key: cord-297715-qcwp2jdv
authors: Machida, Masaki; Nakamura, Itaru; Saito, Reiko; Nakaya, Tomoki; Hanibuchi, Tomoya; Takamiya, Tomoko; Odagiri, Yuko; Fukushima, Noritoshi; Kikuchi, Hiroyuki; Amagasa, Shiho; Kojima, Takako; Watanabe, Hidehiro; Inoue, Shigeru
title: Changes in implementation of personal protective measures by ordinary Japanese citizens: A longitudinal study from the early phase to the community transmission phase of the COVID-19 outbreak
date: 2020-05-17
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.05.039
sha: 
doc_id: 297715
cord_uid: qcwp2jdv

OBJECTIVES: To clarify changes in the implementation of personal protective measures among ordinary Japanese citizens from the early phase of the COVID-19 outbreak to the community transmission phase. METHODS: This longitudinal, internet-based survey included 2,141 people (50.8% men; 20-79 years). The baseline and follow-up surveys were conducted from February 25-27, 2020 and April 1-6, 2020, respectively. Participants were asked how often they implemented the 5 personal protective measures recommended by the World Health Organization (hand hygiene, social distancing, avoiding touching the eyes, nose and mouth, respiratory etiquette, and self-isolation) in the baseline and follow-up surveys. RESULTS: The prevalence of 3 of the 5 personal protective measures significantly improved in the community transmission phase compared to the early phase. Social distancing measures showed significant improvement, from 67.4% to 82.2%. However, the prevalence of avoiding touching the eyes, nose and mouth, which had the lowest prevalence in the early phase, showed no significant improvement (approximately 60%). Multivariate logistic regression analysis revealed, men and persons of low-income households made fewer improvements than women and persons of high-income households. CONCLUSIONS: The prevalence of personal protective measures by ordinary citizens is improving, however there is potential for improvement, especially in regard to avoiding touching eyes, nose and mouth.

With no end in sight to the rapidly evolving coronavirus disease pandemic, a critical element in reducing transmission of the virus is rapid and widespread behavior change in ordinary citizens (Betsch et al., 2020) . Many governments and health authorities have called on ordinary citizens to implement personal protective measures, such as hand hygiene, respiratory etiquette, and social distancing measures, since the early phase of the COVID-19 outbreak (JMHLW, 2020a, U.S.CDC, 2020, WHO, 2020a).

We recently reported the results of a survey on the implementation status of personal protective measures by ordinary citizens conducted on February 25, 2020 during the early phase of in Japan (Machida et al., 2020) . In that study, we found that in the early phase of COVID-19 there was J o u r n a l P r e -p r o o f low prevalence among ordinary Japanese citizens in the implementation of social distancing measures and avoiding touching the eyes, nose and mouth, 2 of the 5 personal protective measures recommended by the World Health Organization (WHO) (WHO, 2020a The company, then invited the 2,400 respondents of the baseline survey to participate in a follow-up survey by email on April 1, 2020. On that day, the number of reported COVID-19 cases in Japan was 2,178, and the number of patients had increased rapidly, mainly in Tokyo (WHO, 2020b). The questionnaires were placed in a secure section of a website, and potential respondents received a specific URL in their invitation email. The 2,400 respondents to the baseline survey responded to the questionnaire voluntarily, and the response cut-off date was April 6. On April 7, a day after the completion date of the survey, the Japanese government declared a state of emergency (Prime Minister of Japan, 2020).

Reward points valued at 50 yen were provided as an incentive for participation (approximately 0.5 US dollars, as of April 2020) in both the baseline and follow-up survey.

Participants described their self-reported implementation of the 5 personal protective measures (hand hygiene, social distancing measures, avoiding touching the eyes, nose and mouth, respiratory etiquette, and self-isolation) recommended by the WHO (WHO, 2020a). Regarding the 4 personal protective J o u r n a l P r e -p r o o f measures, other than self-isolation, participants were asked about the frequency of implementation during the previous week and responded using a 4-point-Likert scale (1: "Always", 2: "Sometimes", 3: "Rarely", or 4: "Never"). As for social distancing measures, participants were asked to disclose the frequency in which they avoided places where many people would be gathered together. Regarding self-isolation, the participants were asked the question, "if you have a fever or a cold, can you take time off from work?" Participants responded using a 5-point Likert scale (1: "Definitely can", 2:

"Probably can", 3: "Probably can't", 4: "Definitely can't" or 5: "Not working". Participants answered the same questions in both the baseline survey and the follow-up survey.

In the baseline survey, participants gave information about their sex, age, marital status (not married/married), working status (working/not working), smoking status (smokers/non-smokers), past medical history (hypertension, diabetes, and respiratory disease), and residential area (Tokyo/other).

In the follow-up survey, participants were also asked about their living arrangement (with others/alone). In addition, the research company provided categorized data as follows: educational attainment (university graduate or above/below), and household income level (< 5 million yen or ≥ 5 million yen).

