key: cord-0707194-510k36vj
authors: Yousef Yang, X.; peng, S.; Yang, T.; Rockett, I. R. H.
title: Changing trends of excess self-protective behavior, and association with belief in prevention myths during the COVID-19 epidemic in China: A panel study
date: 2020-05-20
journal: nan
DOI: 10.1101/2020.05.18.20102434
sha: 80465bef9e56020f334c68c5128c2b0577ccdb2c
doc_id: 707194
cord_uid: 510k36vj

Abstract Objective This prospective observational study examined changing trends of excess self-protective behavior (EPB), and its association with perceived risk, severity and belief in prevention myths during the Chinese COVID-19 epidemic. Methods The study employed a longitudinal design. Participants were recruited for an online panel survey from chat groups on social media platforms. Descriptive statistics and the CATMOD program were used for data analysis. Findings Participants numbered 150 for the linkable baseline survey and 102 for the final survey. There were 5 waves of interviews. The prevalence of participants perceiving a personal risk of contracting COVID-19, and severe consequences of the disease, was 18.6% and 25.5%, respectively. Their prevalence had declined to 4.9% and 17.6%, respectively, by the last observation point. The 5 selected EPBs also manifested a decreasing trend. Belief in COVID-19 prevention myths trended upwards. Perceived risk was positively associated with each EPB, and perceived severity with disinfection of clothes and hoarding of products. Myth adherence was positively associated with disinfection of clothes and both hand washing and sanitization. Conclusion This study yielded new information about EPB among the public during the COVID-19 epidemic. Policy and health education modifications are essential for minimizing the adverse health effects of subscribing to prevention myths.

fundamentally 'rational' in terms of what the actor believes to be true, but in his or her practice comprises irrational as well as rational elements [17] .Irrational beliefs are rigid, inaccurate and illogical, but are used defensively to process external events. Unlikely to find empirical support, these beliefs are self-defeating, unconditional and in conflict with reality [18] .Many studies found that that the more irrational the belief, the more negative the health behaviours [16, 18, 19] .Irrational beliefs commonly manifest in many social and health areas [8] .

Survival is a biological imperative for humans, and self-protection is the common behavioral response for confronting a mortal crisis. In sudden major crises, coping can induce excess self-protective behavior (EPB). COVID-19's evolution on the world scene has not been paralleled by any other communicable disease since the 1918 Spanish Flu pandemic; a catastrophic phenomenon that killed an estimated 50-100 million people globally. The dire threat to personal health and survival, posed by the COVID-19 pandemic, has quickly promoted perceptions of high risk for infection with potentially severe outcomes. In turn, these responses can be a strong stimulus for EPB.

EPB may be disproportionate and not recommended as an effective response to the actual threat; thus, overburdening individuals and society and sparking diversion of scarce critical resources away from places where need for assistance is most acute [10] .In cognitive science, EPB emanates from people's fear and distorted view of the world [8] . Therefore, irrational beliefs or subscription to myths about COVID-19 prevention measures could stimulate pervasive EPB. EPB consumes a high degree of personal physical energy, and in the process diminishes disease immunity. Excessive protective measures can overstress healthcare facilities and other resources, and consequently exert a strong negative impact upon the economy and society as a whole [20] .For example, panic buying of essential consumer items like toilet paper, first aid kits, bottled water, and hand sanitizer, in response to COVID-19, has led to global shortages and price gouging of consumer staples [20] .This response

We conducted a prospective longitudinal observation study to examine temporal trends and changes in EPB, and its associations with selected perceptions and beliefs during the COVID-19 pandemic.

Participants were recruited via a survey advertisement from social media groups on WeChat and Douban, two of the most popular social media platforms in China. Inclusion criteria were membership in a common community; being in the age group 20-60 years; having access to a Smartphone; knowing the Chinese language; and willing to participate in the panel study and provide follow-up information at the scheduled observation points. Participants were excluded if they refused to provide this information or had a medical condition that could limit or preclude their participation. Within the registration system, potential participants were screened to ascertain eligibility. Upon consent, participants received an electronic questionnaire and instructions on how to proceed. After reading the instructions, they were asked to provide an e-consent by tapping the "Confirmation and Authorization" button and then directed to the questionnaire. A special administrative WeChat group was established to manage the follow-up data collection, using a unique QR code for each respondent. The QR code was the vehicle not only for identifying unique participants but prohibiting non-participants from taking the survey. After scanning the QR code, survey participants could enter the investigation group without further preconditions.

