Is COVID-19 a hoax? Correlation between beliefs related to COVID-19 and the use of preventive measures in India

INTRODUCTION

The Spanish influenza pandemic 1918-1919 which caused 50 million deaths worldwide remains an ominous warning to public health. An estimated 1/3rd of the world’s population were infected and had clinically apparent illness during 1918-1919 influenza pandemic.¹ In the last 20 years several viral epidemics such as severe acute respiratory syndrome (SARS-COV) from 2002-2003, H1N1 influenza in 2009, MERS-COV (Middle eastern respiratory syndrome) in 2012 have plagued the world.²

More recently, an alarming rate of cases of novel Corona virus (COVID-19) have been reported across the world since December 2019. Ever since the first case of COVID-19 was confirmed in Hubei province of China, Countries were forced to take unprecedented measures to prevent the rapid spread of this virus. Most countries closed their borders, announced lockdowns, and asked people to follow protective measures against the new corona virus, such as physical distancing and hand washing. Governments and non-governmental organisations across the globe promoted and legally prescribed behaviour to prevent and control the transmission rate.

On one hand, majority of the world population was following the preventive measures to limit person to person transmission of the virus. On the other hand, the corona virus crisis became an ideal breeding ground for speculations and conspiracy thinking.³ Research over the decades has shown that conspiracy theories increase substantially during a crisis such as a pandemic.⁴ A review reported on the alarming results of a survey conducted in United States showed that 49% believed corona virus is a man made epidemic, 44% thought that the threat of COVID-19 is being exaggerated for political reasons and 13% were convinced that corona virus is a hoax.⁵

People who accept the conspiracy theories as true are most likely to not follow the public health orders to control the infection rates.⁵ Following the personal protective and preventive measures are vital to the control and prevention of transmission. The populations’ beliefs and attitude related to COVID-19 have a direct impact on their practice of preventive measures. Therefore, this study was conducted to explore the beliefs, attitude and preventive practices related to COVID-19 among the general population of Chennai, Tamil Nadu.

METHODS

Ethical approval

Ethical approval for this study was obtained from the Institutional Scientific review board. Participation in the survey was taken as implied consent and the anonymity of the participants was maintained.

Questionnaire

The questionnaire was adapted from a previously published study.(6) The questionnaire was pretested on a sample of 30 subjects to test the validity and reliability of the questionnaire. The responses of these participants were excluded from the main study. The final and validated version was developed. It consisted of 12 questions concerning the beliefs, attitude and practice of preventive measures related to COVID-19.

Study population and data collection

As it was not feasible to do an entire community based sampling survey during this period, an online survey was conducted. Google form was utilized to collect the data using a link that was circulated via various social platforms such as Watsapp, Facebook and Instagram. The Google Form contained the declarations of anonymity and confidentiality and instructions for filling in the questionnaire. The questionnaire was collected from December, 2020 to February, 2021. Participants had to be 18 years or older to be included in the survey.

Statistical analysis

Responses were coded and entered into an SPSS database. Data were entered in Microsoft Excel spreadsheet and analyzed using statistical package for social sciences (SPSS) software (version 21, IBM Corporation, Texas, USA). Descriptive statistics were conducted. Bivariate analysis (Chi-square test) was used to assess the association between independent variables with each of the main outcomes of interest.

RESULTS

Table 1 shows the distribution of study subjects. A total of 256 study subjects participated in this survey, of which 209 (81.6%) and 47 (18.4%) belonged to the age group of ≤40 and ≥41 years respectively.

About 49.2% and 50.8% were males and females respectively. Majority of the study subjects (144(56.3%) hailed from a rural region when compared to 112 study subjects (43.8%) belonged to an urban area. Only 3 (1.2%) of our study subjects said they had not attended school, 111 (43.3%) study subjects were graduates and 66 (25.8%) subjects were professionals.

Table 2 shows the aggregate responses to the questions about the beliefs, attitudes and practices related to COVID-19. About 69.9% of the participants thought that corona virus actually exists, most of the respondents (63.3%) also felt the complete lockdown was effective in controlling the spread of the virus. However, 57.8% study subjects attributed the pandemic to man-made biological warfare. Majority of the subjects (>85%) followed the protocols advised by the government, but only 51.6% believed that the virus can be contained by the preventive measures taken by the government.

