key: cord-0291987-kwd734xe authors: Silverman, R. A.; Short, D.; Wenzel, S.; Friesen, M. A.; Cook, N. E. title: COVID-19 related messaging, beliefs, information sources, and mitigation behaviors in Virginia: A cross-sectional survey in the summer of 2020 date: 2021-08-24 journal: nan DOI: 10.1101/2021.08.18.21262217 sha: 5cc768593af7fcd82494043d4566d49f06f54b9e doc_id: 291987 cord_uid: kwd734xe Conflicting messages and misinformation related to the coronavirus (COVID-19) pandemic (SARS-CoV-2) have hindered mitigation efforts. To gain insight and inform effective evidence-based public health messaging, we distributed an online cross-sectional survey from May to July, 2020. Among 3,488 respondents, systematic differences were observed in information sources that people trust, events that impacted beliefs and behaviors, and how behaviors changed by socio-demographics, political identity, and geography within Virginia. Characteristics significantly associated (p<0.05) with not wearing a mask in public included identifying as non-Hispanic white, men, Republican, younger age, lower income, not trusting national science and health organizations, believing a non-evidence-based messages, and Southwest Virginia in logistic regression. Similar, lesser in magnitude correlations, were observed for distancing in public. This study can assist decision makers and the public to improve and effectively target public health messaging related to the ongoing COVID-19 pandemic and future public health challenges in Virginia and similar jurisdictions. The early days of the coronavirus (COVID-19) pandemic (SARS-CoV-2) were 35 characterized by conflicting messaging from nearly all levels of national and international mass 36 media and government [1-4]. As public health and healthcare professionals attempted to quell the 37 growing panic with science-driven narratives, conspiracy theories and misinformation continued 38 to spread through social media platforms such as Facebook, Weibo, and Twitter, often 39 undermining or contradicting the life-saving messages that scientists were trying to communicate 40 [5, 6] . This issue was further compounded by long-standing health, socioeconomic, and racist 41 inequities as well as sharp decreases in funding to state and federal health agencies in the United 42 States [5] . Throughout the pandemic, access to and acceptance of evidence-based messaging to 43 prevent and respond to outbreaks of coronavirus disease (COVID-19) have been inconsistent 44 across populations [7] . Black, Hispanic, and Indigenous populations have been historically 45 excluded from the United States' public health and medical institutions, often suffering 46 disproportionately from many diseases and public health challenges [8, 9] . When combined with 47 the knowledge that ethnic minority, low-income, low-education, and elderly populations are 48 overrepresented in COVID-19 related morbidity and mortality numbers, public health officials 49 will need to effectively reach out to and target those particular groups [10] [11] [12] . 50 Several surveys have evaluated the awareness and concern that members of the public 51 have experienced towards COVID-19 and local, state, and national government responses [7, 52 13] . Results showed that the majority of the general population wants to hear from public health 53 and medical officials, and are likely to trust professional sources that have self-protective and 54 pro-social messages that focus on positive ways to protect themselves and their loved ones [14, 55 that focus on adverse side-effects, misleading medical content, and unsubstantiated rumors [22] . 79 Similar methods have been used to undermine prior vaccine campaigns, and developing effective 80 messaging to counter such disinformation will likely prove to be an important challenge for 81 public health officials [23, 24] . 82 Like many other large states, Virginia has had notable regional differences in case trends 83 over time, with the more densely populated northern and central regions experiencing large case 84 increases during the pandemic's initial wave in the spring of 2020, while the coastal eastern 85 region and the more rural southwestern region experiencing their first large case increases mid-86 summer [25] . Some Virginia college towns, such as Charlottesville, Blacksburg, and 87 Harrisonburg, saw increases in local case counts when students returned in the late summer and 88 mid-winter of 2020-21, showing that the movement of large groups of people can greatly affect 89 community spread in less densely populated areas [26] [27] [28] . Given the continued need for 90 effective evidence-based public health messaging, officials, researchers, and the public can 91 benefit from exploring how people receive information they believe and trust, and how their 92 beliefs influence their behaviors. To gain better insight, we conducted a cross-sectional survey 93 during the summer of 2020 to examine COVID-19 related messaging, beliefs, information 94 sources, and mitigation behaviors among adults in Virginia. 