key: cord-0818053-zc6tb53a
authors: Smith, Louise E.; WW. Potts, Henry; Amlot, Richard; Fear, Nicola T.; Michie, Susan; James Rubin, G.
title: Worry and behaviour at the start of the COVID-19 outbreak: results from three UK surveys (the COVID-19 Rapid Survey of Adherence to Interventions and Responses [CORSAIR] study)
date: 2021-12-27
journal: Prev Med Rep
DOI: 10.1016/j.pmedr.2021.101686
sha: e502b083d53ee435f8c98970b128264a9f882404
doc_id: 818053
cord_uid: zc6tb53a

We aimed to describe worry and uptake of behaviours that prevent the spread of infection (respiratory and hand hygiene, distancing) in the UK at the start of the COVID-19 outbreak (January and February 2020) and to investigate factors associated with worry and adopting protective behaviours. Three cross-sectional online surveys of UK adults (28 to 30 January, n=2016; 3 to 6 February, n=2002; 10 to 13 February 2020, n=2006) were conducted. We used logistic regressions to investigate associations between outcome measures (worry, respiratory and hand hygiene behaviour, distancing behaviour) and explanatory variables. 19.8% of participants (95% CI 18.8% to 20.8%) were very or extremely worried about COVID-19. People from minoritized ethnic groups were particularly likely to feel worried. 39.9% of participants (95% CI 37.7% to 42.0%) had completed one or more hand or respiratory hygiene behaviours more than usual in the last seven days. Uptake was associated with greater worry, perceived effectiveness of individual behaviours, self-efficacy for engaging in them, and having received more information. 13.7% (95% CI 12.2% to 15.2%) had reduced the number of people they had met. This was associated with greater worry, perceived effectiveness, and self-efficacy. At the start of novel infectious disease outbreaks, communications should emphasise perceived effectiveness of behaviours and ease with which they can be carried out.

-In Jan-Feb 2020, 20% of the sample were very or extremely worried about COVID-19.

-40% of participants completed hand or respiratory hygiene behaviours more than usual.

-14% of the sample reduced the number of people they met before any restrictions.

-Uptake of protective behaviours was associated with greater worry about COVID-19.

-Higher effectiveness and self-efficacy for behaviours were associated with uptake.

The early stages of novel infectious disease outbreaks are usually characterised by uncertainty. Unknowns include basic details about transmissibility, disease severity, risk factors for disease, mode of transmission, and degree of population immunity. In the very early stages of the COVID-19 outbreak, the UK public were exposed to a morass of epidemiological information, disagreements between scientists about the status of the outbreak and its likely future path, frequent admissions of uncertainty from trusted sources, and online confusion, speculation and conspiracy theories. (1) In the midst of this, national governments attempted to prepare their citizens for a possible public health crisis and to convey information about behaviours that may help to slow the spread of disease. (2) Uptake of protective behaviours are driven by a more negative appraisal of the threat (greater perceived susceptibility and severity) and a more positive appraisal of the coping response (greater perceived effectiveness and belief that if you wanted to carry out the behaviour, you could [greater perceived self-efficacy]). (3) (4) (5) Threat appraisal is likely to be directly linked to the number of infections in one's locality. In the UK, the first two cases of COVID-19 were declared on 31 January 2020 (6) with seven further cases detected in the subsequent two weeks (see Box 1) . During the influenza A H1N1 pandemic, worry was associated with volume of media reporting seen.(5) On 2 February 2020, a public information campaign was launched by the Department of Health and Social Care, England, advising the UK population to adopt respiratory and hand hygiene behaviours.(7) At the same time, media reports discussed strategies used to prevent transmission in other countries, including restrictions of movement, such as placing regions under "lockdown" measures, (8) and reducing contact with others (now known as "physical" or "social distancing"). Trust in the source of information also influences the impact of communications. (9) (10) (11) At the time of the emergence of COVID-19, politicians were the country's least trusted profession. (12) Box 1. Timeline of the start of the COVID- 19 Many studies have been published investigating uptake of behaviours that prevent the spread of infection, and factors associated with uptake, at the start of the COVID-19 pandemic (e.g. (13, 14) ). However, most of these were conducted as the first set of restrictions were introduced during the first wave of the infections (March 2020). Few studies investigated public sentiments and behaviour before this. One study conducted in Italy found that 67% of survey respondents reported washing their hands more often than usual, while 43% cancelled meetings (data collected 24 to 29 February 2020). (15) Another study conducted in Croatia found that women and people without children were more likely to carry out protective behaviours (data collected beginning 24 February 2020; end date not reported). (16) In the UK, a survey conducted by a market research company showed that 56% of respondents were concerned about COVID-19, 62% were washing their hands with soap and water, and 28%

were avoiding large gatherings of people or certain locations (data collected 27 to 29 February 2020).(17) To the best of our knowledge, there are no publicly available data reporting on public sentiment and behaviour in the UK before this date.

