A survey of patient and public perceptions and awareness of SARS-CoV-2-related risks among participants in India and South Africa

1 1 A survey of patient and public perceptions and awareness of SARS-CoV-2-related risks 2 among participants in India and South Africa 3 4 Short Title: Perceptions and awareness of SARS-CoV-2-related risks 5 6 Oluchi Mbamalu 1*, Surya Surendran2#, Vrinda Nampoothiri3, Candice Bonaconsa1, Fabia Edathadathil3, 7 Nina Zhu 4, Vanessa Carter5, Helen Lambert6, Carolyn Tarrant7, Raheelah Ahmad4,8, Adrian Brink9, 8 Ebrahim Steenkamp 10, Alison Holmes4, Sanjeev Singh3, Esmita Charani1,4, Marc Mendelson1 9 10 1 Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, 11 University of Cape Town, Cape Town, South Africa. 12 2 Health Systems and Equity, The George Institute for Global Health, New Delhi, India. 13 3 Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita 14 Vishwa Vidyapeetham, Kochi – Kerala, India. 15 4 National Institute for Health Research, Health Protection Research Unit in Healthcare Associated 16 Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, 17 London, United Kingdom. 18 5 Health Communication and Social Media, Johannesburg, South Africa. 19 6 Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, 20 United Kingdom. 21 7 Department of Health Sciences, University of Leicester, Leicester, United Kingdom. 22 8 Division of Health Services Research and Management, School of Health Sciences, City, University 23 of London, United Kingdom. 24 9 Division of Medical Microbiology, Faculty of Health Sciences, National Health Laboratory Service, 25 Groote Schuur Hospital, University of Cape Town, South Africa. 26 10 Statistical Consulting Unit, Department of Statistical Sciences, University of Cape Town, South 27 Africa. 28 29 * Corresponding author 30 Oluchi Mbamalu 31 Division of Infectious Diseases & HIV Medicine 32 Department of Medicine 33 University of Cape Town 34 G26/68 Groote Schuur Hospital Observatory,7925 35 Cape Town, South Africa 36 Tel: +27 79 794 9346 37 Email: [email protected] 38 39 Alternative corresponding author 40 Marc Mendelson 41 Division of Infectious Diseases & HIV Medicine 42 Department of Medicine 43 University of Cape Town 44 G26/68 Groote Schuur Hospital Observatory,7925 45 Cape Town, South Africa 46 Tel: +27 79 794 9346 47 Email: [email protected] 48 49 50 # This research was conducted when the author was affiliated with the Department of Infection 51 Control and Epidemiology at Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi 52 – Kerala, India. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 2 53 ABSTRACT 54 A cross-sectional survey was performed among the adult population of participating 55 countries, India and South Africa. The purpose of this study was to explore perceptions and 56 awareness of SARS-CoV-2-related risks in the relevant countries. The main outcome measures 57 were the proportion of participants aware of SARS-CoV-2, and their perception of infection 58 risks. 59 Self-administered questionnaires were used to collect data via a web- and paper-based survey 60 over three months. For data capturing, Microsoft Excel was employed, and descriptive 61 statistics used for presenting data. Pearson’s Chi-squared test was used to assess 62 relationships between variables, and a p-value less than 0.05 was considered significant. 63 There were 844 respondents (India: n=660, South Africa: n=184; response rate 87.6%), with a 64 61.1% vs 38.3% female to male ratio. Post-high-school or university education was the lowest 65 qualification reported by most respondents in India (77.3%) and South Africa (79.3%). Sources 66 of information about the pandemic were usually media and journal publications (73.2%), 67 social media (64.6%), family and friends (47.7%) and government websites (46.2%). Most 68 respondents correctly identified infection prevention measures (such as physical distancing, 69 mask use), with 90.0% reporting improved hand hygiene practices since the pandemic. 70 Hesitancy or refusal to accept the SARS-CoV-2 vaccine was reported among 17.9% and 50.9% 71 of respondents in India and South Africa, respectively. Reasons cited included rushed vaccine 72 development and the futility of vaccines for what respondents considered a self-limiting flu- 73 like illness. 74 Respondents identified public health promotion measures for SARS-CoV-2. Reported 75 hesitancy to the up-take of SARS-CoV-2 vaccines was much higher in South Africa. Vaccination 76 campaigns should consider robust public engagement and contextually fit communication . