Background
On December 31st 2019, the World Health Organization (WHO) received a notification of an unknown viral pneumonia outbreak in the Hubei Province of China. This outbreak was later found to be caused by the Severe Acute Respiratory Syndrome Coronavirus 2 [
1,
2]. The disease, now called Coronavirus Disease 2019 (COVID-19), has quickly spread to most countries of the world, affecting almost 5 million individuals and causing more than 320,000 deaths. Until May 22, 492,124 cases were registered in the South America, with 55,3% being in Brazil [
3].
COVID-19 is primarily transmitted by respiratory droplets with a similar incubation time and development time as the previously known Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) [
1,
4]. The rapid international spread of COVID-19 pressured the WHO to declare the COVID-19 epidemic as a public health emergency of international importance in late January 2020. Such a decision is taken when an event with major public health implications crosses the borders of the country initially affected, demanding immediate international action [
5]. In the absence of antivirals and while awaiting the large-scale introduction of COVID-19 vaccination [
6], various public health strategies to contain the infection have been implemented around the world. These strategies commonly consist of enforced or semi-enforced “lockdowns” and closure of national and/or intra-national borders, as well as promotion of respiratory hygiene (masking, coughing/sneezing etiquette) and hand hygiene. The package of containment measures for COVID-19 around the world probably represents the largest global public health intervention in human history, though the societal and individual impact of these measures is not yet well-understood.
The population-level adherence to such measures may determine to a considerable extent the national magnitude and duration of the COVID-19 pandemic [
7,
8]. However, little is known on population-level adherence to the various containment measures implemented worldwide, with most studies focusing on adherence to hygiene measures among healthcare workers [
9‐
11]. In-depth documentation of adherence to containment measures is nonetheless essential, on the one hand to feed into initiatives attempting to model outbreaks [
7,
12], and on the other hand to adapt and target health promotion messages to sub-populations that may be struggling to adhere to specific measures [
13], such as specific age groups.
In Brazil, the first case of COVID-19, reported by the Ministry of Health (MOH) on February 26th, was a 61-year-old man who had traveled to Italy between February 9 and 21 of 2020. Two tests were positive for COVID-19 infection. Since then, the number of infected persons in Brazil has increased dramatically [
14]. Physical distancing and confinement measures were implemented by the Brazilian government after COVID-19 was declared a pandemic on March 16th [
5]. Events expected to attract large numbers of people were cancelled, universities and schools were closed, and only services considered essential to the population remained functional, such as markets, pharmacies and bakeries. However, traveling between Brazilian states remained possible. To document how the containment measures affected the lives of the Brazilian people, and to understand which containment measures were best adhered to by which strata of the population, we conducted an online survey on the adherence of the Brazilian people to individual public health measures and impact of the COVID-19 outbreak on people’s lives. A particular emphasis was placed on age as a stratifying factor, considering the clear association of COVID-19 severity with age, and the general need for adapting health messaging to specific age groups.
Discussion
Our study shows that, during the survey period, Brazilians were following the COVID-19 preventive measures relatively well. Hand hygiene measures were adhered to most, followed by physical distancing and respiratory hygiene. In all categories of measures, a clear age effect was observed, with younger individuals scoring lower than older respondents on the adherence score.
Overall, only 45.5% reported wearing a face mask when going out. This is much lower than in Asian countries, where most people wore face masks once the COVID-19 epidemic was introduced in their country [
15‐
17]. This is also lower than the 91.7% face mask use reported in a similar online survey in Ecuador in April 2020 and the 99.8% face mask use in a survey in Peru in June 2020 [
18]. This is however higher than in several European countries where wearing face masks was initially advised only in health care settings, following WHO recommendations at the time [
19‐
21]. Checking one’s temperature for the early detection of a COVID-19 infection at least twice a week was only practiced by 10.8% of the respondents. This may be a point of concern, as WHO reported that temperature screening was able to detect the majority of exported cases during the COVID-19’s expansion [
22].
When assessing the profile of individuals with poor general adherence, men were less adherent compared to women, which mirrors findings from a Knowledge, Attitudes, and Practices study conducted in China (17). In our study, younger age was also associated with a lower overall score. In another large online survey in Brazil conducted between April 24th and May 24th, assessing only the degree of adherence to physical contact restriction measures, greater adherence was found among females compared to males but it was mainly the 30 to 49 year old group that was less adherent and not the younger age group [
23]. People living in rural areas and poor neighborhoods were also less adherent: in rural areas people may not perceive themselves at high risk of COVID-19, and therefore may not respect the national restriction measures and not practice individual hygiene measures [
24]. Therefore, extra communication and health education may be needed to change the risk perception in rural areas and popular neighborhoods [
25]. Brazilian students reported difficulties to stay home, which may be related to a need to travel to their original homes in periods when schools and universities were closed [
26] or could be related to differing social habits among this population. Encouragingly, respondents with underlying diseases followed the preventive measures well, which is important considering their higher risk for more severe disease.
