Awareness, perceived risk and protective behaviours of Myanmar adults on COVID-19

INTRODUCTION

Coronavirus disease 2019 is an infectious disease caused by novel corona virus and World Health Organization (WHO) formally named the disease as “COVID-19”.¹ It was firstly identified in late December 2019 in Wuhan, Republic of China, and then had spread globally.^2,3 On 13^th January 2020, the first global incidence of lab-confirmed "COVID-19" was found in Thailand and within this month, the other "COVID-19" cases from Wuhan were imported to Japan and Republic of Korea.⁴

On 11^th March 2020, the WHO declared the 2019-20 coronavirus outbreak as a pandemic as the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries became tripled.^3,5,6 After declaring the COVID-19 is pandemic, on 13^th March, there were 118 infected countries, 125,048 total confirmed cases, 4,613 deaths and CFR 3.6% in globally. Italy, Republic of Korea, Iran, France and Germany still have highest morbidity and mortality rates. According to the data as reported by 18^th March 2020, infected countries increased to 159 and in these countries 179,112 total confirmed cases, 7,426 deaths and CFR became 4.1% in globally.⁷ Up to 21^st March, Italy faced the highest burden of confirmed cases and mortality outside China followed by the United States of America, Spain, Germany and Iran.⁸

Outbreak potential of COVID-19 in Myanmar is high due to being a neighboring country of China and establishing cross-border trade and migrant workers not only with China but also with other outbreak countries like Thailand, India, Malaysia and Singapore, etc. On 24^th March, Ministry of Health and Sports (MOHS) announced that there were two confirmed cases in Myanmar and became the last country infected by COVID-19 among ASEAN countries except Laos.⁹ The community's knowledge on the aetiological agent, epidemiological parameters like incubation period, mode of transmission, signs and symptoms and preventive measures are essential in prevention of COVID-19. People should be aware on the natural history of COVID-19 and the risk behaviours. Host's protective behaviours such as wearing masks, hand hygiene and social distancing are major options to prevent the infection while no treatment or vaccination is available. Moreover, risk perception on COVID-19 is a main determinant of practicing protective behaviours. Assessing the awareness, perceived risk and personal protective behaviours of each and every individual is crucial to be more effective of current COVID-19 prevention and control activities in this country. Yangon and Bago regions were selected since these areas were densely populated areas and with people in all walks of life are living in these areas. Hence this study was conducted to assess the awareness, perceived risk and personal protective behaviours of Myanmar adults for prevention and control of COVID-19.

METHODS

The cross-sectional study was carried out at Yangon and Bago regions during 3^rd March to 20^th March among 597 adults age above 18 years of both sexes using pretested questionnaire by face to face interview method. From Yangon region, Dagon Ayar and Aung Minglar highway bus stations and two factories and from Bago region four urban wards were purposively selected. A total of 446 adults from Yangon region and 151 adults from Bago region were selected consecutively. Awareness and protective behaviour questions were developed based on the IEC materials disseminated by MOHS and WHO. Perceived risk questions were developed based on the Health Belief Model using four points Likert scale. Pretest was also done to assess the clarity, comprehensibility and the internal consistency of questionnaire was assessed using Cronbach's alpha. Pretested questionnaire was converted into digital data collection form based on open data kit (ODK) platform and data was collected using KoBo Collect data collection tool by mobile devices (Tablets) to assure data quality and validity.

Collected data was checked for missing values, completeness and errors. Data cleaning was done such as removing the incomplete data and missing values. Descriptive statistics was used to describe the background characteristics of study population. Frequency tables were used to describe the awareness, perceived risk and protective behaviours. Participants' knowledge level was assessed using scoring system of 1 point for correct answer based on the questions related to knowledge on causal agent, human to human transmission, identifying neither vaccine nor definitive treatment, preventive measures and high-risk persons, and then the maximum possible score was 16 (see in Annexure). Individual's perceived risk on each item was described by stacked bar charts. Total perceived risk score was calculated by summing the Likert score. There were 18 perceived risk items; hence, the minimum and maximum possible score were 18 and 72. The total knowledge score variable and perceived risk score variable were categorized into high (≥80%), moderate (50-79%) and low (<50%) according to modified Bloom's cut-off value. Associations between practicing protective behaviours and independent variables such as background characteristics, knowledge and perceived risks were assessed by binary logistic regression analysis after testing assumptions and collinearity. All statistical analyses were conducted by STATA version (15.1) and p value was set at <0.05 as a statistical significance.