This panel study analyzed five waves of data collected over a month: wave 1(5/Feb/2020), wave 2(12/Feb/2020), wave 3(19/Feb/2020), wave 4 (26/Feb/2020), and wave 5(4/March/2020). The entire observation period covered the peak and trough of the COVID-19 epidemic in China. Diagnosed patients respectively numbered 3,887, 2,015, 394, 433, and 133 at the time of each wave (National Health Commission of People's Republic of China, 2020).

An online survey was implemented on Wenjuanxing (www.wjx.cn), a survey service website similar to Qualtrics or Surveymonkey, but tailored to Chinese users. Each wave of the survey had a dedicated electronic questionnaire access link. The online questionnaire link was posted to the respondent group, centrally managed in a WeChat group, and accessible every Wednesday from 10:30 am to 4:30 pm. Data were collected from 9:00-11:00 am every Monday. Data collectors and facilitators were third-year doctoral students in a public health program. All responses were anonymous. The questionnaire took approximately 10 minutes to complete, and the same survey 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 May 20, 2020. . https://doi.org/10.1101/2020.05.18.20102434 doi: medRxiv preprint protocol was used for every wave of the survey to assure homogeneity of data administration and collection. This study was approved by the ethics committee of Zhejiang University. As appropriate, a token of appreciation, a total of 30 RMB was given to those participants who completed all 5 questionnaires.

In this study, basic individual demographic characteristics were tapped: age, gender, ethnicity, education level, marital status and occupation. Perceptions of risk and disease severity were respectively captured through the items "continual fear of infection by COVID-19"and "becoming be deported back to their place of origin. Items were rated on a 5-point Likert-type scale, which ranged from 1 (strongly disagree) to 5 (strongly agree). Item scores were summed to attain a total score for belief in COVID-19 prevention myths. The higher that score, the greater the level of irrational prevention belief. The Cronbach's α coefficient was 0.70, suggesting the questionnaire had to handle their family and occupational responsibilities if, and when, they contracted COVID-19 (Transferring responsibilities).

All data were entered into a database using Microsoft Excel. They were then imported into SAS (9.3version) for the statistical analysis. Across survey waves, descriptive statistics were calculated for belief in prevention myths, perceived high risk for contracting the disease, perceived high severity of disease consequences, and EPB prevalence. The CATMOD program was used to conduct repeated measures analysis of variance to determine changing trends across the five observation points, and to examine the association between perceived disease risk and severity, and belief in prevention myths, respectively, with EPB using the method of weighted least squares [21] .

One hundred-and-fifty participants were recruited at baseline. The baseline was linkable and there were three intermediate and a final observation point, with 102 participants available for analysis throughout; 99 came from 24 provinces located across China, differentiated by region. The remaining 3 were international.

Of the study sample, 61.8% were female and 93.1% were Han Chinese. The average age of participants was 39.1 years (SD: 12.5), 43.1%were never married, and 50.0% were married (Table 1) .

The prevalence of belief in COVID-19 prevention myths was higher among males than females (OR: 3.33) and increased with age (OR: 6.64, 7.31). Married people had a lower prevalence of high perceived risk (OR: 0.36), and the middle-aged (40-49 years) had a higher prevalence of perceived disease severity than comparison groups (OR: 1.85). Disinfection of clothes was less prevalent among females than males (OR: 0.34), and among professionals than people in other occupational groups (OR: 0.35). Hand washing was more prevalent among females than males (OR: 3.48) and less prevalent among the married than the never married (OR: 0.43). Hoarding products was more prevalent among females (OR: 2.46), the middle-aged (OR: 4.32), the least educated (OR: 0.32), and the married than their respective demographic counterparts (OR: 0.13).

All participants knew the disease had attained epidemic proportions and was highly contagious at the time of the first survey was implemented. The prevalence at baseline of the perceptions of high risk of contracting COVID-19 and disease severity was 18.6% and 25.5%, respectively, and declined to 4.9% and 17.6% by the last observation point-a statistically significant change. The prevalence of the five types of EPB showed a statistically significant downwards trend across the total observation 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 May 20, 2020. . https://doi.org/10.1101/2020.05.18.20102434 doi: medRxiv preprint period of this panel study. Simultaneously, there was a statistically significant upwards trend in belief in COVID-19 prevention myths (Table 2) .

