Introduction
The pandemic of COVID-19, caused by SARS-CoV-2, represents the most rapidly spreading infectious disease since the influenza pandemic of 1918–19. Responding effectively to the COVID-19 pandemic requires the collaborative efforts of health officials of all countries. It also necessitates people worldwide changing their individual behaviours in response to the public health imperative of infection control. Consequently social and behavioural sciences play central roles in coping with the challenges caused by the current COVID-19 and future pandemics [
1,
2].
Possible routes of transmission include close contacts between people, contracting the virus though surface spread (via fomites), contracting it via large droplets (through coughing and sneezing), and airborne (aerosol) transmission especially in enclosed spaces [
3]. Importantly, transmission of the SARS-CoV-2 is possible from infected people who are asymptomatic [
4]. Preventive measures therefore need to be applied irrespective of apparent symptoms. Furthermore, the newly emerged variants of the SARS-CoV-2 impose further concerns and the need for public health programs, notwithstanding the roll-out of mass vaccination programs [
5]. Infectivity is assessed by the basic reproduction number (R0) (i.e. without any intervention) and is estimated to be 3.32 [2.81–3.82] [
6]. A key goal is to decrease this number to below 1.0 through coordinated prevention efforts which requires the engagement of members of the community and their adherence to these preventive approaches. Adherence to advice on preventive behaviours may be expected to reduce the spread of infection and give opportunity to the health care system to build up and maintain appropriate resources to treat severe cases [
7]. The issue is whether and how this will be achieved in a sustained way.
Prevention of transmission of SARS-CoV-2, therefore, requires behaviour change that dramatically alters human interactions, independently of economic status, cultural heritage and geographical location. Countries facing the COVID-19 epidemic need to and most have implemented public health interventions and legislation to decrease the frequency of close personal contact by spatial distancing [
8] and to promote physical or chemical barriers to virus transmission, through wearing face masks and gloves, and hand washing, respectively. A meta-analysis of studies investigating interventions to prevent influenza provided evidence of benefit from multiple preventive behaviours [
9]. For example, hand washing in combination with face mask use reduces significantly influenza virus transmission [
9]. Countries, however, differ in which protective measures are recommended. For example, the recommendation of wearing a face mask varies across countries [
10,
11]. The degree of adherence necessary for effective prevention across populations is still not known, but we assume that consistent – every day or almost every day – use of preventive behaviours can significantly decrease the rate of viral transmission.
Understanding both distal (underlying) and proximal predictors of preventive behaviours may help predict different rates of viral submission in subgroups of the population. In most countries reporting death rates from COVID-19, these have been greater in men than women. In China and Italy deaths of men have been more than twice those of women. In New York City men constitute about 61% of patients who die [
12,
13]. Men comprise 62.4% of COVID-19 deaths among those under 75 years of age in Hungary. Could it be that men are less likely to adopt preventive behaviours and more likely to become infected and die from the disease? Of course gender differences may be influenced by age, culture, other socioeconomic factors [
14] or comorbidity status [
12]. Preventive behaviours may play a role in the social disparities in SARS-CoV-2 infection, hospitalisation, and mortality [
15].
In practical terms, the more immediate (proximal) predictors are of crucial importance. Health beliefs and other cognitive factors may explain different levels of adherence to preventive behaviours [
16]. These include perceived susceptibility to, and perceived severity of the infection and its consequences. In the previous SARS pandemic, threat perception, perceived susceptibility and severity varied across countries [
17]. However, in this study, the link between cognitive variables and infection control or preventive behaviours was not determined.
The present study had two aims. The first aim was to estimate the pattern of preventive behaviours and adherence and non-adherence to them. Adherence was defined as the person’s willingness to follow consistently those preventive behaviours which can decrease the chance of transmission of SARS-CoV-2. The second aim was to understand the role of distal factors such as gender, age, and socioeconomic status and proximal health beliefs in explaining the variance of preventive behaviours in the general population. It was hypothesised that men are less likely to adopt preventive behaviours than women. We also wished to examine particular preventive behaviours in young people and in those of lower socioeconomic status.
Discussion
It is encouraging that most participants reported adhering to the main preventive behaviours recommended by the public health authorities. However, it is concerning that men throughout the age ranges were less likely to adopt the recommended measures than women, and this applied to all four preventive approaches. Young people were less likely to adopt preventive approaches than those aged 30 years or more, which was related in part to lower perceived susceptibility to a severe COVID-19 illness.
The SARS-CoV-2 incidence rate has remained relatively low in Hungary probably due to forthright decisions to implement broadly-based public health approaches at an early stage. These include measures aimed at spatial distancing and adopting hygienic approaches that were introduced at an early stage of the pandemic. Based on our results, a large proportion of the population adhered to the recommendation of avoiding close contacts and personal hygienic behaviours to control viral transmission. However, not all behaviours were followed equally: using face masks and protective gloves were less common and more variable among people who were inclined to follow all the other protective measures.