95 3% were Hispanic, 83% were non-Hispanic White, 5% were Black, 3% were Asian, and 87% 143 identified as heterosexual or straight. Six percent were 18-24 years old, 6% were 25-29, 16% 144 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 158 All but 16 respondents (0.5%) answered the question: "Where do you get information 159 that you trust about coronavirus/COVID-19?" Of these (n=3,472), most reported national science 160 and health organizations (85%) as a trusted source for COVID-19 information and over 50% of 161 respondents reported state/local health departments (75%), healthcare professionals (74%), and 162 online news sources (55%) as a trusted source. Information sources reported by less than half of 163 respondents included family and friends (26%), faith leader (4%), local TV news (34%), national 164 TV news (49%), printed newspaper (20%), radio (20%), social media (22%), local government 165 leaders (46%), and federal government leaders (22%). Only 2% of these respondents reported 166 not following any COVID-19 updates (see Fig 2a) . that you trust about coronavirus/COVID-19? (Check all that apply)" for all respondents (2a), and 171 by gender (2b), age-group (2c), race/ethnicity (2d), political identity (2e), education level (2f), 172 income level (2g), and Virginia region (2h). 173 More women than men received information they trusted from local government leaders 175 (48% vs. 41%), and state or local health departments (77% vs. 73%) and more men than women 176 received information they trusted from family/friends (31% vs. 25%), and federal government 177 leaders (26% vs. 20%), all of which were statistically significantly difference (p<0.05) (see Fig 178 2b ). Young adults age 18-24 were more likely than those of all older ages combined to receive 179 trusted information from family and friends (39% vs. 25%) and social media (31% vs. 21%) and 180 less likely from printed news (6% vs. 21%), radio (10% vs. 21%), and local government leaders 181 (36% vs. 47%) (see Fig 2c) . Slightly less non-Hispanic White and Asian respondents received 182 trusted information from faith leaders (4% and 3%, respectively) than other races including 9% 183 of Black and 10% of multiracial respondents. Non-White were also more likely than White 184 respondents to receive information from local TV news (42% vs. 33%), and social media (27% 185 vs. 21%) (see Fig 2d) . White respondents were more likely than non-White respondents to 186 receive information from printed local newspaper (21% vs. 14%), national science and health 187 organizations (87% vs. 82%), or state and local health departments (77% vs. 71%) (see Fig 2d) . 188 More Democrats than Republicans received information they trusted from national science and 189 health organizations (93% vs. 72%, respectively), State or local health department (83% vs. 190 62%), online news (65% vs. 41%), national TV news (55% vs. 43%), local government leaders 191 (54% vs. 46%), printed newspaper (45% vs. 13%) and radio (26% vs. 14%) (see Fig 2e) . More 192 Republicans than Democrats received information they trusted from federal government leaders 193 (46% vs. 13%), faith leaders (6% vs. 3%), or did not follow coronavirus/COVID-19 updates (5% 194 vs. 0.3%). Similar proportions by political identity received information from local TV news, 195 family/friends, healthcare-professionals, and social media. Other differences presented in Fig 2 196 were not statistically significant (p≥0.05). 197 More of those with than without a college degree received information from local printed 198 newspapers (22% vs. 13%), radio (22% vs. 15%), online news (58% vs. 44%), local government 199 leaders (47% vs. 43%), national science and health organizations (89% vs. 74%), and State or 200 local health departments (79% vs. 64%) (see Fig 2f) . More of those without than with a college 201 degree received information from local faith leaders (6% vs. 4%), local TV news (38% vs. 33%), 202 and federal government leaders (26% vs. 20%). More higher-than middle-and lower-income 203 individuals received information from local printed newspapers (23%, 18%, 15%), online news 204 (58%, 55%, 51%), local government leaders (49%, 43%, 45%), national science and health 205 organizations (89%, 84%, 83%), and State or local health departments (80%, 77%, 70%) (see Fig 206 2g ). Differences in information sources were also observed across regions (see Fig 2h) . 