Perceived high risk for contracting COVID-19 was positively associated with each type of selected EPB, and perception that the disease had severe consequences was positively associated with disinfection of clothes and hoarding of products. Belief in the disease prevention myths was positively associated with disinfection of clothes and both hand washing and sanitization (Table 3) .

At baseline, this study found that 18.6% and 25.5% participants, respectively, believed they were at high risk of contracting COVID-19, and that this disease seriously threatened their health. Turning to previous studies, one found approximately 10-30% of the general public were very worried or moderately worried about the possibility of contracting influenza during an outbreak [22] . Another reported that during the period February 1 st through 10 th , when disease cases were increasing dramatically, 15.3% of Shanghai and Wuhan residents perceived COVID-19 as a very serious disease [23] . Our research commenced at the peak of the epidemic, and one-fifth to one-quarter of study participants perceived the disease was very serious and their risk of contraction was high.

COVID-19 is a new disease, and the epidemic may profoundly impact people mentally and behaviorally. Viewed as a stimulus, this disease can be overwhelming and elicit strong mental and behavioral responses. Many studies have found that COVID-19, now a global pandemic, generates negative mental and behavioral outcomes[9,10] that may include inappropriate health-protective and help-seeking behaviours [20] . mobilized all of their physical and mental energy to cope with COVID-19 at the beginning of the epidemic. However, as time passed, such energy waned and rational thinking diminished as belief in prevention myths became more common. This information is useful for formulating prevention policy and educational programming.

The risk of disease or injury and the severity of outcomes are crucial themes in individual health behavior. This study provided new evidence that perceived risk of contracting COVID-19 and perception of the severity of its consequences were both positively associated with several types of EPB, findings generally compatible with those from some other studies[3,4,12].We found a negative association between belief in prevention myths and some of the constituents of EPB. Affirmation for our findings, other investigators also found a relationship between such a belief and negative health behaviour [16.18] .

EPB transcends normal self-protective behaviors, with special significance from a disease prevention perspective. For effective prevention, it is necessary both to avoid inadequate prevention measures that increase the likelihood of a disease epidemic, and to avoid excessive activities that waste personal and social resources. These two scenarios may vary across cultures. Inadequate prevention may be a prominent problem in Western culture and excessive prevention in Eastern culture [8] . A related dimension of such cultural variance is societal "rigidity" versus "porousness" [26] ."Rigid" cultures, such as those of Singapore, Japan, and China, have strict social norms and punishment for deviance, whereas "porous" cultures, such as those characterizing the U.S., Italy, and Brazil, reflect weaker social norms and greater permissiveness [27] ."Qǐ rén yōu tiān" from ancient China is a tale about a person who worried every day the sky would collapse. This study found that in the COVID-19 epidemic there was pervasive over-prevention among members of the public. Excessive prevention consumes too much personal energy and societal resources, and hence impedes disease control and economic recovery. Government and society at large must give this issue more attention.

Reforms in health policy and health education will be essential for minimizing the adverse effects of belief in prevention myths and associated deleterious behavior.

There are two study limitations. First, our sample size is small. Nevertheless, the sample originated from 24 provinces covering diverse regions and a wide array of demographic characteristics. On the other hand, sample attrition may introduce a "cluster" bias since many longitudinal studies likely over-represent some of these characteristics, such as high educational attainment. A more sophisticated design and representative sample would be necessary to resolve this problem. A secondly limitation in this study is the lack of a clear definition of EPB. We operationalized this concept through empirically identifying 5 constituents from a social norms perspective.

Operationalization of the concept of belief in prevention myths may so be thought as an external 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 May 20, 2020. . https://doi.org/10.1101/2020.05.18.20102434 doi: medRxiv preprint criterion for measuring the validity of EPB [8, 16, 19] . Belief in prevention myths was significantly associated with 3 of the 5 types of EPB we utilized in this study. This finding enhances the validity of our measure of EPB. The concept and its operationalization requires further research

This study provides new information on the relationship between belief in COVID-19 prevention myths and EPB among the Chinese public, in the context of perceived risk of contracting the disease and perception of the severity of its consequences during the epidemic. As the virus spreads relentlessly around the globe, our findings could guide similar research outside China in less and more developed countries. They harbor important implications for understanding and decreasing EPB, as appropriate, during this new global pandemic.

The authors declare that they have no competing interests 

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