In our study, nearly 18% of the sample was identified as non-adherent or have limited adherence to the public health recommendations. Non-adherence rates in lifestyle-related behaviour change advice are around 30% [
20]. The non-adherence rates reported in the present study are therefore lower but are more concerning because of the implications for imminent morbidity and mortality. Nearly 20% of persons in the present study reported a low level of adherence to spatial distancing, face mask use and/or taking personal hygienic precautions; thus, they have an increased risk of contracting and transmitting the SARS-CoV-2 virus and other respiratory infections in the future. At the time when countries try to relax the tight control over virus transmission, it becomes even more important to know the proportion of non-adherent individuals and the predictors of response to preventive advice. The present data were collected during the first wave of the pandemic in Hungary; therefore, it represents the collective response to the new challenge. Therefore, our results may be informative in future outbreaks of variant coronaviruses and similar threats.
Several countries have experienced higher rates of severe COVID-19 illness and deaths among men compared with women [
12,
13,
21]. This should be compared with the data from the present study of male gender being another important predictor of non-adherence. An increased risk of death among males was documented in relation to the previous SARS-virus induced acute respiratory syndrome, in which males had 66% higher risk of dying than females [
22]. Several hypotheses have been proposed to explain this gender difference, including different rates of smoking [
23,
24]. Our data highlight the gender difference in adherence to preventive behaviours. Since we do not have data about the smoking status of our participants we cannot control for the covariance between smoking and non-adherent behaviours. Previous studies also supported the gender disparities in handwashing behaviour and knowledge regarding personal hygienic behaviours [
25,
26]. Our results regarding the gendered preventive behaviours are in accordance with other studies from different countries that documented gender disparities in adherence behaviours (see for a brief review [
27]. However, further research is necessary to disentangle the multiple behavioural mechanisms explaining why males seem to be more vulnerable to respiratory infections. We also need research on the gendered meaning of preventive behaviours that would explain the lower rate of preventive behaviours among men [
28]. Lower rate of adherence, lower level of self-care and/or lower level of perceived threat among males may be important factors explaining the higher rate of general mortality among men compared to women [
29].
Being of a younger age is an important predictor of non-adherence to preventive behaviours [
27]. Frequent communication regarding the SARS-CoV-2 virus stressed the fact that COVID-19 threatens mainly the older population. This could lead to a false safety message to younger people [
30], though 1% of hospitalisation due to COVID-19 in China was among those aged 20–29 years, and 3% from the age group of 30–39 years old [
31]. Based on nine relevant health indicators, approximately one-third of young people are medically vulnerable to severe COVID-19 illness, at least in the U.S. [
32]. Lower adherence among younger people may be associated with their perceived lower vulnerability and their tendencies to make impulsive decisions, take more risks to gain social and emotional stimulation (such as social gatherings), and underestimate the long-term consequences of their behaviour [
33]. Our study demonstrated different rates of preventive behaviours. The variance of the use of physical barriers may be due to several factors including (1) the lack of practice of face mask use; (2) the social meaning of face masks and gloves in Europe; and (3) messages from the WHO and the country’s officials regarding the use of face masks and protective gloves (WHO, 2020). However, previous experience with prevention of influenza emphasised the use of face mask with hand hygienic measures [
9]. It is important to note that face mask use did not decrease the frequency of the use of other preventive techniques, therefore it did not increase illusory safety. It can be recommended without the serious side effect of neglecting other infection control means. Furthermore, recent evidence supports the idea that face mask can protect from the transmission of viral RNA [
34].
Our study is unique since we also focused on patterns of adherence behaviours. Previous studies focused mainly on predicting or explaining specific preventive behaviours; however, in the case of the complex set of preventive behaviours which can prevent viral transmission, the person-oriented type of analysis focusing on the pattern of behaviours has the specific advantage in identifying subgroups of the population sharing similar characteristics. Thus, in our study, we identified subgroups with different levels of adherence. The understanding of the covariates of these subgroups informs the prevention experts how to tailor health promotion programs. This study is also different from those studies using online convenience samples because we applied a probabilistic random sampling method, which enabled us to have a sample that proportionally represents the Hungarian adult population. Furthermore, this sampling method significantly reduces the selection bias.
Our study is not without limitations. The cross-sectional design does not allow definitive conclusions about causation, and self-reported data may be distorted by social desirability bias. An independent direct observational study could validate our findings. Noteworthy, independent observational studies of face mask use behaviours [
35,
36] and handwashing behaviours [
25,
26] validated our findings regarding the gender difference in preventive behaviours. However, in the present pandemic there is a compelling need for timeliness of studies. Understanding adherence to public health recommendations will help to decrease the likelihood of SARS-CoV-2 transmission and potentially the severity of the COVID-19 illness, and should help us in the future to prevent and contain influenza and other still unknown viral pandemics. Everyone, irrespective of their particular risk of these infections, can contribute to the health of the community as a whole. The findings from the present study emphasise that developing ways of engaging men, young people and those of low socioeconomic status in adopting preventive behaviours and emphasising the severity of the illness is vital not only for optimal prevention of SARS-CoV-2 transmission now and in the future, but also for effective control of related respiratory infections.
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