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 3 77 strategies with multimodal, participatory online and offline initiatives to address public 78 concerns, specifically towards vaccines developed for this pandemic and general vaccine 79 hesitancy. 80 Key words: Awareness, Infection prevention, Perception, COVID-19, Vaccination 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 4 101 INTRODUCTION 102 The SARS-CoV-2 pandemic has highlighted the importance of infection prevention at 103 individual and community levels. The World Health Organization (WHO) has indicated that for 104 public health infection prevention measures to be successful, all members of society 105 (communities and professional groups included) should be fully engaged [1]. These measures 106 include but are not limited to physical distancing, masking, hand hygiene, avoiding poorly 107 ventilated indoor spaces, and isolation/quarantine if infected or exposed. For efficient buy-in 108 and contribution to these measures, individuals should understand the risks, mode of viral 109 transmission, and consequences of infection. As such, the success of infection prevention 110 measures depends on individual and community-level awareness and the adoption of 111 infection prevention behaviours, which in turn depends on their perceptions and cognizance 112 of risk. 113 While effective public engagement has been highlighted as key to gaining buy-in [2-4], 114 additional research is needed to explore public awareness, perceptions and behaviours about 115 SARS-CoV-2 and how these may influence adherence to public health measures, especially in 116 low- and middle-income countries (LMIC). India (lower-middle-income) and South Africa 117 (upper-middle-income) [5] are countries with emerging economies where the SARS-CoV-2 118 pandemic has had a significant impact [6]. Redeploying the capacity within an existing 119 research collaboration across participating sites in these two countries [7, 8] , we investigated 120 the public’s perceptions and awareness of SARS-CoV-2-related risks and infection prevention 121 practices through analysis of data contributed by participants across the two countries. 122 123 124 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 5 125 METHODS 126 Study design 127 We conducted a cross-sectional web- and paper-based survey. Data were collected using a 128 self-administered questionnaire. Any adult member (over 18 years old) of the public, who 129 provided informed consent before participation, was eligible to participate. 130 131 Study development 132 The study development followed the STROBE cross-sectional reporting guidelines [9], as 133 shown in Table 1 under Supporting Information. 134 135 Table 1 (Supporting Information): Reporting Checklist for cross-sectional study 136 137 The research team – made up of pharmacists, physicians, nurses, social scientists, patient 138 advocate and public engagement specialist, and quantitative data analysts – designed a 42- 139 question survey to elicit information on the public’s knowledge, perceptions and awareness 140 of SARS-CoV-2 infection risks. The 4-part survey included participant demographics, general 141 knowledge of SARS-CoV-2, perceived risks and barriers, and self-efficacy. In South Africa, 142 survey questions and participant information leaflets were translated into IsiZulu, IsiXhosa 143 and Afrikaans languages, whereas in India, the paper-based survey was translated into 144 Malayalam for local distribution. The survey was piloted with members of the public, and 145 relevant revisions were made before dissemination. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 6 146 Study settings and participant recruitment 147 The survey was open for participation by any member of the public over a 3-month duration. 148 Voluntary response sampling was utilized. All invited individuals received participant 149 information leaflets, and those willing to participate had to provide informed consent before 150 commencing the survey. Participation was voluntary across both countries. 151 In South Africa, the survey was available online in three languages – IsiXhosa, Afrikaans and 152 English. In India, the survey was available online in the English language, and in the paper 153 format in two languages, English and Malayalam. 154 155 Data collection 156 Data collection took place from 15 September to 15 December 2020 and coincided with the 157 first wave of the SARS-CoV-2 pandemic in India and the beginning of the second wave in South 158 Africa. In South Africa, the survey was available online via Qualtric. In India, in addition to the 159 online platform in English, paper surveys (in English and Malayalam) were also distributed 160 among participants (patients, patient carers and/or visitors) at the study site (hospital) in 161 Kerala. 