key: cord-291709-x9llke60 authors: Lin, Yulan; Alias, Haridah; Luo, Xiao; Hu, Zhijian; Wong, Li Ping title: Uncovering physical and attitudinal barriers to adherence to precautions for preventing the transmission of COVID-19 and anxiety level of people in Wuhan: 2 months after the lockdown date: 2020-09-22 journal: Psychosomatics DOI: 10.1016/j.psym.2020.09.005 sha: doc_id: 291709 cord_uid: x9llke60 BACKGROUND: Wuhan, the epicentre of the coronavirus diseases (COVID-19) outbreak, has been locked down on January 23, 2020. We aimed to investigate the barriers to the physical prevention, negative attitudes and anxiety levels. METHODS: A online cross-sectional survey was conducted with the people living in Wuhan between March 12th and 23rd, 2020. RESULTS: Of a total of 2,411 complete responses, the mean and standard deviation (SD) for the total physical prevention barriers score was 19.73 (SD ± 5.3; range 12−45) out of a possible score of 48. Using a cut-off score of 44 for the State-Trait Inventory (STAI) score, 79.9% (95%CI 78.2−81.5) of the participants reported moderate to severe anxiety during the early phase of the outbreak and 51.3% (95%CI 49.2−53.3) reported moderate to severe anxiety after the peak of COVID-19 was over (during the study period). Comparing anxiety levels in the early phase of the outbreak and after the peak of the outbreak, 58.5% (95%CI 56.5−60.5) recorded a decreased anxiety. Females reported a higher likelihood to have decreased levels of anxiety than males (OR=1.78, 95%CI 1.48−2.14). Low negative attitudes score were associated with a higher decrease in anxiety (OR=1.59, 95% CI 1.33−1.89). CONCLUSIONS: The attitudinal barriers to prevention of transmission of COVID-19 are more prominent than physical prevention barriers after the peak of COVID-19. High anxiety levels even after the peak warrant serious attention. Late December of 2019, an epidemic of coronavirus disease 2019 (COVID-19) spread 30 rapidly from Wuhan, Hubei Province, China(1, 2) . Since then the Chinese government has 31 taken unprecedented public health measures to contain the outbreak. The epicentre has been 32 under complete lockdown since January 23, 2020. In just two months after the lockdown of to prevent the novel coronavirus are yet to be available, the society at large should continue 44 to sustain preventive practices to further contain the outbreak and prevent its re-emergence. 45 In addition to physical prevention measures, addressing negative attitudes toward infection remains an important aspect of the management and control of the outbreak. The 47 coronavirus outbreak has affected scores of global populations. The highly contagious and 48 fatal cases have provoked considerable negative attitudes, such as embarrassment, 49 social stigma and discriminatory behaviour against people with COVID-19 50 infection. Infectious disease negative attitudes have been recognized as major barriers to 51 timely and effective health care or treatment-seeking (6, 7). In addition, it may also affect the 52 emotion and mental well-being of a person (8). Therefore, efforts to combat the 53 new coronavirus should include addressing both the physical and the attitudinal barriers to 54 adherence to precautions for preventing the transmission. The COVID-19 pandemic is presenting a great challenge to the mental wellness of the people 56 in China, especially in Wuhan which was placed under strict lockdown(9).Likewise, the 57 pandemic also causes unprecedented mental health burden in the United States(10), United outbreak revealed that more than half of the public rated the psychological impact as 61 moderate to severe (15). Nevertheless, the study was conducted in 194 cities throughout 62 China, but information on the psychological well-being of people in the epicentre of the 63 outbreak is currently lacking. The escalating outbreak that lasted for nearly 2 months before 64 its peak, was deemed to have caused deep-rooted psychological distress to the public, 65 especially in the city of Wuhan. Now that the outbreak has ceased, it remains unclear what is 66 the extent of the consequences of the traumatic ordeals of COVID-19 on the public. Post-67 traumatic distress has been recognized as an important public health concern after a traumatic 68 event, as it may cause various functional impairments, including a person's work ability and 