences, what do those around you think COVID-19 is? What recommended preventive measures against COVID-19 do you know? In your opinion, what is the importance of these PHSM in fighting COVID-19?

We conceptualized misinformation as false or inaccurate information disseminated leading to misunderstanding, confusion, or harm based on previous definitions [52, 53]. We acknowledged that there is a challenge of determining the validity of information among the people, especially when there are conflicting statements from the experts. The topic guide’s question aimed at seeking misinformation was: According to your own experiences, what do those around you think COVID-19 is? The question aimed to capture insights on how COVID-19 was discussed and understood in the participant’s social circles including those that aligned or diverged with public health official guidance.

Data was collected during the month of September and October 2022. Both the FGDs and the KII were conducted physically, and there were no repeat interviews. For each session, audio recorders were used to record participants’ narratives. The FGDs were approximately 45 min long, while the KIIs lasted for approximately 30 min. The KIIs and FGDs were conducted in English, and two local languages, Shona and Ndebele, were used depending on the preferences of the participants. Each session was led by a skilled moderator while the assistant moderator observed and took notes. An observation checklist was used for recording key features of the study site including location (i.e. homestead, church, market place, or any other public place), presence of hand washing infrastructure/sanitizers, whether people were washing their hands, correct wearing of face mask and whether people were practicing physical distancing.

Data processing and analysis

All the audio recordings were transcribed verbatim and translated into English by some members of the local research team who were fluent in the languages spoken by the participants. Transcripts were cross-checked to ensure accuracy of the original content and any discrepancies were addressed by consensus among the members of the research team proficient in the languages used by the participants. Transcription of the FGD and in-depth interviews resulted in a mammoth of transcripts which could not be analyzed by simply perusing through the text, hence we formulated code charts. The authors opted for soft copy code charts as it allowed them to have a glimpse of all FGD information at one glance and allowed for easy relation to contributions from one FGD to another regarding similar concepts. The coding process was made easy as the authors had read and re-read the transcripts to capture the meaning and trend of ideas during the verbatim manual transcription. The codes were initially clustered and sorted out, categorized according to meaning and trend of ideas. Code networking generates sub themes and themes from the raw data. Codes that had similar ideas or meaning were grouped together during the dissection process. The authors used different color coding charts for the purpose of matching codes with similar idea or meaning. All the dissected codes were grouped and networked in accordance with meaning pattern into sub themes. Sub themes were networked and generated themes that attempted to address the research objective of interest. No software was used in the analysis. Supplementary File 1 shows the standard for reporting qualitative research checklist completed according to O’Brien et al. [54].

Credibility and trustworthiness

To enhance study credibility of the study, the researchers sampled diverse population groups with different demographic characteristics (geographical area, age, economic status, religion, social status, and cultural norms). Purposive sampling was employed in the selection of participants to remove selection bias inherent in already existing population groups. The researchers employed the circling reality principle by obtaining data on the same study variables from different study groups. To enhance dependability, the researchers also triangulated through data sources such as KII and FGDs, with a similar guide questions. To enhance honesty and opening up among participants, the researchers established a good rapport, trustworthiness and assured them of confidentiality. Throughout the study, the researchers continuously engaged in ongoing reflection and discussions to ensure a balanced and nuanced analysis. Participants were quoted directly and a complete description of the entire process is given to increase transferability.

Results

Study participant demographics

Of the 130 participants expected in the study, 128 (98.4%) participated (Table 2). Two participants who had been recruited for the FGDs were absent on the study sites on the days of the discussions: one for traditional healers in Chiredzi and one for women leaders from the Epworth district. Among the participants, 70 (54.7%) were males. The average age of the participants was 46 years (SD = 11). Regarding education, 79 (61.8%) had attained a secondary level of education. Among the KII participants, 20 (66.7%) were males, 17 (56.7%) had attained a secondary level of education, and the remaining 13 (43.3%) had acquired a tertiary education. Approximately 50 (51.0%) of the FGD participants were males, 62 (63.3%) had attained a secondary level, and 26 (26.5%) had a tertiary level of education (Table 2).

Table 2 Distribution of participants by age, sex and level of education

The three themes identified were (1) beliefs about COVID-19, (2) knowledge about COVID-19 (knowledge of origin, definition, signs and symptoms and recommended preventive measures) and (3) misinformation and counter beliefs about COVID-19 (regarding nature, existence and recommended preventive measures).