Taken together, these observations suggest that tailoring of the public health messages may be indicated. A reinforcement of specific messages, such as mask use and temperature taking, may be beneficial, and using delivery methods tailored to the specific age groups could allow higher uptake. Especially communication methods to the younger age group could benefit from such tailoring, and possibly approaches relying on social media and including influencers to spread public health messages could be considered [
27]. Of note, the observation that most respondents’ concern was higher for their loved ones than for themselves could be incorporated in such health messages; possibly by emphasizing how adhering to measures protects one’s close environment.
In general, our results indicate that following an intensive COVID-19 prevention campaign [
28] the Brazilians gradually became aware of the importance of adopting simple methods to prevent COVID-19 transmission. For only 7.9% of the respondents indoor confinement was experienced as extremely difficult. Initially the MOH of Brazil expected a peak of COVID-19 infections during the second half of April. However, it did not happen. The satisfactory adherence to the preventive measures may have delayed the peak of the epidemic.
COVID-19 associated mortality during the study period was highest in the North region of Brazil (Amazonas) and in two states in the Northeast (Ceará and Pernambuco) [
29]. Our study showed that the Northeast region had less difficulty to adhere the restrictive measures. This difference between regions may have been influenced by the adoption of restrictive measures to varying degrees by the governors of the Brazilian states. Indeed, 11 states have decreed lockdown for at least one municipality in their state. Only the state of Amapá decreed a lockdown for all your municipalities.
There has been a lot of confusion about how to deal with the COVID-19 epidemic in Brazil. The president has minimized the actions of the MOH, downplaying the importance of quarantine, and is defending vertical isolation to avoid financial collapse. Vertical isolation or shielding implies that most people return back to normal life and people with underlying diseases, older adults and pregnant women continue to respect physical distance and reduce their social activities. Regarding this vulnerable group, 29.4% stated to have underlying diseases in our survey. This is a concern, as older age and the presence of (an) underlying health condition(s) are associated with increased COVID-19 related mortality [
30,
31] On the other hand, Brazilian respondents with underlying diseases adhered better to the containment measures.
The lack of unified actions against COVID-19, by the federal government, led to the resignation of the health minister on April 16 [
32,
33]. From that moment on, there was a relaxation of quarantine measures, opening of part of the trade, and consequently less physical distancing. The lack of national coordination by the government in response to the pandemic reveal the conflictual positions between the federal government and governors from the 27 states of the country [
34]. This increased the number of COVID-19 cases and associated deaths [
30,
31].
At the end of April, the COVID-19 death toll in Brazil had already exceeded that of China [
3] (more than 5000 deaths) and this scenario got worse, not reaching the flattening of the curve and overloading the Brazilian health system [
35]. As of December 31th 2020, more than 7,000,000 cases had been confirmed in the country, causing almost 200,000 deaths [
3].
Our findings suggest a considerable initial willingness of the Brazilian people to follow the quarantine and other containment measures. However, this willingness seems to have been irrevocably subverted through the political stance against the public health measures with as a consequence that currently South America became the new epicenter of the pandemic with Brazil as the most affected country [
3].
Our study had several limitations
. The number of respondents was relatively small compared to the entire Brazilian population, and respondents were unevenly spread over the national territory. Indeed, only 2,6% of the participants reported residing in rural areas. The reason for this low number of participants from rural areas most likely is because in those areas people have less internet access and consequently are less linked to social media [
24,
25]. While 51.8% of the Brazilian population are women [
36], 71,8% of the respondents in our survey were female. Such a higher proportion of female respondents was also observed in other studies on COVID-19-related practices [
17]. Participants were more likely to be higher educated individuals living in cities and in the Southeast region. The latter may be explained by the fact that since the beginning of the pandemic, this region recorded the largest number of COVID-19 infections. Moreover, broadband internet quality is best in the Southeast region [
37]. Our survey was also not able to reach vulnerable populations, such as the homeless, prisoners, older adults, migrants and people with mobility problems. Such populations may be at increased risk for COVID-19 infection and should be considered as priority key groups in the prevention and control of Covid-19 [
26,
38]. Our study findings are based on self-reports without a possibility to verify whether these responses corresponded with the real preventive behaviour of the respondents.
At the time of writing, the COVID-19 vaccination started in more than 30 countries [
39], and in Brazil, it is scheduled to start at the end of January 2021. However, it will still be challenging to deal with the vaccine hesitance movements and the political polarization [
40] that it is taking place in relation to vaccination.
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