Ethical approval

Ethical approval was obtained from the Institutional Review Board, University of Public Health, Yangon, (UPH-IRB) (2020/IR research/1). Each and every subject was explained about the study, the research purpose and their written consents were obtained. The study did not collect the name of the respondents on the questionnaire form to ensure confidentiality. Voluntary participation and privacy were ensured during data collection.

Funding

The MOHS supported research grant through ‘implementation research, clinical research and public health research funds’ for data collection in this study. The funding agency had no role in data collection, analysis, or interpretation of the data, the writing of the report, or the decision to submit for publication. The manuscript represents the name of the viewed authors only, not the view of UPH, and MOHS.

RESULTS

Knowledge regarding to COVID-19

The average (SD) age of 597 respondents was 37.1 (14.3) years and their age ranged from 18 years to 84 years. Most common age group was 21-40 years (54.4%). More than half (56.5%) were females and 63.5% were married. About 43% of participants were from Yangon region, 32% from Bago region, 14% from Ayeyarwaddy region and the rest (12%) from Kayin, Sagaing, Shan, Rakhine and Tanintharyi. Nearly two-third (63%) of respondents were high school and above education level. Among 597 respondents, 77.1% earned money by working outside home (Table 1).

Among 597 respondents, almost all (97.8%) have heard about COVID-19. Therefore, the following responses regarding knowledge on COVID-19 derived from 584 respondents who have heard about COVID-19. Out of those 584 respondents, 29.3% could mention the COVID-19 is a viral infection and 91.3% answered it can be spread from person to person. Regarding the knowledge on its mode of transmission (MOT), droplet infection was identified as one of MOT by the highest proportion, 66.6%, followed by direct contact by 29.6%. Regarding its symptoms, fever and cough were the most frequently reported answers by 57.4% and 59.4% respectively. More than 70% had knowledge that there was neither vaccine nor definitive treatment for COVID-19. Among 584 respondents, frequent hand washing with soap and water or alcohol-based hand sanitizer was considered one of preventive measures by 54.8%, the highest proportion, followed by avoiding crowded places by 45.2%. About one third of respondents (35.9%) described 65 years and above aged persons were high risk of contracting COVID-19, in the meanwhile, only 4.8% mentioned smokers.

Two-third of respondents replied they obtained health information about COVID-19 from social media, 12.7% from MOHS source and only 4.6% from healthcare personnel. Then, 42.3% of respondents selected mass media as the most trusted source of information. While asking them the action they should do if they found people with COVID-19 suspected symptoms, 75.5% respondents replied they would inform to the health authority. While calculating total knowledge score for COVID-19, the mean score (SD) of study participants was 5.3 (2.5) and the total score ranged from 0 to 16. Most of participants (87%) had low knowledge i.e. less than score 8 and only 1.2% of participants had high knowledge i.e. greater than score 12 (Table 2).

^†Excluded 13 cases who never heard of COVID-19, *Multiple responses.

Risk perception towards COVID-19

Figure 1, describes perceived susceptibility to COVID-19 among the respondents. About 90% of respondents perceived that susceptibility of disease was higher among people working abroad or working together with foreigners, going to crowded area while almost all respondents (96%) perceived that susceptibility can be reduced by adopting healthy lifestyles. However, some respondents wrongly perceived that susceptibility of disease was low chance among young people (39%) and no chance among healthy people (32%) while about 20% of respondents thought that family members were less likely to get disease from sick person (Figure 1).

Almost all respondents (97%) perceived that disease will be more severe for elderly and people with comorbidities. About 86% perceived that COVID-19 will cause severe signs and symptoms and about 78% thought that infected person could not survive. Three out of four respondents (73%) believed that infection could be occurred without signs and symptoms. More than half of them (61%) disagreed on the statement ‘COVID-19 can be treated’ and 89% also perceived that spontaneous recovery was impossible (Figure 2).

More than 80% of the respondents were confident that they can get access to the reliable health information regarding to COVID-19, they will eat healthy diet and wash their hands frequently to prevent COVID-19 transmission. However about 25% of respondents had no or low confident that they can prevent infection, they will avoid crowded area and use mask if they go to crowded area to prevent COVID-19 (Figure 3).

Total perceived risk score was calculated from items regarding to perceived susceptibility (6 items), severity (6 items) and efficacy (6 items). Negative items were score reversely and calculated the sum of all items to get perceived risk score. One point for strongly disagree, two for disagree, 3 for agree and 4 for strongly agree. These scores were categorized according to Bloom's cut off value into low, moderate and high-risk score. The results found that there were no respondents in low risk perception category, 77.2% were in moderate risk perception category and 22.8% in high risk perception category.