162 163 Ethics Statement 164 The study was approved by the relevant human research ethics committees at the Amrita 165 Institute of Health Sciences, Kerala, India (Ref: IRB-AIMS-2020-232) and the University of Cape 166 Town, South Africa (Ref: 311/2020). Formal consent was obtained prior to participation in the 167 survey. For the online and paper versions of the survey, consent was indicated by the 168 participant ticking the relevant box for consent on the survey form. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 7 169 Statistical analysis 170 Data from participants who completed the paper-based format were captured in a Microsoft 171 (MS) Excel file and codes assigned, while data of participants who completed the online form 172 were exported to MS Excel. The data from the paper-based and online versions of the survey 173 were cleaned and combined. 174 Descriptive statistics were used to report participant characteristics and survey responses. 175 The underlying outcomes were awareness of the pandemic, perceived threats and barriers, 176 and self-efficacy. Responses were captured as categorical variables, reported as percentages 177 of received feedback for each item of interest (missing data were excluded) or, where 178 possible, data were scaled from strongly agree to strongly disagree. Pearson’s Chi-squared 179 test was used to assess relationships between variables, and p < 0.05 was considered 180 statistically significant. 181 182 RESULTS 183 Participant demographics 184 There was a total of 844 respondents (660 participants from India and 184 participants from 185 South Africa). There were 318 respondents to the online survey and 342 patients or patient 186 carer respondents to the paper survey in India. The response rate for the online survey was 187 87.6% (502/573), calculated as the ratio of participants who clicked on the survey link versus 188 those who commenced participation. The response rate for the paper version of the survey 189 could not be estimated, as respondents returned a higher number of the completed survey 190 forms than the initial number disseminated, indicating the forms had been copied and shared 191 more widely. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 8 192 There were more female (515/844, 61.0%) than male (323/844, 38.3%) respondents (Table 193 1). Three entries for age were excluded (one was invalid with two selections and two were 194 missing), resulting in a total response of 657 for age entries. Most of the respondents in India 195 and South Africa were in the 20-29-year (310; [n=657] 47.2%) and 40-49-year (57; 31.0%) age 196 groups, respectively. 197 Table 1 Self-reported respondent demographics Characteristic India South Africa Total n (%) n (%) n (%) Country of residence 660 (78.2) 184 (21.8) 844 (100) Gender (n=660) (n=184) (n=844) Male 285 (43.2) 38 (20.7) 323 (38.3) Female 369 (55.9) 146 (79.3) 515 (61.1) Prefer not to say 5 (0.8) 0 5 (0.6) Missing 1 (0.2) 0 0 Age n = 657 (%) n = 184 (%) n = 841 (%) Younger than 20 years 41 (6.2) 7 (3.8) 48 (5.7) 20 to 29 years 657 (47.2) 14 (7.6) 324 (38.5) 30 to 39 years 133 (20.2) 21 (11.4) 154 (18.3) 40 to 49 years 82 (12.5) 57 (31.0) 139 (16.5) 50 to 59 years 49 (7.5) 49 (26.6) 98 (11.7) 60 to 69 years 30 (4.6) 27 (14.7) 57 (6.8) 70 years and older 12 (1.8) 9 (4.9) 21 (2.5) Regular water supply n = 650 (%) n = 176 (%) n = 826 (%) Yes 560 (86.2) 172 (97.7) 732 (88.6) No 90 (13.8) 4 (2.3) 94 (11.4) Education n = 653 (%) n = 175 (%) n = 828 (%) Primary schooling 28 (4.3) 1 (0.5) 29 (3.5) Secondary schooling 113 (17.3) 25 (13.6) 138 (16.7) Post-high school 291 (44.6) 96 (52.2) 387 (46.7) Post-graduate degree 219 (33.5) 50 (27.2) 269 (32.5) Other 2 (0.3) 3 (1.6) 5 (0.6) Employment n = 633 (%) n = 166 (%) n = 799 (%) Student 135 (21.3) 5 (3.0) 140 (17.5) Employed, part time 35 (5.5) 11 (6.6) 46 (5.8) Employed, full time 249 (39.3) 62 (37.3) 311 (38.9) Self-employed 47 (7.4) 50 (30.1) 97 (12.1) Retired/Pensioner 27 (4.3) 19 (11.4) 46 (5.8) I was furloughed/laid off during the lockdown 8 (1.3) 5 (3.0) 13 (1.6) . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 9 Unemployed 122 (19.3) 13 (7.8) 135 (16.9) Other 10 (1.6) 1 (0.6) 11 (1.4) 198 199 The percentage of student respondents was higher in India (21.3%, 135/633) than South 200 Africa (3.0%, 5/166). Unemployment was higher among respondents in India (19.3%, 201 122/163) than in South Africa (7.8%, 13/166), while there were more self-employed (30.1%, 202 50/166) and retired (11.4%, 19/166) respondents in South Africa. 