Beliefs about the existence of COVID-19

There were various beliefs regarding the existence of COVID-19 among the Zimbabwean population. Although participants concurred that the disease existed, during the early stages of the pandemic, the communities did not understand the nature of COVID-19 and its existence. After receiving health education, many started to acknowledge the disease.

“Initially, the local population groups within this area did not understand the nature of COVID-19 and its existence, but as time progressed, after so many sensitization campaigns by village health workers, they are acknowledging its presence gradually” (FGD participant 8, Makonde District, village health worker).

Participants mentioned that some people in the community who initially did not acknowledge the existence of COVID-19 started believing in it after they had witnessed the death or illness of family, neighbours or friends due to the disease. Some COVID-19 deaths involved community members who did not follow COVID-19 protocols during the burial of people who had succumbed to the disease.

“There was a time when people thought it was not real; it was just a myth, but as time progressed and we had more relatives who were dying and some who were sick, people started believing that COVID-19 is real and exists. Unfortunately, there was a young boy who died in Botswana due to COVID-19, and the body was brought to their community—. Relatives, and the community opened the coffin for body viewing. Most of the people who were there fell sick. Some even died, especially elderly individuals. Some community members came to school and said, ‘Ma’am, COVID-19 is real; may we have masks because we have one of our relatives who died? Unfortunately, most people had to learn through experiencing the passing on of a relative to then acknowledge that COVID-19 is real” (KI 2, Gokwe South District, district schools inspector).

Participants initially believed that the disease was going to affect China only, but within a short space of time; the disease had rapidly spread to other countries, and its existence was confirmed by positive tests among those who were infected.

“COVID-19 is real because since its advent in China, we thought the pandemic was going to be confined to China only, but it has spread like veld fire and to those who are affected; positive test results have confirmed its existence” (KI 2, Makonde Districtnde District, village health worker).

Participants stated that despite most people believing in the existence of COVID-19, others did not believe regardless of what was witnessed during the COVID-19 pandemic. They attributed COVID-19 deaths to other causes.

“Among all these COVID-19 incidences, some people still deny the reality of COVID-19; they feel that the high death rate was due to other causes not linked to COVID-19” (FGD participant 5, Makonde District, village health worker).

Knowledge regarding COVID-19

Participants were clear about the origins and transmissibility of COVID-19. They knew that it was a recent transmissible viral disease that started in China, in 2019 which has evolved to become a global pandemic. They knew that its name was derived from the year it started in combination with the virus that caused it. Participants described the disease as follows:

“COVID-19 is a viral disease that originated from China in 2019; hence, it was named COVID-19. COVID-19 is highly transmissible” (FGD participant 8, Rushinga District, youth leader).

“According to our understanding, it was a disease that originated in China as an outbreak (epidemic) and then evolved into a pandemic as it established itself globally. This is a disease that has caused devastation worldwide” (FGD participant 1, Zengeza District, religious leader).

Participants reported that the local people also knew the disease as a severe form of flu, which is more virulent than the other flu types and differs from the different types of influenza that have been experienced so far. The likening of the disease to the flu was influenced by symptoms that were more or less like those of the flu.

“The local people say COVID-19 is flu, but the type of flu which is severe than the usually known flu as affirmed by the nature of symptoms that resemble flu” (KI 2, Makonde District, village health worker).

Although this was not frequently mentioned, participants reported that some community members are aware that the COVID-19 virus has mutated.

“Along the way, it has mutated itself more and more; hence, there have been discoveries of different strains” (FGD participant 2, Binga District, health worker).

The participants acknowledged that COVID-19 is a pandemic that is highly transmissible, airborne and can be spread through contact. The movement of people from one point to another was identified as the cause of the spread of disease from China to other countries. Gatherings or meetings leading to overcrowding were considered contributing factors to disease transmission.

“— spread by people travelling by flights to other countries possibly as a result of movement by people out of China to other parts of the world that is how it was spread” (FGD participant 2, Gokwe South District, school teacher).

“--- It is spread through the air. It is also spread through contact when we gather in meetings and when people greet each other” (KI 3, Rushinga District, youth leader).

Some of the modes of transmission highlighted by the participants included breathing close to each other, coughing, and sneezing. They even knew that the disease could be spread from one person to another through talking. The saliva and mucus transferred to hands during sneezing and coughing could also serve as a transmission route resulting from shaking hands. This was expressed among others in the following ways:

“COVID-19 is a virus; it attacks humans, and it spreads through the air through coughing and sneezing” (KI 2, Gokwe South District, district schools inspector).