In this study, we report data from the first three weekly waves (28 January to 13 February 2020) of a national survey carried out during the COVID-19 outbreak. We assessed population levels of worry, respiratory and hand hygiene behaviours, and reducing the number of people that you met. We investigated associations between worry and sociodemographic characteristics and perceived risk of COVID-19. We investigated associations between self-reported behaviour and sociodemographic characteristics, psychological and contextual factors.

Weekly online surveys were conducted by BMG research on behalf of the English Department of Health and Social Care (DHSC) (Wave 1: 28 to 30 January 2020, n=2016; wave 2: 3 to 6 February 2020, n=2002; wave 3: 10 to 13 February 2020, n=2006). We analysed these data as part of the CORSAIR study [the COVID-19 Rapid Survey of Adherence to Interventions and Responses study]).(18) Standard opinion polling methods (non-probability sampling) were used to aid rapid data collection, which was essential during the evolving crisis.

Participants were recruited from Respondi, a specialist research panel provider (n=50,000) and were eligible for the study if they were aged 16 years or over and lived in the UK. Quotas based on age and gender (combined) and Government Office Region reflected targets based on the Office for National Statistics. (19) Participants were reimbursed in points (equivalent to approximately 25p) that could be redeemed in cash, gift vouchers or charitable donations.

The survey for waves 1 and 2 was developed by DHSC, based on materials developed in 2014 in preparation for a future influenza pandemic by our team. (20) These items were refined in three rounds of qualitative interviews (n=78) and had their test-retest reliability checked in two telephone surveys (n=621). (21) . Survey materials were substantially expanded in wave 3 (see Appendix A for full items). Unless stated otherwise, we recoded answers of "don't know" as missing data.

Participants were asked how worried about COVID-19 they were on a five-point scale (asked in all survey waves). We recoded this item as a binary variable ("not at all", "not very", or "somewhat worried" versus "very" or "extremely worried").

We asked participants if, in the last seven days, they had completed respiratory and hand hygiene behaviours such as washing hands thoroughly and regularly, using hand sanitiser and tissues, and cleaning surfaces "as much as usual," "more than usual," "not done this," or "not applicable" (see Appendix A; wave 3 only). We created a single binary variable indicating whether a participant had completed one or more respiratory or hand hygiene behaviour "more than usual". For these analyses, answers of "not applicable" were counted as not having completed the behaviour "more than usual".

Participants were also asked whether they had reduced the number of people they had met in the past seven days (wave 3 only). Answers were recoded to give a single binary variable (reduced the number of people met versus not).

Participants were asked to what extent they thought COVID-19 posed a risk to themselves and people in the UK (asked in all survey waves).

In wave 3, participants were asked to what extent they agreed that COVID-19 would be a serious illness for them.

In wave 3, participants were asked to what extent they agreed with seven items relating to misinformation that was circulating at the time of data collection (see Appendix A).

Individual items were scored from +2 (strong agreement with a correct answer) to -2 (strong disagreement with a correct answer); we coded "don't know" as 0. Responses were judged as "true" or "false" based on information provided by the UK Government at the time. Scores were summed and rescaled (range 1 to 29), with higher scores indicating higher knowledge.

In wave 3, participants were asked how much they had seen or heard about COVID-19 in the past seven days. Participants were also asked if they had seen or heard the "Catch it, Bin it, Kill it" campaign, (7) and advice on how to protect themselves and others from COVID-19.

Participants were asked to identify the three sources that they had received most of their information about COVID-19 from in the past seven days from a list of sixteen sources. We created separate binary variables to indicate whether participants had received most of their information from official sources, the mainstream media, or unofficial sources (see Appendix A). For each information source, participants were said to have used that source if they indicated it as one of their top three.

Participants were asked to state to what extent they agreed that the Government was putting the right measures in place to protect the British public, they were getting the information they needed, and they knew what to do to limit their risk of contracting COVID-19 (asked in all survey waves). We summed scores to give a single continuous variable indicating 

Participants were asked to what extent they agreed that individual behaviours were effective at preventing the spread of COVID-19 and how confident they were that they could perform that behaviour (self-efficacy; wave 3 only). We created separate binary variables for perceived effectiveness and self-efficacy for each behaviour ("strongly agree" or "agree" versus "neither agree nor disagree," "disagree" or "strongly disagree").

Participants were asked to state: their age at questionnaire completion; gender; whether they had dependent children; whether they themselves or another household member had a chronic illness; their employment status; whether they themselves, a family member, or friend worked for the NHS; and their ethnicity. Index of multiple deprivation was derived from participants' residential postcode. In wave 3, participants were also asked their highest level of education.

This work was conducted as a service evaluation of the DHSC's public communications campaign and was exempt from ethical approval following advice from the King's College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee.

A target sample size of 2,000 was used for each wave, allowing a 95% confidence interval of, at most, plus or minus 2.2% for the prevalence estimate for each survey item.

