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 <CNY50,000. Among 176 all the occupation categories, industrial workers followed by housewife/retired reported the 177 highest proportion of a high physical prevention barriers score.

The mean and SD for the total negative attitudes score was 11.5 (SD ± 4.1; range 5 to 20) out 179 of a possible score of 20. The median was 11.0 (IQR 9.0 to 14.0). The negative attitudescores 180 were categorized as a score of 11 to 20 or 5 to 10, based on the median split; as such, a total 181 of 1348 (55.9%; 95%CI 53.9 to 57.9) were categorized as having a score of 11 to 20 and 182 1063 (44.1%; 95% CI 42.1 to 46.1) had a score of 5 to 10. severe anxiety during the current moment. Table 2 shows the prevalence of moderate to In total, 41.4% (95% CI 39.5 to 43.5) recorded current anxiety scores similar or higher than 201 the score during the early phase of the outbreak, whereas 58.5% (95% CI 56.5−60.5) 202 recorded current anxiety levels lower than during the early phase of the outbreak. Table 3 203 shows the multivariate analysis of factors associated with a reduced level of anxiety. Females 204 reported a higher likelihood of having decreased levels of anxiety than males (OR=1.78, 205 95%CI 1.48 to 2.14). Having lower negative attitudes score was associated with a higher 206 decrease in anxiety (OR=1.59, 95% CI 1.33 to 1.89). The 31−50 years age group, participants 207 whose average annual income was CNY50,000 to 120,000, and office workers reported the 208 highest likelihood of having a decreased anxiety level. 

To our knowledge, this study is the first investigation aimed preventive measures, attitudes 212 and anxiety levels of the public in Wuhan, the epicentre, after the peak of COVID-19, and the 213 findings could offer an insight into the strategies required to effectively address prevention 214 gaps and the provision of emergency psychological intervention.

In general, the study participants have a good level of physical prevention measures even 216 though the peak of the COVID-19 is declared over. A large proportion has difficulty in using 217 eye-protection, which could be due to difficulties in obtaining face shields or goggles. Of 

Of important note, the study found a relatively higher proportion expressed negative attitudes 241 toward COVID-19 infection. This implies that attitudinal barriers are more prominent than 242 physical prevention barriers. A prominent negative attitude-avoidance behaviour-found in 243 this study implies the importance of encouraging the cultivation of timely and appropriate 244 health-seeking attitudes when one is suspected of having been infected with COVID-19. It is 245 equally important to note that cognitive avoidance also contributes to a delay in taking 246 precautions to prevent the spread of COVID-19. Also noteworthy is that the second most 247 prominent negative attitudes after cognitive avoidance were embarrassment and fear of being known to have COVID-19 infection, whereby both were reported by over one-third of the 249 study participants. Likewise, fear and embarrassment were found to deter seeking medical 250 care in other infectious diseases such as Hepatitis B infection and HIV(24, 26) . Equally 251 essential to note is the findings of significant differences in negative attitudes according to 252 demographics. In contrast to physical prevention measures, the older adults in this study 253 demonstrated higher negative attitudes toward COVID-19. In this study, males and 254 participants from higher income groups also tend to demonstrate higher negative attitudes 255 toward COVID-19, which provides important population-level information to address socio-256 economic factors that drive attitude disparities.

The finding that nearly 80% of respondents reported moderate to severe anxiety during the This perhaps implies that females are able to recuperate emotion more quickly than males.

More importantly this study also found that a more positive attitude towards COVID-19 279 infection is associated with a reduction in anxiety levels, which again emphasizes the study is an open survey, hence the denominator is not observable and the response rate is 301 unable to be calculated. Therefore the current study may be affected by sampling 302 bias.Therefore, the results should be interpreted with caution. Despite these limitations, 303 the study data contribute tremendously to the understanding of public responses and anxiety 304 levels, especially now that the epidemic is growing exponentially. 

Outbreak of pneumonia of unknown etiology in Wuhan, China: 345 The mystery and the miracle

The continuing 2019-nCoV epidemic 347 threat of novel coronaviruses to global health -The latest

International journal of infectious diseases : IJID : official publication of the 349 International Society for Infectious Diseases

China says its COVID-19 peak is over

Tuberculosis stigma as a social 359 determinant of health: a systematic mapping review of research in low incidence countries. 360 International journal of infectious diseases : IJID : official publication of the International Society for 361 Infectious Diseases

A comparative study of the stigma 363 associated with infectious diseases (SARS, AIDS, TB). Hong Kong medical journal = Xianggang yi xue 364 za zhi

Applied Innovations and 366 Technologies

Timely mental health care for the 368 2019 novel coronavirus outbreak is urgently needed. The lancet Psychiatry

COVID-19 and mental health equity in the United States. Social psychiatry and 370 psychiatric epidemiology

Mental health before and during 372 the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The lancet 373 Psychiatry

Mental health services in Italy during the 378 COVID-19 outbreak. The lancet Psychiatry

Challenges for mental health services 380 during the 2020 COVID-19 outbreak in Germany. Psychiatry and clinical neurosciences

Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic 384 among the General Population in China. International journal of environmental research and public 385 health

Post-traumatic stress disorder: evidence-based 387 research for the third millennium. Evidence-based complementary and alternative medicine : eCAM

The epidemiology of 390 trauma and post-traumatic stress disorder in a representative

Long-term psychiatric morbidities among SARS 393 survivors. General hospital psychiatry

Threat to democracy: Physical and 395 mental health impact of democracy movement in Hong Kong

The development of a six-item short-form of the state scale of the 398

The British journal of clinical psychology

Longitudinal assessment of 401 community psychobehavioral responses during and after the 2003 outbreak of severe acute 402 respiratory syndrome in Hong Kong. Clinical infectious diseases : an official publication of the 403 Infectious Diseases Society of America

Some norms and reliability data for the State--Trait 405

Anxiety Inventory and the Zung Self-Rating Depression scale. The British journal of clinical 406 psychology

Analyzing barriers for implementation of public health and social 408 measures to prevent the transmission of COVID-19 disease using DEMATEL method. Diabetes & 409 metabolic syndrome

Clinical features of patients infected with 411 2019 novel coronavirus in Wuhan

Communicating 413 the Risk of Death from Novel Coronavirus Disease (COVID-19)

HIV-related stigma: 416 implications for symptoms of anxiety and depression among Malawian women

Public Mental Health Crisis during COVID-19 Pandemic, China. Emerging 424 infectious diseases

Role and importance of consultation-liaison 426 psychiatry during the Covid-19 epidemic

Consultation-liaison psychiatry in China. Shanghai archives of psychiatry

† Decrease in STAI score -STAI score after peak < STAI score early phase of outbreak