Regarding the 5 personal protective measures, when a participant responded with 1 ("Always"/"Definitely can") or 2 ("Sometimes"/"Probably can") on the 4-point-Likert scale, it was determined that the personal protective measures had been implemented. In both the baseline survey and follow-up survey, we clarified the prevalence of each personal protective measure, and the implementation of all personal protective measures. In regard to self-isolation and implementing all personal protective measures, those who selected 5 ("Not working") in the baseline survey or followup survey, were excluded from the analysis (n=776). The McNemar test was performed to compare the prevalence of each personal protective measure between the baseline survey and follow-up survey.

To clarify the association between each sociodemographic factor and behavior changes related to each personal protective measure, a multivariate logistic regression analysis was performed to focus on those who did not implement the personal protective measure in the baseline survey. The dependent variable was set as a dichotomous variable coded as "1" if the personal protective measure was adopted in the follow-up survey and "zero" otherwise. The dependent variable was prepared for each of the 5 smoking status (smokers/non-smokers), residential area (Tokyo/other), educational attainment (university graduate or above/below), and household income level (< 5 million yen or ≥ 5 million yen).

Regarding self-isolation, those who selected 5 ("Not working"), in either the baseline survey or followup survey, were excluded from the analysis, therefore working status was removed from the aforementioned independent variables. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Japan, Tokyo, Japan). Two-sided p values less than 0.05 were considered to be statistically significant.

Of the 2,400 respondents in the baseline survey, valid responses were obtained from 2,141 respondents in the follow-up survey (response rate: 89.2%, Table 1 ). 

We set out to determine the status of behavior change in personal protective measures among ordinary Japanese citizens from the early phase of the COVID-19 outbreak to the community transmission phase, in addition to the association between each sociodemographic factor and behavior change.

There were significant improvements in social distancing measures during the community transmission phase compared to the early phase of the COVID-19 outbreak. However, the prevalence of avoiding touching the eyes, nose and mouth was approximately 60%, indicating no significant improvement. Moreover, men and persons with low household income levels made fewer behavior awareness activities related to avoiding touching the eyes, nose and mouth, which is assumed to be the reason for the lack of improvement in that behavior. Moreover, face touching behavior is a common habit (Kwok et al., 2015) , therefore unless one is extremely careful, it may be difficult to stop. This study suggests that the implementation status of personal protective measures in ordinary citizens can change with each pandemic phase and awareness activities that are introduced. It may be important to monitor these changes for developing effective educational activities.

The multivariate logistic regression analysis revealed that men and persons with low household income levels made fewer behavior changes adopting personal protective measures. It may be effective to focus on populations with such sociodemographic characteristics when providing education on personal protective measures during an infectious disease pandemic, which can lead to constraints on both time and resources. Previous studies on self-isolation have reported that people who are unable J o u r n a l P r e -p r o o f to work from home or lose income when absent from work have a lower rate of self-isolation (Blake et al., 2010 , Eastwood et al., 2009 . It may be essential to implement recommendations for working from home as well as salary compensation to enhance the prevalence of self-isolation, rather than simply executing awareness activities.

This study has some limitations that should be considered. The most important point is the fact that participants in this study were recruited from people enrolled at a single internet research company, and the results may have been affected by a selection bias. Relatively little is known about the characteristics of people in online communities (Wright, 2017) . Furthermore, the age and sex demographics of the participants in this study were different from that of the general Japanese population (Statistics Bureau of Japan, 2019). Second, the results may only be directly applied to the Japanese population. In the case of other populations with different cultural, ethnic, and geographical backgrounds, the prevalence of personal protective measures and implementation status of behavior change may be differ considerably when compared with those reported in the present survey. Despite these limitations, to the best of our knowledge, this study is the first study to clarify the behavior changes in personal protective measures among ordinary Japanese citizens from the early phase of COVID-19 in Japan to the community transmission phase, and to identify an association between the behavior changes and each sociodemographic factor.

J o u r n a l P r e -p r o o f citizens from the early epidemic phase of COVID-19 to the community transmission phase. The prevalence of many personal protective measures, including social distancing measures, by ordinary citizens during the COVID-19 pandemic improved, but leaves potential for improvement, especially in terms of avoiding touching eyes, nose and mouth. Monitoring these changes may be relevant when considering effective educational activities to raise and promote awareness and adherence to preventive measures.

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

This study was approved by the Ethics Committee of Tokyo Medical University, Tokyo, Japan (No:

T2019-0234). Informed consent was obtained from all the respondents.

The authors declare no conflicts of interest. J o u r n a l P r e -p r o o f

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Sometimes", or "Definitely can", or "Probably can" (in the case of self-isolation) for each personal preventive measure

at the time of the baseline survey, and "implementing each measure" at the time of the follow-up survey. Participants who had already implemented a personal protective measure at the time of the baseline survey were excluded in the analysis for that particular protective measure. Independent variables were sex, age (older adults ≥ 65 years old/persons under 65 years old), marital status (not married/married), working status (working/not working), living arrangement (with others/alone), smoking status (smokers/nonsmokers), residential area (Tokyo/other), educational attainment

If you have a fever or cold, can you take time off from work?" participants selected one of the items of the 5 point-Likert scale. Those who selected 5

The authors declare that they are unaware of any competing financial interests or personal relationships that could have influenced the work reported in this paper.

We would like to express our sincere gratitude to all the participants who enrolled in this study.