207 208 Twenty-three percent of respondents reported being "very worried" about catching 209 COVID-19 and 34% were "very worried" about experiencing severe disease or complications if 210 they were to catch COVID-19. Most respondents considered COVID-19 to be very serious 211 (82%) or somewhat serious (13%). Statistically significant differences (p<0.05) were found 212 between women vs. men (85% vs. 77%), Democrats vs. Republicans vs. others (95% vs. 61% vs. 213 78%), those 60 or more years old vs. those under 60 years old (91% vs. 81%), LGTBQ+ vs. 214 heterosexual (89% vs. 83%), and higher-income vs. lower-income (86% reporting $100,000 vs. 215 78% making less than $20,000), and those with vs. without a college degree (86% vs. 75%) 216 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 24, 2021. ; https://doi.org/10.1101/2021.08.18.21262217 doi: medRxiv preprint considered COVID-19 to be very serious. Other demographic characteristics were not 217 statistically significantly different in terms of perceived seriousness of COVID-19. Differences 218 by race and ethnicity were also observed with 91% of Asian, 87% of Black and Hispanic, 84% of 219 multiracial and White, non-Hispanic respondents reporting they believed COVID-19 to be very 220 serious. 221 Among those who answered the question: "Which if any of the following impacted your 222 belief that COVID-19 was serious" (n=3,371), more than half selected hearing about COVID-19 223 in other countries (77%) or other states (73%), public-school closings (69%), the governor 224 recommending a stay-at-home order (51%), mandating a stay-at-home order (65%), and 225 declaring a state of emergency (68%), the CDC recommending that everyone wear a face mask 226 in public (67%), restaurant dining rooms shutting down, (58%), and sporting events being 227 canceled or postponed (52%) (see Fig 3a) . Less than half selected becoming sick (3%) or 228 knowing someone who became sick (30%), being high-risk or living with some-one who is high-229 risk for severe disease (40%), starting to work from home (35%), being laid off or losing their 230 job (5%), when stores began limiting purchases of essential items (42%), when religious services 231 were moved online (40%), and when a public figure tested positive (17%). Two percent of those 232 who responded to this question said they did not think COVID-19 is serious, and 11% selected 233 some other reason not listed in the survey. whether or not you think the coronavirus/COVID-19 is serious? (Check all that apply)" for all 238 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 24, 2021. ; https://doi.org/10.1101/2021.08.18.21262217 doi: medRxiv preprint respondents (3a), and by gender (3b), age-group (3c), race/ethnicity (3d), political identity (3e), 239 education level (3f), income level (3g), and Virginia region (3h). 240 241 Among those who answered the question: "Which if any of the following impacted your 242 belief that COVID-19 was serious," women were statistically significantly (p<0.05) more likely 243 than men to state someone they knew became sick (31% vs. 26), being or living with someone 244 high-risk (42% vs. 32%), public schools closing (71% vs. 63%), the governor declaring a state of 245 emergency (70% vs. 63%), the CDC recommending face masks (69% vs. 63%), hearing about it 246 in other countries (78% vs. 75%) and states (74% vs. 69%), stores limiting purchases (43% vs. 247 38%), religious services gong online (41% vs. 35%), and the governor recommending a stay at 248 home order (52% vs. 47%) and mandating stay at home order (68% vs 57%) (see Fig 3b) . Young 249 adults were more likely than all other age-groups combined to select restaurant dining rooms 250 (66% vs. 57%), being furloughed (laid off) or losing their job (16% vs. 4%), stores limiting 251 purchases, (52% vs. 42%), and a public figure testing positive (26% vs. 17%) and less likely to 252 select hearing about COVID-19 in other countries (72% vs. 78%), the governor recommending a 253 stay-at-home order (41% vs. 52%), though this is not true for when the governor mandated the 254 stay-at-home order (68% vs 66%) compared to other age groups (see Fig 3c) . Non-white people 255 were more likely than white people to select personally becoming sick (6% vs. 2%) or someone 256 they knew becoming sick (45% vs. 28%), stores limiting purchases (52% vs. 41%), religious 257 services