“This virus can be spread through contact. When we communicate, saliva can be spread from one person to another. Saliva and mucus can also be transferred through shaking hands, thus, spreading” (KI 2, Rushinga District, youth leader).

Participants showed good appreciation of COVID-19 symptoms. They described that it is characterized by coughing, difficulty breathing, runny nose, general body weakness, shivering, fever, body pains, headache, sneezing and pneumonia. The cough due to COVID-19 infection was described as dry or severe, and the disease was considered fatal if not managed.

“The population groups say COVID-19 ---- causes body pains, headache, difficult breathing, a runny nose, and body weakness and can be fatal if no treatment is provided in time. COVID-19 can cause end-organ damage like kidney failure, and the public is encouraged to seek medical attention when they experience such symptoms” (FGD participant 9, Seke District, community member).

“COVID-19 is a viral infection that affects people causing severe cough, leading to death if no treatment is rendered” (FGD participant 4, Seke District, community member).

Participants showed that the Zimbabwean population was knowledgeable about the preventive measures for COVID-19, such as physical and/or social distancing, proper wearing of face masks, vaccination and hand hygiene. Additionally, there was a need to avoid gatherings or overcrowding to limit transmission of the COVID-19 virus.

The first one is that of social distance and that there should be a space of one meter from one another; second, proper wearing of a mask; third, washing of hands after touching anything; and last, the fourth one, not going to crowded places and protecting oneself from crowded places” (KI 3, Makonde District, village health worker).

“Social distancing, masking, avoiding large crowds and treatment in addition to the obvious; vaccination” (KI 2, Gokwe South District, district schools inspector).

After attending a funeral for a COVID-19-related death or when attending to someone with COVID-19 illness, participants reported that community members were aware of the importance of self-quarantining. Health workers taught the community to avoid households with COVID-19 patients to prevent the spread of the disease. Participants further mentioned the need for self-quarantine, self-isolation and social distancing to control the spread of COVID-19.

“Self-quarantine and self-isolation are very critical when one feels unwell or after being exposed to the virus through caring for someone or by attending a funeral for someone who died from COVID-19” (FGD participant 2, Seke District, community member).

Participants were aware of the significance of adhering to cough etiquette to avoid COVID-19 transmission. Other preventive measures mentioned by the participants included avoiding contact through hugging and kissing. Those with multiple sexual partners were considered at-risk for COVID-19 since they could have body contact with different persons in a short space of time. Men were encouraged to avoid sharing cigarettes and cups when drinking beer. Participants also agreed that people should avoid touching surfaces that are frequently touched by others.

“--------- avoid hugging even with your neighbours. Avoid touching areas that are frequently touched by everyone because if you touch surfaces that have been exposed to some with COVID, you can also contract the disease” (KI 3, Rushinga District, youth leader).

Misinformation and counter beliefs regarding the nature and existence of COVID-19

Despite having a considerable number of participants possessing knowledge of the nature and existence of COVID-19, there were counter myths and misinformation regarding the same illness. Participants reported that some people believed that the aetiological agent of COVID-19 is a bacterium, while others believed that it is caused by a collection of viruses.

“COVID-19 is a condition or disease that results from multiple or a collection of viruses” (FGD participant 1, Makonde District, village health worker).

Among the many misconceptions about COVID-19 was its originality. As highlighted by the participants, some people believed that COVID-19 did not exist, believing that COVID-19 was just a new name for influenza.

“Some local people say there is nothing called COVID-19. Some elderly people say that COVID-19 is a new name for a condition that has been present for several years and was called influenza” (FGD participant 10, Seke District, community member).

There was also a belief that this was a result of a laboratory error in China. Participants reported that some of the misinformation circulating was that the Chinese people were trying to create something in the laboratory but had failed to control it, which resulted in the product being transmitted through the air to cause COVID-19.

“What we have heard others saying is that COVID-19 is a result of some experiments that were being conducted in China, that got out of hand and the disease started being transmitted through the air. It appears there was something they were trying to create but they then failed to control it in China. That is what I heard others say” (FGD participant 1, Gokwe South District, school teacher).

Participants also highlighted that people also believed that COVID-19 affects only the affluent since they were able to travel outside the country where the disease was believed to be.

