Community adoption of protective behaviours: before and during the COVID-19 pandemic

Non-pharmaceutical interventions are effective in controlling the COVID-19 pandemic [[1]Mendez-Brito A. Bcheraoui C.B. Pozo-Martin F. Systematic review of empirical studies comparing the effectiveness of non-pharmaceutical interventions against COVID-19.J Infect. 2021; 83 (https//doi.org/10.1016/j.jinf.2021.06.018): 281-293Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar]. The adoption rates of the use of mask and hand hygiene increased to 90% to 100% during the pandemic in some countries [[2]Chan E.Y.Y. Kim J.H. Kwok K.-O. Huang Z. Hung K.K.C. Wong E.L.Y. et al.Population adherence to infection control behaviors during Hong Kong’s first and third COVID-19 waves: a serial cross-sectional study.Int J Environ Res Public Health. 2021; 18 (https//doi.org/10.3390/ijerph182111176)11176Crossref Scopus (8) Google Scholar], although practice rates remained low to moderate (<10% to <90%) in other countries [[3]Urbán R. Paksi B. Miklósi A. Saunders J.B. Demetrovics Z. Non-adherence to preventive behaviours during the COVID-19 epidemic: findings from a community study.BMC Public Health. 2021; 21 (https//doi.org/10.1186/s12889-021-11506-0): 1462Crossref PubMed Scopus (10) Google Scholar]. With the relentless emergence of novel SARS-CoV-2 variants of concern, there is a need for the normalisation of protective behaviours, including self-initiated mask wearing, hand hygiene, and home rest when unwell, in communities. Understanding the characteristics of individuals who did not consistently practise protective behaviours during the COVID-19 pandemic can guide the design of public health interventions ahead of future waves of COVID-19. We conducted a nationally representative population-based survey from November 2020 to January 2021 [[4]Guo H. Hildon Z.J. Lye D.C.B. Straughan P.T. Chow A. The associations between poor antibiotic and antimicrobial resistance knowledge and inappropriate antibiotic use in the general population are modified by age.Antibiotics (Basel). 2021; 11 (https//doi.org/10.3390/antibiotics11010047): 47Crossref PubMed Scopus (14) Google Scholar]. Wearing a mask was mandatory in both indoor and outdoor public areas, and the practices of social responsibility to stay at home if unwell and good personal hygiene were encouraged. Households were randomly selected from a proportionately stratified national census. The household member with the most recent birthday was invited to complete the survey. Six questions on a 5-point Likert scale (never/rarely/occasionally/often/always) assessed protective behaviours (“I wash my hands with soap and water to prevent infections”, “I wear a mask when I have a cough or cold”, “I stay at home and rest, when I have a cold/flu”) before and during the COVID-19 pandemic. A multivariable logistic regression model was constructed to assess factors associated with the non-adoption or inconsistent adoption (never/rarely/occasionally) of any of the three protective behaviours during the pandemic. In addition to sociodemographic factors, we assessed for the adoption of healthy lifestyle habits and defined a high-level of adoption when the respondent provided all the following responses to the five statements on a 5-point Likert scale (never/rarely/occasionally/often/always): “I consume fruits and vegetables” (often/always), “I smoke cigarettes” (never), “I exercise at least three times a week” (often/always), “I take sugary drinks” (never/rarely/occasionally), and “I have at least 7 hours of sleep every night” (often/always) [[5]Parincu Z. Healthy habits: definition, lists, & examples. Accessed 23 January 2023. https://www.berkeleywellbeing.com/healthy-habits.Google Scholar]. Of 4791 households that were approached, 2004 (41.8%) participated in the survey. Among the respondents, the mean age was 44.5 years (standard deviation, 15.0 years), 52% were females, and 39% were highly educated (degree holders). The age and gender distribution of the study population was representative of the Singapore population in 2020 [[4]Guo H. Hildon Z.J. Lye D.C.B. Straughan P.T. Chow A. The associations between poor antibiotic and antimicrobial resistance knowledge and inappropriate antibiotic use in the general population are modified by age.Antibiotics (Basel). 2021; 11 (https//doi.org/10.3390/antibiotics11010047): 47Crossref PubMed Scopus (14) Google Scholar]. Before the pandemic, 67.8% of people consistently performed hand hygiene, 14.3% consistently wore a mask when having a cough or cold, and 77.8% stayed at home and rested when having a cold. During the pandemic, 92.4%, 95.7%, and 96.6% of people, respectively, did so. Furthermore, although 11.8% of people had consistently adopted all three protective behaviours before the pandemic, 87.4% did so during the pandemic. After adjusting for educational level and presence of chronic illness, those aged <30 years (adjusted OR [AOR], 1.48 [95% CI, 1.07–2.07]), male sex (AOR, 1.71 [95% CI, 1.30–2.25], Chinese (AOR, 1.45 [95% CI, 1.05–2.01]), low adopters of a healthy lifestyle (AOR, 1.67 [95% CI, 1.09–2.56]), and those who did not or inconsistently adopted protective behaviours before the pandemic (AOR, 9.08 [95% CI, 3.34–24.70]) were more likely not to or inconsistently