Social distancing and Frequent hand washing was chosen by majority of the study subjects (55.5% and 78.5% respectively) as the most effective preventive and protective measure to stop viral transmission. Most of the participants 34.8% used hand sanitizer 3-5times /day. About 48.4% of the participants thought that the 3 PLY mask is the most effective type of mask. Nearly 61.7% of participants thought there could be cross contamination from a disposed mask, 81.7% always wore a mask in public and 27.0% of the participants always kept >6 feet distance apart from others. (Table 2)

Table 3 shows the attitudes, beliefs and behaviors related to COVID-19 based on Place of Origin and Gender. Less number of subjects (64.6%) belonging to rural regions believed that corona virus actually exists when compared to 76.8% urban study subjects, however this difference was not statistically significant. For the same question, more females (76.2%) stated they thought corona virus actually exist when compared to 63.5% males believed the same (p<0.03). About 36.9% females also believed the virus can be contained by the preventive measures taken by the government; this was statistically different when compared to males (23.8%) (p<0.02).

Majority (>80%) of the study subjects belonging to rural and urban regions followed the protocols advised by the government. Most rural and female subjects in our study (81.9% and 84.6% respectively) used frequent hand washing as a protective measure at home when compared to 74.1% urban and72.2% male study subjects, this difference was statistically significant (p<0.001 and p<0.04 respectively).

More number of urban and female study subjects (53.6% and 59.2% respectively) when compared to the rural and subjects (44.4% & 37.3% respectively) thought that 3 Ply mask is most effective (p<0.007 and p<0.001 respectively). A significantly higher number of female study subjects thought that there can be cross contamination from the disposed mask when compared to males (p<0.01).

Table 4 shows the attitudes, beliefs and behaviors related to COVID-19 based on Age groups. More than 55% of the study subjects below the age of 40 years thought the most effective preventive measure to stop the viral transmission was social distancing while 53.2% of them who were above 41 years of age thought mask was most effective (p<0.05). A significantly higher number of <40 years study subjects thought that there can be cross contamination from the disposed mask when compared to >41 years (p<0.001).

Table 5 shows attitudes, beliefs and behaviors related to COVID-19 based on Level of Education. More than 75% of the graduates and professionals believed that corona virus actually exists, while more than 25% of those who completed only school said they did not believe the virus exists (p<0.001). Interestingly, 81% professionals and 51.6% graduates believed this was a man made virus, however they also believed social distancing was most effective preventive measure (p<0.001 & p<0.002 respectively). Majority of the professionals used hand sanitizers 3-5 times a day, believed 3 ply mask was most effective and that disposed masks could cause cross contamination and always wore a mask in public (p<0.009, p<0.001, p<0.006 and p<0.007 respectively).

Table 6 shows the attitudes, beliefs and behaviors related to COVID-19 based on employment status. Majority of essentially employed subjects believed corona virus actually existed, used hand sanitizer >5 times / day and thought the 3 ply mask is the most effective type of mask (p<0.05).

DISCUSSION

We would like to emphasise that the present study is one of the few studies assessing the beliefs, attitude and practice of the general public in India. This is noteworthy for multiple reasons, our study findings could significantly add to the literature of the perception of the public towards not only COVID-19 but also potentially infectious diseases of the same scale and magnitude of transmission, the level of adherence to preventive and control measures amongst the public and their support to the governmental measures taken to control the spread in the community.

We found that most of the study participants (>65%) believed in the existence of corona virus and 63% supported the complete lockdown and felt it was effective in controlling the viral spread. Other studies asked people if they believed if COVID-19 was a contagious disease, more than 85% of the respondents believed it was contagious.^7-9 In a survey done in USA, higher number of respondents (>80%) said they supported stay-at-home order and nonessential business closures. Another survey done in India, it was reported that 96% subjects supporting the lockdown in India.^6,10 Widespread support for community mitigation strategies and commitment to COVID-19 public health recommendations indicate that protecting health and controlling disease are public priorities amid this pandemic, despite daily-life disruption and adverse economic impacts.⁶

The lower percentage supporting the lockdown in our study may be attributed to the various socio demographic characteristics of our study population. Most of our respondents belonged to rural regions and fell under the non essential employment category, which might have exposed them to a financial uncertainty or instability. These factors could have perhaps driven less percentage of our study population to not support the complete lockdown.

Interestingly, nearly 58% of our study respondents stated that they believed corona virus to be a man made virus. However, more than 85% stated that they followed the protocols advised by the government. Another study reported that about 26.8% of their study respondents believed the virus is a bio-weapon.⁷ Similar to our findings, Czeisler et al reported that >75% of their study subjects would not feel safe if the community strategies were not in place.⁶ Likewise, Ferdous et al found that 88% of their surveyed population followed the rules put in place by the government.¹¹

Frequent hand washing and social distancing were considered as effective protective and preventive measure respectively by most respondents. Hand washing and social distancing were also selected by majority respondents in several other Indian and International studies.^7,8,10-14 Nearly 87% of the respondents always wore a mask in public, similar findings were reported in several studies.^6,7,12 Usage of face mask in public was higher in a few studies, while results lower than our findings have also been reported.^8,9,13,15