Regarding perception to information in social media, most of the respondents (87%) agreed sharing the COVID-19 news from MOHS to others to avoid rumours and they perceived that the news from this source can be accessed easily and timely (80%). However, some of the respondents replied that they considered the COVID-19 news from Facebook and social media are reliable news (41%) and they used to share information from these media without verifying the source (36%) (Figure 4).

^†Excluded not relevant respondents, *Multiple responses, ꭝGood was defined if participants wash hands frequently, cover the mouth and nose during coughing and sneezing, discard used masks and tissue in the dustbin.

The study assessed the respondents' perception towards quarantine regarding to prevention of COVID-19. About 40% of respondents had negative perception regarding to the effectiveness of home quarantine for suspected cases.

More than half of respondents (62%) perceived that quarantine cannot control the spread of COVID-19. In contrast, most of the respondents thought that hospital quarantine should be done for close contact (74%) and people who came back from abroad (79%) (Figure 5).

Community's perception towards COVID-19 prevention was assessed and it was found that almost all respondents (99%) agreed the important role of community in prevention of COVID-19 so that they agreed to inform suspected cased to health authority and to follow the instructions of MOHS to prevent disease. More than 90% agreed that community has responsibility to prevent spreading rumors from social media. However, about 20% of respondents thought that community does not need to participate in prevention of COVID-19 (Figure 6).

Reported protective behaviours

Among 584 participants who heard about COVID-19, their reported protective behaviours were as follow: 45% wash hands frequently, 34% avoided travel or trip, 58% avoided crowded area to prevent COVID-19, about 47% always completely cover the mouth and nose during coughing and sneezing and 83% discarded used mask or tissues into dustbin. The most common reasons for not washing hands were: no need to wash, not a usual habit, wash only before and after eating and after latrine, forget to wash hands and afraid suffering from heat stroke. Regarding to health advice to fever/cough patient, 87% reported they will give advice to go clinic, 7% want to give advice to avoid crowded places while 6% want to give advice to avoid close contact with others. Only 3% said they don't know what advice should be given to fever patients.

Participants' reported practices were categorized into good- if participants wash hands frequently, cover the mouth and nose during coughing and sneezing, discard used masks and tissue in the dustbin and; poor- if participants did not practice previously defined activities. It was found that about 22% of participants were identified as good since they practiced above 3 protective behaviours to prevent COVID-19 (Table 3).

Multivariable binary logistic regression analysis was done to identify the factors influencing the protective behaviour for COVID-19 and the results were presented by adjusted odds ratio (aOR) with 95% confidence intervals in Table 4. It was found that knowledge score (aOR=1.19, 95%CI-1.08, 1.30) was significantly and positively influence the protective behaviours but perceived risk score (aOR=1.03, 95%CI- 0.99, 1.07) was not significant. The protective behaviour of participants from Ayeyarwaddy (aOR=0.41, 95%CI- 0.19, 0.91) and from other states and regions (aOR=0.49, 95%CI-0.24, 0.99) were significantly less than that of participants from Yangon. The protective behaviours of COVID-19 were not influenced by other variables age group, sex, education and occupation (Table 4).

aOR=Adjusted odds ratio, ***p<0.001, **p<0.01, *p<0.05.

DISCUSSION

Almost all respondents ever heard about COVID-19 and among them one third mentioned correctly virus/novel coronavirus as a causal agent. Majority of respondents had low knowledge regarding to aetiology and prevention of COVID-19. Less than one fourth of respondents had high level of risk perception towards COVID-19. Two out of five respondents considered news from social media as a reliable information and shared this news without verifying the source. Most of the respondents believed that they can easily access to the COVID-19 news from MOHS. More than half of the respondents thought that quarantine cannot control the spread of infection while less than half of respondents did not agree home quarantine is necessary for suspected cases. Almost all respondents had positive perception regarding to community participation in prevention of disease. Regarding to protective behaviours, only one out of five respondents had good reported protective behaviours.. Knowledge score and region of residence were significantly influenced the respondents' protective behaviour for COVID-19.

To prevent COVID-19, individual must have adequate knowledge regarding to aetiology, mode of transmission and preventive measures. This study found that Myanmar adults had low knowledge regarding to causal agents. Only two third realized that it can be transmitted by droplets and one third knew it can be transmitted by close contact. These findings were also consistent with the study conducted by Bhagavathula et al, in which they assessed the awareness and perception of COVID-19 among health care workers and reported that knowledge of transmission (60%) and disease onset (64%) was poor among the health care workers.¹⁰ Being a new emerging disease with not fully understood the natural history might be the possible reason for low knowledge among Myanmar adults. Another possible reason was that even though MOHS timely disseminated information and instructions for COVID-19, they were interested only in the occurrence and mortality but not give much attention to disease aetiology and preventive measures or thought that not necessary to be aware.