“Here, in Africa, people who died of COVID-19 were wealthy people, such as ministers, because they can afford to travel to places where there is a disease. Us the ordinary people cannot afford to do that” KI 1, Zengeza District, religious leader)

Participants reported that some people perceived COVID-19 as God’s way of punishing people since the world has turned evil, while others saw it as bad omen from the oceans. Some participants viewed the advent of COVID-19 in the sociocultural context, citing that it was a bad omen from ancestral spirits and the oceans because the ancestors were not happy with what was happening to the earth. Participants also mentioned that some people believed that the ancestors inspired by spirit mediums predicted that there was going to be a global pandemic that would affect the entire population and that many deaths would occur across the universe due to the pandemic, and people would be urged to take heed of what would be taught and encouraged as preventive measures.

“From what I heard from my neighbours, church mates and other common people, some religions attribute it to God’s wrath as the world has turned evil; as such, he is using this disease to correct this human problem. On the other hand, those who ascribe to traditional culture, they would say the soil (ancestors) is refusing what is happening on earth as such it has brought bad omen to correct this-----” (FGD participant 4, Gokwe South District, school teacher).

Participants cited that because people learn about COVID-19 through social media, they have mixed information about the disease. The existence of COVID-19 was attributed to the 5th generation mobile network (5G network), and the community believed that the effects of this network were the ones causing COVID-19.

“Some local people attributed COVID-19 to the 5G network, which is a very high-speed and efficient form of network. Therefore, according to the people’s narratives, the effects of the 5G network are those causing illness assigned the name COVID-19—” (FGD participant 5, Seke District, community member).

Participants stated that while some people perceived the disease as a biological weapon or biological warfare being lodged by the Chinese against Americans, some believed that it was a biological warfare against Italians as they wanted to change the bible.

“Debate was where we stay, some say especially Italy the disease was targeting them as they wanted to edit or change the bible, and on the other hand some were saying it was targeting the Chinese as a war with the Americans” (FGD participant 6, Mbare District, transporter).

Participants also cited that other people felt that although they acknowledged COVID-19 as a disease that is preventable, the problem of infodemics was confusing their knowledge. It was noted that some people believed that the World Health Organization (WHO) was not providing full information regarding the exact origins of the disease. Participants cited that people believed that COVID-19 was for financial gain where producers would make money through the production and selling of personal protective equipment (PPE) and vaccines.

“----. The challenges that came upon with social media and our in-house meeting committees involved spreading rumours surrounding COVID-19 such as that the WHO is hiding the truth from the public regarding the nature of COVID-19. According to them, the people who manufactured the virus did so for the money-making business. After creating the virus, they went on to say that we came up with a vaccine to manage the illnesses caused by the virus” (FGD participant 5, Seke District, community member).

Participants reported that some old people believed it was God’s way of uniting families through the lockdowns. Families no longer spent time together because of different activities, such as work and school.

“There was also a view I heard, ----- there was an old lady who said God has everything to do with our families. He saw that family establishments were now perishing, people no longer had time together as families, kids were going forth to school, and fathers were off to work and bars, so this was done to unite families, families had quality times and love was rekindled in the homes” (FGD participant 7, Gokwe South District, school teacher).

Among the measures for preventing COVID-19, participants reported that the community also believed that the use of natural herbs was important for preventing infection with the disease. Some of the natural herbs mentioned by the community included guava leaves, ginger, garlic, and lemon bush (Lippia javanica), which are locally known as muzumbani/umsuzwane, lemons and lemon leaves. Drinking warm water and steaming were also thought to be ways of preventing COVID-19. Despite the unfounded beliefs about the use of natural herbs, the population was aware of the need for physical exercise to stay strong.

“Steaming with lemon leaves, guava leaves and muzumbani. This is also inclusive of drinking warm water in the morning, afternoon and evening” (FGD participant 6, Zengeza District, religious leader).

“Steaming, physical exercise, ginger, garlic in the morning before eating anything” (FGD participant 7, Zengeza District, religious leader).

Discussion

The study has shown that there was awareness of the origin, transmission, signs and symptoms of COVID-19 among the Zimbabwean communities. It was also noted that the populace was conversant with public health measures such as maintaining social distancing, wearing masks, and maintaining hand hygiene. However, misinformation, such as that the virus was manmade, a money-making venture, a disease of the wealthy people, and God’s way of uniting families was observed to have circulated through social media. The information documented in this study informs public health responses and community engagement activities aimed at building a well-informed population which can resiliently respond to and manage public health emergencies.