Despite the number of females who believed in the existence of the virus being higher (p=0.03), they were not certain about whether the virus can be contained by the preventive measures prescribed by the government (p=0.02). Nevertheless, a higher proportion of females followed the protocols set by the government, this was similar to the findings of Ferdous et al.¹¹ More females when compared to males also considered frequent hand washing to be the most protective measure (p=0.04). These findings are consistent with other studies showing that, in response to infectious diseases, men were significantly less likely take preventive and protective measures than women.^11,13,16-18 Contrasting results were reported by a few studies.^10,12

While a lower number of rural study subjects believed in the existence of the corona virus when compared to the urban study subjects, we did not find any significant association. A higher number of study subjects in the rural regions thought hand washing was the most effective protective measure (p=0.001). It is important to draw attention to our finding that there was no difference in the practice of preventive strategies between the rural and urban study subjects. However, Czeisler et al found higher percentages of respondents from urban areas reported use of cloth face coverings than did rural area respondents.⁶ In an Egyptian survey, it was reported that rural people had a lower practice score as compared to urban people.⁷

In our study, 90.3% of the respondents in rural area claimed that they were always wearing a face mask in public, this is more when compared to the study done by Gupta et al where only 77% of the rural population claimed that they were using face mask in public.¹² This could be because most of our study subjects were either graduates or professionals, this is higher compared to Gupta et al wherein most subjects had only primary education or less.¹²

Our findings showed that the positive belief about corona virus was significantly associated with the high practice of preventive and protective measures. Others have previously reported similar associations when performing KAP surveys toward COVID-19.^19–21 Efficacy beliefs have a significant and robust impact on practicing preventive behaviours towards COVID-19 among the public. Consistent with evidence that efficacy belief serves as significant predictors of preventive behaviours.^22–24

In our study, there was a significant association between the level of education and the reason for this pandemic, where >75% professionals and graduates believed in the existence of the virus. However, 81% of the professionals and 51% graduates believed this was a man-made virus. Most preventive and protective measures were practiced by most professionals (p=0.001). Previous studies found similar results.¹⁰ The positive association found between the practice and educational background supports the claim of higher awareness and education leads to increased adherence to the preventive strategies. It could also be attributed to the reason that people with higher education get more sensitized by information provided by the government and media.

Periodic assessments of public beliefs, attitudes, and preventive measures would prove useful to inform the policymakers and healthcare professionals, for future planning if subsequent outbreak waves occur and if additional periods of expanded mitigation efforts are necessary to prevent the spread of COVID-19 and save lives. As the pandemic progresses and mitigation strategies evolve, understanding public attitudes, behaviours, and beliefs is critical. Adherence to recommendations to wear a face mask and physical distancing guidelines are of public health importance. Strong public support for these behaviours suggests an opportunity to normalize safe practices and promote continued use of these and other recommended personal protective behaviors to minimize further spread of COVID-19.

Limitations

This study has several limitations. Like other online surveys, this study was limited to the people who had smartphones, e-mail IDs and the ability to read and we used convenience sampling through the networks of the researchers and disseminated the forms through social media platforms. Thus, the majority of the respondents were from the southern part of India. Therefore, further research should be done on a larger sample representative of all regions of the country. The findings of this study should not be generalized to the whole population. This represents a major limitation of this study.

Second, beliefs and adherence to recommendations were self-reported; therefore, responses might be subject to recall and response biases. The restricted number of questions to encourage participation and increase response was another limitation. A further limitation of the present study is the possibility of the participants giving socially desirable responses.

CONCLUSION

In summary, the present study was able to provide a comprehensive representation of the beliefs, attitudes and practices of Indians towards COVID-19. Our findings suggest that the surveyed population has an acceptable level of positive beliefs, attitude, and good practices towards COVID-19. India is currently experiencing its second wave of rise in the corona virus cases; vaccines for COVID-19 have been developed and are being administered in a phased manner across the country. However, serologists and other experts say that despite the vaccine, all protective measures should be followed. In the present scenario, the current study findings along with other similar literature may provide essential data to the policy makers for the reopening policies, the restriction levels of the mitigation strategies and bringing life back to normalcy.

Additionally, we recommend that more emphasis on effective messaging should be placed on people belonging to lower education and income strata. Vulnerable populations who require proper health education and guidance for prevention and control of COVID-19 should be targeted. Pandemics of this magnitude and resulting high death rates call for consistent messaging from the government and/ or health authorities as they are key to aid public knowledge and understanding of COVID-19. This then helps the prevention and control of transmission and subsequent outbreak waves unless the community develops herd immunity.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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