Regarding to perceived risk towards COVID-19, all of the respondents had moderate to high level of perceived risk score. However, some of the respondents wrongly perceived that young and healthy people had little chance to get disease and most of them thought that disease was very severe and fatal. Perceived severity of Myanmar adults were lower than the study conducted among community in Hong Kong¹¹ in which almost all participants perceived that disease was very severe. However, the proportion of response to curability of disease among Myanmar adults were two times more than those in Hong Kong study. Regarding to survivorship if infected, two populations had similar responses i.e. 22% in Myanmar adults vs. 18% in Hong Kong population. Perceived efficacy towards preventive measures such as hand hygiene, cough etiquette and social distancing i.e. avoiding travelling to abroad and crowded area were not too much lower in Myanmar than those of Hong Kong study i.e. about 80% vs. 90%.

Our study found that social media and mass media were main sources of information for Myanmar adults and these findings were more or less similar with Hong Kong study in which their common sources were social platform and websites but different with health care workers study in which their primary sources were not only social media but also official government websites.^10,11 Although both Myanmar adults and people from Hong Kong use social media and websites as the main sources, only about 40% of Myanmar adults and 26% of Hong Kong people perceived these sources as the reliable sources. Some of the Myanmar adults used to share the news from social media such as Facebook without verifying the source and this habitual action might spread the rumours and false alarms which in turn might cause the unnecessary stress and worries in the community.

Myanmar adults' reported hand washing behaviour and cough etiquette were very much lower than Hong Kong study (44.9% vs. 95.8% and 47.3% vs. 97.1%, respectively). Moreover, social distancing activities such as avoiding to crowded places and travel or trip were also lower in Myanmar compared to Hong Kong study (57.9% vs. 88.1%). The differences in practicing protective behaviours between two studies might be due to the differences in knowledge level and risk perception towards COVID-19. In addition, the outbreak has already been occurred in Hong Kong which increased awareness and practicing more protective behaviours among Hong Kong community. Although many studies mentioned that knowledge and risk perception enhance preventive behaviors, our study found that only knowledge influenced to practice protective behaviours but not risk perception.^12,13

Moreover, it was found that respondents from Yangon region reported more protective behaviour than other states and regions. Most of the respondents from Yangon were urban population and have better access to internet and other information sources than respondents from other regions. They are more concern about quarantine since Yangon has an international airport and most of the supermarkets and hotels were currently implementing thermal scanning at the main entrance to prevent COVID-19. These activities and easily accessibility of mass media and social media were the possible explanations for doing more protective behaviour among respondents from Yangon region. Moreover, apart from Bago region, the respondents from other states and regions including Ayeyarwaddy might be from rural area and small towns where information accessibility and activities that related to COVID-19 prevention were very much lower than Yangon region.

This study was first study that assessed the awareness, perception and protective behaviours for COVID-19 among Myanmar adults. However, the study has limitations. First, the sample was purposively selected from Yangon and Bago regions using consecutive sampling method; hence, the results cannot be generalized for the whole adult population. Second, we asked their reported behaviour instead of observing their actual practice. As a consequence, the reported practice might be overestimated. Last, we categorized the region of residence generally by regions and that unintentionally included urban respondents in Yangon and Bago regions while we cannot make sure that the respondents from Ayeyarwaddy and other states and regions were only from urban. Rural respondents were less likely to be aware and practicing less protective behaviour. This urban-rural effect might be confounding to the study's results regarding to regional difference.

CONCLUSION

This study highlights the knowledge, perception and protective behaviour of Myanmar adults currently practicing regarding to COVID-19. The findings point out that community has no enough knowledge and inadequate protective behaviours which can favour infection spread if the disease might have occurred. Since the study provides enhancing effect of knowledge towards protective behaviours, the awareness raising activities and mass media health education should urgently be conducted focusing on effectiveness of hand washing, cough etiquette, social distancing and responsibility to inform suspected cases to local health authority to prevent COVID-19. Further research using nationally represented sample is warranted.

ACKNOWLEDGEMENTS

Our deepest appreciation goes to the MOHS, Myanmar for initiation and support in conducting of this research project. We are very grateful to department of medical research for financial support through “implementation research, clinical research and public health research funds”. We would like to acknowledge administrative support of regional health authorities for their kind permission and support for data collection in the community. Last but not least, we would like to express our thanks to master students and faculty members of UPH, Yangon for their active participation in data collection and respondents of this study for their enthusiastic involvement in answering the survey questions.

Funding: Implementation research, clinical research and public health research funds, Ministry of Health and Sports

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Review Board, University of Public Health, Yangon

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ANNEXURE