203 204 Knowledge and concerns of SARS-CoV-2 transmission and infection 205 Reported sources of SARS-CoV-2 information, completed by 652 and 172 participants in India 206 and South Africa, respectively, are shown in Figures 1a and 1b. Media and journal publications 207 were the most common sources of information, along with social media, family and friends, 208 and government websites. On social media across both countries, Facebook®, WhatsApp® 209 and YouTube® were the most frequently used sites for information about the pandemic. 210 211 Figure 1a Respondents’ sources of SARS-CoV-2 information (traditional and social 212 media) in India (n=652) 213 214 Figure 1b Respondents’ sources of SARS-CoV-2 information (traditional and social 215 media) in South Africa (n=172) 216 217 In Table 2, the respondents’ knowledge of SARS-CoV-2 transmission routes, infection course 218 and prevention/management options is summarised. The primary route of SARS-CoV-2 219 transmission identified was nasal/oral droplets, airborne particles, and infected body fluids. 220 More than half of the respondents also demonstrated knowledge of SARS-CoV-2 incubation 221 and symptom manifestation, quarantine objectives, and general duration of isolation for 222 infected patients. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 10 223 Table 2 Respondent’s knowledge and experiences of the pandemic Response (%) Knowledge of SARS-CoV-2 India South Africa Total Major routes of transmission Infected bodily fluids 426/516 (82.6) 55/119 (46.2) 481/635 (75.7) Nasal or oral droplets 555/591 (93.9) 158/165 (95.8) 713/756 (94.3) Airborne 352/458 (76.9) 114/147 (77.6) 466/605 (77.0) Foodborne 113/328 (34.5) 9/101 (8.9) 122/429 (28.4) Waterborne 119/322 (37.0) 5/98 (5.1) 124/420 (29.5) Other (please specify) 11/60 (18.3) 5/ 25 (20.0) 16/85 (18.8) Time to symptom onset n = 626 (%) n = 171 (%) n = 797 (%) Immediately – there is no delay 42 (6.7) 1 (0.6) 43 (5.4) 0 to 2 weeks 448 (71.6) 152 (88.9) 600 (75.3) 2 to 4 weeks 80 (12.8) 12 (7.0) 92 (11.5) Over 4 weeks 10 (1.6) 2 (1.2) 12 (1.5) I don't know 35 (5.6) 4 (2.3) 39 (4.9) Multiple entries 11 (1.8) 0 11 (1.4) Perceived reason for quarantine of SARS- CoV-2-positive individuals n = 625 (%) n = 171 (%) n = 796 (%) To help them get better 22 (3.5) 0 22 (2.8) To prevent them from infecting others 430 (68.8) 124 (72.5) 554 (69.6) There is no good reason for that 3 (0.5) 12 (7.0) 15 (1.9) Other, please specify 1 (0.2) 2 (1.2) 3 (0.4) I don't know 9 (1.4) 0 9 (1.1) Multiple entries 159 (25.4) 33 (19.3) 192 (24.1) Duration of isolation (if not admitted to a healthcare facility) n = 625 (%) n = 171 (%) n = 796 (%) As soon as coughing stops 5 (0.8) 0 5 (0.6) 10 to 14 days after symptoms first started 314 (50.0) 136 (79.5) 450 (56.5) As soon as they feel better 36 (5.7) 3 (1.8) 39 (4.9) 21 days after symptoms stop 110 (17.5) 9 (5.3) 119 (14.9) For asymptomatic cases: as advised by healthcare guidelines 61 (9.7) 10 (5.8) 71 (8.9) They do not need to be isolated 3 (0.5) 9 (5.3) 12 (1.5) I don’t know 28 (4.5) 4 (2.3) 32 (4.0) Multiple entries 71 (11.3) 0 71 (8.9) Changes in hand washing practices n = 615 (%) n = 167 (%) n = 782 (%) I wash/sanitise my hands more often 561 (91.2) 143 (85.6) 704 (90.0) I wash/sanitise my hands less often 13 (2.1) 0 13 (1.7) There is no difference in how often I wash/sanitise my hands 18 (2.9) 23 (13.8) 41 (5.2) Other, please specify 2 (0.3) 1 (0.6) 3 (0.4) I don`t know 6 (1.0) 0 6 (0.8) Multiple entries 15 (2.4) 0 15 (1.9) Avoided visit to healthcare facility because of SARS-CoV-2 n = 594 (%) n = 161 (%) n = 755 (%) Yes 171 (28.8) 60 (37.3) 231 (30.6) . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 11 No 353 (59.4) 70 (43.5) 423 (56.0) Not applicable/had no need to visit a healthcare facility 70 (11.8) 31 (19.3) 101 (13.4) Would you have a SARS-CoV-2 vaccination? n = 587 (%) n = 161 (%) n = 748 (%) Yes 482 (82.1) 79 (49.1) 561 (75.0) No 36 (6.1) 55 (34.2) 91 (12.2) I don't know 69 (11.8) 27 (16.8) 96 (12.8) 224 225 226 More frequent hand washing was reported across both countries (90.0%); however, a higher 227 percentage of respondents in South Africa (13.8%) than in India (2.9%) noted no difference in 228 their hand hygiene practices. Overall, 75.0% of all the respondents indicated their willingness 229 to receive vaccination when it becomes available; however, the percentages were higher in 230 India (82.1%) than in South Africa (49.1%). The most common reasons cited for apathy to 231 vaccination were perceptions of rushed vaccine development and the futility of vaccines for 232 what respondents considered a self-limiting flu-like illness. 