69 daily performance (16, 17) . The previous SARS outbreak evidenced serious consequences of 84 We commenced a cross-sectional, Web-based survey using an online questionnaire between 85 March 12th and 23rd, 2020. The inclusion criteria were that the respondents were residents of 86 Wuhan who were between 18 and 70 years old. The researchers used the social network, WeChat (the most popular messaging app in China), 89 to circulate the survey link to the residents of Wuhan. When participants completed the 90 survey, they received a note to encourage them to disseminate the survey link to all their contacts. The participants were informed that their participation was voluntary, and consent 92 was implied through their completion of the questionnaire. The questionnaire was developed 93 in English and was then translated into Chinese. Local experts validated the content of the 94 questionnaire, after which it was pilot-tested. The survey consisted of three sections, which 95 assessed i) demographic background, ii) barriers to prevention measures, iii) negative attitude 96 toward COVID-19, and iv) anxiety levels. Negative attitudes consist of questions about feelings of fear, avoidance, keeping a secret, 107 embarrassment, and stigma associated with COVID-19 (5-item). Optional answers were on a 108 4-point Likert scale, with the items scored as 1 (strongly disagree), 2 (disagree), 3 (agree), or 109 4 (strongly agree). The possible total negative attitudes score ranged from 4 to 20, with 110 higher scores representing higher levels of negative attitudes. The 6-item state version of the State-Trait Anxiety Inventory (STAI-6) assessing anxiety 113 levels that was used in this study was adapted from previous studies (19, 20) . The participants 114 rated the frequency of experiencing six emotional states, namely being calm, tense, upset, 115 relaxed, content, and worried, concerning the current COVID-19 outbreak. The participants 116 were asked to rate their current level of anxiety (defined as anxiety levels after the peak) and 117 their anxiety level during the early phase of the outbreak (during the first week of the 118 lockdown). A 4-point scale was used (1 = not at all, 2 = somewhat, 3 = moderately, 4 = very 119 much). The scores on the three positively worded items were reverse-coded. The total 120 summed scores were prorated (multiplied by 20/6) to obtain scores that were comparable 121 with those from the full 20-item STAI (giving a range from 20 to 80) (20). A cut-off score of 44 was used to indicate moderate to severe symptoms (21, 22). The differences in the level of 123 anxiety levels were calculated. Participants were grouped into 1) having current anxiety 124 levels lower than during the early phase of the outbreak − which is defined as having 125 decreased anxiety levels − and 2) having current anxiety levels similar or higher than the 126 early phase of the outbreak. A total of 2,411 complete responses were received. As shown in the first and second column 150 of Table 1 , slightly over half of the participants were females (55.6%) and the highest 151 educational level was university (51.3%). Slightly over one one-third (37.2%) of the participants were aged 31-50 years old. Distribution by income groups shows that most of the 153 participants were earning an average monthly income below CNY50,000 (43.5%) and 154 between CNY50,000 and 120,000 (31.9%). shown that a relatively higher proportion reported negative attitudes toward COVID-19 than 161 those toward physical prevention barriers. Over half reported strongly agree/agree with 162 regard to avoidance behaviour (56.2%), followed by embarrassment (39.9%) and fear 163 (38.8%). The mean and standard deviation (SD) for the total physical prevention barriers score was Table 1 shows the multivariable logistic regression analysis of 170 demographic characteristics associated with having a higher score in physical prevention 171 barriers. The age group 18−30 years reported a significantly higher likelihood of having high 172 physical prevention barriers score than those aged 51−70 (OR= 1.87; 95% CI (1.42 to 2.46). Participants on an average annual income >CNY130,000 (OR=2.01; 95% CI 1.56 to 2.60) 174 and CNY50,000 -120,000 (OR=1.52; 95% CI 1.23 to 1.86) reported a higher likelihood of 175 having a higher physical prevention barriers score than those earning