Sociodemographic characteristics of participants by wave were compared using χ 2 tests (categorical data) and one-way ANOVAs (continuous data).

We used binary logistic regressions to calculate univariable associations between worry and sociodemographic characteristics and perceived risk of COVID-19. We used a second set of logistic regressions adjusting for sociodemographic characteristics (excluding education 1 ).

We used separate binary logistic regressions to calculate univariable associations between behavioural outcomes (uptake of a respiratory and hand hygiene behaviours, reducing the number of people met) and sociodemographic characteristics, worry about COVID-19, perceived risk of COVID-19, knowledge about COVID-19, information heard about COVID- 19 , and perceptions about UK Government response. We tested associations between behaviour, effectiveness and self-efficacy separately for each behaviour. We used a second set of logistic regressions adjusting for all sociodemographic characteristics (including education).

For analyses investigating behaviour, we ran post hoc logistic regression analyses adjusting for worry about COVID-19 as well as sociodemographic characteristics.

The survey method used quota sampling with weightings. In practice, the weights did not substantially affect rates of worry or uptake of behaviours. Therefore, the analyses reported in this paper are unweighted.

Given the number of analyses conducted on outcomes (worry, n=16; respiratory and hand hygiene behaviours, n=26; reducing the number of people met, n=28), we applied a Bonferroni correction (worry, p≤.003; respiratory and hand hygiene behaviours, p≤.002; reducing the number of people met, p≤.002).

Approximately 50% of participants were female (Table 1 ). There were no significant differences between waves, apart from for age (F(2,6021)=3.6, p=.03), with participants being slightly younger in later survey waves. In post hoc analyses controlling for worry and sociodemographic characteristics, associations between reducing the number of people met and age; having a dependent child; index of multiple deprivation; ethnicity; and perceived severity of COVID-19 for oneself were no longer statistically significant.

The start of all novel infectious disease outbreaks are characterised by uncertainty. Analyses of sociodemographic factors associated with adopting protective behaviours before a major outbreak can inform targets of communications for use in future outbreaks. Having completed at least one respiratory or hand hygiene behaviour more than usual was associated with being younger, having a dependent child in your household, and working for the NHS.

These associations remained when adjusting for worry. Other studies have also found an association between uptake of preventive behaviours and being a parent. (16) One study conducted in Switzerland found an association between uptake of preventive behaviours and older age (34) ; this has been a common pattern throughout the pandemic. (18, 38) Other studies conducted at the start of the pandemic found no association between age and uptake. (34, 35) For NHS workers and parents, increased uptake of recommended behaviours may have reflected a greater familiarity with, and habitual use of, hygiene behaviours.

However, NHS workers were less likely to report having reduced the number of people they had met, as were women. This may have been due to greater occupational contact with people and caring responsibilities in these groups respectively.

Several limitations should be considered for this study. First, behavioural outcomes were selfreported. Social desirability and recall bias may have inflated reported rates of uptake of protective behaviours. However, research suggests that there is no association between social desirability and self-report of health behaviours in online samples. (39) Whether participants understood the description of the behaviour (e.g. "thorough handwashing") in the way that we intended is also unclear. Second, while the use of an online market research panel is helpful in ensuring data are collected quickly, people who actively sign up for such panels may not be representative of the general public in terms of, for example, the amount of time they spend online and hence the likelihood of them encountering online public health campaigns. Third, the cross-sectional nature of the data makes it impossible to determine the direction of causality. Fourth, for measures of effectiveness and self-efficacy, we coded answers of "neither agree nor disagree" with "disagree" and "strongly disagree" given that there is evidence suggesting that many people who use middle options in a Likert scale are not expressing the absence of an opinion, but instead using it as a socially desirable way of disagreeing. (40) 

In the early stages of the pandemic in the UK, uptake of protective behaviours was associated with greater worry, risk perceptions, perceived effectiveness of, and self-efficacy for behaviours, and information receipt. All outbreaks of novel infectious diseases start with a period of uncertainty. Our data advance knowledge by giving an important insight into public sentiment in the period before a major outbreak and can be used to inform communications and public health actions at the start of any future outbreak of a novel infectious disease.

Preparedness plans should include designing official communications encouraging the uptake of respiratory, hand hygiene and distancing behaviours for use in novel infectious disease outbreaks. Communications should emphasise the effectiveness of these behaviours at preventing the spread of illness and ease with which they can be adopted. Whether worry and uptake of protective behaviours in future novel infectious disease outbreaks will follow the pattern of their predecessor will only be uncovered with time. 

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conceptualisation, data curation, formal analysis, methodology, writingoriginal draft. Henry WW Potts: conceptualisation, funding acquisition, methodology, writing -review & editing. Richard Amlȏt: conceptualisation, funding acquisition, methodology, writing -review & editing. Nicola T Fear: conceptualisation, funding acquisition, methodology, writing -review & editing. Susan Michie: conceptualisation, funding acquisition, methodology, writing -review & editing