moving online (47% vs. 39%), and a public figure testing positive (23% vs. 17%) (see 258 Fig 3d) . Democrats were more likely than Republicans to select knowing someone who was sick 259 (32% vs. 24%), public schools closing (74% vs. 62%), restaurants closing (61% vs. 53%), the 260 governor declaring a state of emergency (80% vs. 45%), starting to work from home (40% vs. 261 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 3f) . More of those without than with a college degree 270 reported their believe was impacted by becoming sick (5% vs. 3%), being or living with 271 someone who is high-risk (47% vs. 39%), being furloughed (laid off) from work (9% vs. 4%), 272 stores limiting purchases (46% vs. 41%) and religious services moving online (46% vs. 38%). 273 Fewer higher-income (>$100,000) than middle-income ($60,000-$99,999) and lower-274 income (<$60,0000) reported their belief was impacted by being or living with someone who is 275 high-risk (37%, 41%, 44%), being furloughed (laid off) from work or losing their job (4%, 5%, 276 9%), stores limiting purchases of essential items (37%, 46%, 48%), religious gatherings being 277 moved online (36%, 42%, 41%), a celebrity getting testing positive for COVID-19 (16%, 16%, 278 22%), and/or the governor recommending a stay at home order (49%, 55%, 52%). More higher-279 than middle-and lower-income reported beginning to work from home (39%, 35%, 32%), and 280 hearing about COVID-19 in other countries (80%, 77%, 75%) (see Fig 3g) . Differences in what 281 impacted the beliefs that COVID-19 was serious were also observed across regions (see Fig 3h) , 282 with statistically significant differences (p<0.05) observed for becoming sick, knowing someone 283 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 24, 2021. ; https://doi.org/10.1101/2021.08.18.21262217 doi: medRxiv preprint who became sick, being or living with someone at high risk, beginning to work from home, and 284 sporting events being cancelled or postponed. 285 286 Over 80% of respondents reported that one or more of the following evidence-based 287 messages impacted their beliefs and/or behaviors: "the coronavirus is highly contagious;" "stay 288 home stay safe;" "stay home, save lives, slow the spread;" "practice social distancing;" "don't 289 touch your face;" and "wash your hands for at least 20 seconds" (see Fig 4) . Twelve percent of 290 respondents reported believing in one or more of the following alternative messages: COVID-19 291 "was developed as a bioweapon" (6%), "was developed to lower social security payments to 292 seniors" (1%), "is a sign of the apocalypse/end times" (3%), "is a hoax" (1%), "can be treated 293 with natural remedies" (3%), "was developed for population control" (3%), and/or "was 294 developed to increase sales of cleaning supplies" (4%). The same proportion (12%) of men and women (see Fig 5a) , more young adults vs. older 303 ages combined (22% vs. 12%), with the lowest among those 70 years old and greater (5%) (see 304 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 24, 2021. ; https://doi.org/10.1101/2021.08.18.21262217 doi: medRxiv preprint Fig 5b) , less of those who identified as non-Hispanic White (10%) compared to other 305 races/ethnicities including 37% of Black, 22% of multiracial, 21% of Hispanic, and 15% of 306 Asian (see Fig 5c) , more Republicans (24%) than Democrats (7%) and others (15%) (see Fig 5d) 307 believed in one of more alternative messages. The percent of those who believed in one of more 308 alternative messages decreased with increasing education (29% of high-school degree or less to 309 6% of those with a doctoral degree) (see and/or changed your behavior based on each message" by gender (5a), age-group (5b), 318 race/ethnicity (5c), political identity (5d), education level (5e), income level (5f), and Virginia 319 region (5g). Alternative messages response options include: COVID-19 "was developed as a 320 bioweapon," "was developed to lower social security payments to seniors," "is a sign of the 321 apocalypse/end times," "is a hoax," "can be treated with natural remedies," "was developed for 322 population control," and "was developed to increase sales of cleaning supplies." 323 324 325 Those who believed in an alternative message were statistically significantly more likely 326 than those who did not to receive trusted information from family and friends (32% vs. 26%), a 327 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 24, 2021. ; https://doi.org/10.1101/2021.08.18.21262217 doi: medRxiv preprint faith leader (8% vs. 3%), local TV news (38% vs. 33%), social media (29% vs 21%), federal 328 government leaders (33% vs. 20%), or report not following COVID-19 updates (see Fig 5h) . 