adopt protective behaviours during the COVID-19 pandemic (Table 1).Table 1Univariate and multivariable logistic regression analysis of factors associated with the non-adoption or inconsistent adoption (never/rarely/occasionally) of protective behaviours during the pandemic (N = 2004)FactorsN (%)Crude OR (95% CI)pAdjusted OR (95% CI)pNon-consistent adoption of protective behaviours before pandemic1767 (88.2%)9.51 (3.51–25.79)<0.0019.08 (3.34–24.70)<0.001Low level of adoption of a healthy lifestyle1674 (83.5%)1.74 (1.15–2.65)0.0091.67 (1.09–2.56)0.018Age, <30 y395 (19.7%)1.43 (1.05–1.94)0.0251.48 (1.07–2.07)0.019Male sex954 (47.6%)1.77 (1.35–2.31)<0.0011.71 (1.30–2.25)<0.001Chinese ethnicity1438 (71.8%)1.47 (1.08–2.02)0.0161.45 (1.05–2.01)0.025Lower educational level1216 (60.7%)1.02 (0.78–1.34)0.8811.15 (0.86–1.52)0.345Presence of a chronic illness648 (32.3%)1.17 (0.88–1.54)0.2791.23 (0.91–1.66)0.175 Open table in a new tab Although previous studies have assessed the associations of sociodemographic characteristics with the adoption of protective behaviours during the COVID-19 pandemic [[2]Chan E.Y.Y. Kim J.H. Kwok K.-O. Huang Z. Hung K.K.C. Wong E.L.Y. et al.Population adherence to infection control behaviors during Hong Kong’s first and third COVID-19 waves: a serial cross-sectional study.Int J Environ Res Public Health. 2021; 18 (https//doi.org/10.3390/ijerph182111176)11176Crossref Scopus (8) Google Scholar,[3]Urbán R. Paksi B. Miklósi A. Saunders J.B. Demetrovics Z. Non-adherence to preventive behaviours during the COVID-19 epidemic: findings from a community study.BMC Public Health. 2021; 21 (https//doi.org/10.1186/s12889-021-11506-0): 1462Crossref PubMed Scopus (10) Google Scholar], none to date has compared the association between the adoption of protective behaviours before and during the pandemic. Our study shed light on the strong influence of the consistent adoption of protective behaviours before the pandemic on their adoption during the pandemic. Although the presence of a national mandate may have increased mask wearing during the pandemic, hand hygiene and home rest were health advisories not mandated by law. Hence, our observations were reflective of an increase in the self-initiated adoption of protective behaviours, showing the potential for the rapid adoption and social normalisation of such behaviours during future COVID-19 waves without the need for strict enforcement. This is particularly important as the requirements for mandatory wearing of a mask in public areas are progressively being lifted in countries, in spite of warnings of a tridemic of SARS-CoV-2, influenza, and respiratory syncytial virus infections [[6]Joint EC, WHO and ECDC statement: influenza season epidemic kicks off early in Europe as concerns over RSV rise and COVID-19 is still a threat. European Centre for Disease Prevention and Control. Accessed 23 January 2023. https://www.ecdc.europa.eu/en/news-events/joint-ec-who-and-ecdc-statement-influenza-season-epidemic-kicks-early-europe-concerns.Google Scholar]. Furthermore, our findings corroborated with those reported in other national studies in the identification of males and younger adults (aged <30 years) being less consistent in their adoption of protective behaviours during the COVID-19 pandemic [[3]Urbán R. Paksi B. Miklósi A. Saunders J.B. Demetrovics Z. Non-adherence to preventive behaviours during the COVID-19 epidemic: findings from a community study.BMC Public Health. 2021; 21 (https//doi.org/10.1186/s12889-021-11506-0): 1462Crossref PubMed Scopus (10) Google Scholar]. The promotion of protective behaviours could be more targeted at these subpopulations. Our findings could be limited by non-differential social desirability and recall biases, rendering the observed effect a conservative estimate of the true effect of the adoption of protective behaviours before the pandemic on their adoption during the pandemic. We further observed that a high level of adoption of a healthy lifestyle before the pandemic was associated with the consistent adoption of protective behaviours during the COVID-19 pandemic. In 2023, Singapore will launch its Healthier SG strategy to promote healthier living in the community [[7]Ministry of Health Singapore. Healthier SG. Accessed 4 December 2022. https://www.healthiersg.gov.sg.Google Scholar]. The promotion of protective behaviours could be bundled with the promotion of healthy lifestyles, normalising them in communities and increasing resilience against COVID-19 and future pandemics. AC and HG planned and supervised the conduct of the study and conceived the manuscript. AC drafted the manuscript and analysed the data. HG interpreted the data and provided inputs to the manuscript draft. Both authors critically reviewed the manuscript. Both authors reviewed and approved the final version of the manuscript prior to submission. The authors declare that they have no conflicts of interest. This project is supported by the Health Services Research Grant, National Medical Research Council, Singapore (NMRC/HSRG/0083/2017). This work has been presented as an e-poster at the International Congress on Infectious Diseases 2022. This study was approved by the National Healthcare Group Domain Specific Review Board in Singapore (NHG DSRB Ref: 2017/01179).