The study has showed that the Zimbabwean community appreciates that COVID-19 exists and that control measures are necessary to curb its spread. All the subpopulations interviewed in this study expressed a general understanding of COVID-19 and its PHSMs despite some misinformation circulating in society. This finding contrasts with a study conducted in the Harare metropolitan province in March 2020 reporting poor knowledge of COVID-19 among participants [28]. Understanding the disease, its origins, its signs and symptoms, preventive measures and their usefulness is a window of hope that can be exploited in the improvement of compliance with COVID-19 PHSMs. In Uganda, people who had knowledge about face mask use were more likely to wear face masks [55], while in Ghana those with COVID-19 knowledge adhered to preventive measures [12].

Participants in our study reported that initially the people in their communities did not believe or understand the nature of COVID-19. They cited that people gradually believed and understood the disease either after receiving health education or when they had witnessed sickness or death due to COVID-19. Zimbabwe experienced its first case of COVID-19 in March 2020. More than 2 years after the first case was detected, different waves had been experienced in the country, regionally and internationally; however, our study showed that there were still some people who believed that COVID-19 does not exist even though they reside in communities where COVID-19 cases have been detected or where death due to the disease has been witnessed. Acknowledging the disease and demonstrating an understanding of it are the basis of positive perceptions of its preventive measures. Communication regarding the disease should be conveyed in a way that allows sufficient understanding and rationale of the proposed preventive strategies. A negative belief requires intense education to overcome such a resistive attitude in the presence of an infectious disease.

Study findings show that there were misinformation and wrong beliefs circulating among the Zimbabweans regarding the origins of COVID-19; for example, the virus is a punishment from God, and it is man-made. Some of these misconceptions were also noted in Ghana, Nigeria and Pakistan [12, 17, 21]. Some of the misconceptions recorded in our study included the belief that COVID-19 was a disease of the affluent. This kind of belief would make a socioeconomically disadvantaged community likely not to adhere to preventive measures considering themselves to be at no risk. Misinformation about COVID-19 and its preventive measures among the population is not unexpected considering the surge in infodemics globally through different types of media, especially social media. Nevertheless, it can influence people’s perceptions and attitudes toward COVID-19 preventive guidelines [56], consequently increasing the risk of infection [57].

In this study, it was noted that the Zimbabwean community also had a vast array of plants/traditional herbs and ways that they believed could prevent or treat COVID-19. Some of the ways they perceived to be preventive or curative, such as steaming and drinking warm water, were also circulating on social media during the pandemic. Plants such as Lippia javanica, ginger and garlic have been traditionally considered useful for home treatment of flu and common colds. The similarity in symptoms between individuals with common colds, flu and COVID-19 could have driven people to believe that these traditional herbs can prevent/treat COVID-19. Some people testified to have received protection or treatment from these herbs. Nevertheless, in the absence of supporting scientific evidence, the use of these materials in treating COVID-19 remains a myth. Thus, additional research is needed to understand the contributions of these traditional herbs to COVID-19 prevention and treatment.

The study was conducted in diverse parts of the country and among diverse social groups, thus providing credible evidence to public health managers about existing gaps that need attention regarding COVID-19 and its prevention in Zimbabwe or in the case of similar outbreaks. The commonalities noted in responses among the diverse group of participants may have been due to shared information sources such as, social media, official public health messaging from the government through community trusted sources such as print and broad cast media, community trusted sources as health workers, village health workers and community leaders.

Study strength and limitations

We triangulated the data by using KIIs and FGDs and different data sources (diversity in social status, geographic location, age, religion, cultural values and economic status) to increase the trustworthiness and validity of the study, thus providing a comprehensive understanding of knowledge, beliefs and misinformation regarding COVID-19 in Zimbabwe. However, our study was limited because it was conducted at a single point in time, thus, did not make it possible to describe and understand any changes in knowledge, beliefs, or misinformation about COVID-19 and its preventive measures, which may change with time.

Conclusion

The study revealed that there is knowledge on preventive measures of COVID 19 in Zimbabwe. However, there were also false beliefs and misinformation regarding the origins and preventive measures of the disease which may likely influence non-compliance to preventive measures. Despite that COVID-19 is no longer a public health emergency at global level, addressing misinformation and false beliefs is crucial to reduce their impact on public health behaviours and community resilience to future public health crises. Thus, there is need for targeted communication strategies to counteract the false beliefs and misinformation while increasing knowledge about the disease to the communities. Continued monitoring of information that reaches the population is important so that public health communication is tailor made to respond to evolving community narratives and needs.