329 Those who did not believe any alternative messages were more likely than those who did to 330 receive trusted information from a healthcare professional (74% vs. 69%), local newspaper (21% 331 vs. 13%), radio (21% vs. 15%), online news (57% vs, 45%), local government leaders (48% vs. 332 38%), national science and health organizations (88% vs. 67%), and state or local health 333 departments (78% vs. 59%). 334 335 (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 6c) , more Democrats than Republicans and others (97%, 77%, and 87%, 358 respectively), increased by education level from 76% of those with a high-school education or 359 less to 94% of those with a doctoral degree, and more higher-than middle-and lower-income 360 (92%, 89%, 87%). Those in Southwest Virginia reported less mask wearers (86%) than other 361 regions (91%-95%) (see Fig 6f) . Distancing was more common than masking in all groups, but 362 showed similar demographic trends as wearing a mask. 363 More of those who reported wearing vs. not wearing a mask reporting national health and 364 science organizations (89% vs. 58%), state or local health departments (78% vs. 51%), health 365 care professional (75% vs 64%), online news (57% vs. 38%), local government leaders (49% vs. 366 24%), local TV news (35% vs. 26%), local newspaper (21% vs. 6%), and radio (21% vs. 13%) as 367 a trusted source of information (see Fig 6i) . A smaller proportion of those who reported wearing 368 vs. not wearing a mask reported the federal government as a trusted source (21% vs. 28%) or not 369 following COVID-19 information (1% vs. 12%). Similar trends were observed for distancing 370 (see Fig 6j) . 371 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 2 ). The odds of reporting not wearing a mask in public was 378 greater for those identifying as a Republican vs. Democrat (OR=5.42, 95% CI= 3.63, 8.09), those 379 who did not vs. did report national science and health organization(s) as a trusted information 380 source (OR= 3.16, 95% CI= 2.21, 4.51), those who believed one or more alternative messages 381 vs. not believing in any (OR= 2.09, 95% CI= 1.48, 2.94). Not having a college degree was 382 associated with not wearing a mask in unadjusted analyses (OR= 1.98, 95% CI= 1.54, 2.55) but 383 in adjusted analyses (OR= 0.98, 95% CI= 0.71, 1.35). All other associations were statistically 384 significant (p<0.05) in both adjusted and unadjusted analyses. Odds ratios for distancing showed 385 similar associations as for masking, but at a smaller magnitude. Region, gender, race/ethnicity, 386 and education were not statistically significant (p<0.05) in adjusted analyses for distancing. 387 (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. In a convenience sample of adults residing in Virginia, we found many differences in 394 where people received information that they trust, what they believed, and how their behaviors 395 changed in response to the COVID-19 pandemic by socio-demographics, political identity, and 396 geography within Virginia. Respondents who identified as non-Hispanic White, men, 397 Republican, other political identity, younger age, income <$100,000, did not report national 398 science and health organizations as a trusted source, reported believing an alternative message, 399 and/or living in Southwest Virginia had greater odds of not wearing a mask than their 400 comparative groups in both unadjusted and adjusted logistic regression. Differences in physical 401 difference were also observed for physical distancing for these same variables, but at a lower 402 magnitude as distancing was more likely than masking across all groups so differences were less 403 pronounced. 404 Our study was subject to several limitations. First, we conducted numerous comparisons 405 and did not adjust for multiple comparisons due to the exploratory nature of this study and some 406 statistically significant associations could be due to chance. Second, complete demographic and 407 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. showed that while older adults were generally more concerned and had higher anxiety levels 427 about potential COVID-19 infection, they were also less concerned than younger adults about the 428 short-and long-term economic instabilities caused by the pandemic [30-33, 36, 40]. Other 429 studies also found that women, racial/ethnic minorities, and those with lower socioeconomic 430 All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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