233 234 Self-efficacy: perceptions of SARS-CoV-2 infection prevention measures 235 Respondents’ perceptions and concerns about their ability to cope with SARS-CoV-2 infection 236 prevention measures are presented in Figure 2, given their perceived knowledge and 237 awareness of the pandemic and infection risks. More than half of respondents in each country 238 reported that they have sufficient knowledge of SARS-CoV-2, understood available 239 information on the pandemic, would know what to do or questions to ask if they or someone 240 else contracted SARS-CoV-2, and have access to healthcare were they to become ill with SARS- 241 CoV-2 infection, and would be able to cope with extended containment measures such as a 242 lockdown. Compared to South Africa, more respondents in India reported concern over 243 infection, its financial implications and associated stigma. On the intent to wear a face mask, . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 12 244 8.6% and 26.2% of respondents in India and South Africa reported dissatisfaction with this 245 measure while outdoors, respectively. 246 247 Figure 2: Respondents’ perceptions of self-efficacy in relation to coping with the 248 COVID-19 pandemic in South Africa (SA) and India 249 250 There was no statistical significance between hand washing and water supply (Table 3), as 251 even those without access to water supply reported that they washed their hands more 252 frequently since the pandemic (p = 0.2168 and p = 0.7970 in India and South Africa, 253 respectively). Water supply showed a mixed relationship with employment as some full-time 254 workers had no access to water. The test highlights a difference between participants in the 255 two countries; p = 0.008 and 0.4471 for India and South Africa, respectively. 256 257 Table 3 Relationships between selected variables A. Is hand washing affected by water supply? India South Africa Hand wash frequency Yes No Yes No Wash more 476 79 140 3 Wash less 13 0 0 0 No change 15 2 22 1 Other 2 0 1 0 Don’t know 5 1 0 0 Multiple 10 5 0 0 p-value 0.2168 0.797 B. Is water supply affected by employment? India South Africa Employment Status Yes No Yes No Student 124 9 5 0 Part time 27 8 11 0 Full time 217 29 62 0 Self-employed 40 7 47 3 Unemployed 101 20 12 1 Retired 18 8 19 0 Other 8 2 1 0 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 13 Laid off 4 4 5 0 p-value 0.0008026 0.4471 C. Is avoidance of healthcare facilities because of fear of COVID-19 contraction influenced by age? India South Africa Age Yes No N/A Yes No N/A =70 2 10 0 1 5 1 p-value 0.001451 0.9008 D. Is avoidance of health care facilities because of fear of COVID-19 contraction influenced by employment? India South Africa Employment Status Yes No N/A Yes No N/A Student 37 57 27 2 1 1 Part time 12 20 1 5 3 3 Full time 57 137 27 25 21 11 Self-employed 11 28 2 10 26 10 Unemployed 31 79 5 5 6 1 Retired 9 17 0 8 7 2 Other 5 3 1 0 1 0 Laid off 1 4 3 0 2 2 p-value 0.0002084 0.4076 258 259 Our results show that some respondents avoided healthcare facilities during this pandemic. 260 Some participants in this study, particularly in India, reported avoiding healthcare facilities 261 because of a fear of contracting the COVID-19 virus; this was affected by employment status, 262 more in India (p = 0.0002) than in South Africa (p = 0.4076). 263 264 265 266 . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 14 267 DISCUSSION 268 This study provides insight into the public’s awareness and perspectives of the SARS-CoV-2 269 infection and risks in two middle-income countries hard hit by the pandemic [6]. The aim was 270 to gain some understanding of the knowledge and views about the pandemic, particularly 271 when considering the expected roles that the public have in this pandemic regarding social 272 distancing and infection prevention through hand hygiene, mask use and vaccination uptake. 273 At the time of the study, these two countries were at different phases of the pandemic 274 infection curves with no viable vaccines available. Although these data are somewhat dated, 275 these findings add to the body of knowledge on the public’s perceptions of the pandemic. 276 Also, how a better understanding of this information can be leveraged for improved infection 277 prevention and behavioural interventions and promotions for this and the future infectious 278 disease pandemics. Such knowledge will be helpful in infectious disease pandemic control and 279 mitigation, including in the ongoing COVID-19 pandemic. The insight from this study can assist 280 with measures to address continued vaccine hesitancy and inequity when many countries are 281 dealing with a fourth or subsequent infection wave. 282 From the onset of the pandemic, efforts have been communicated to inform the public of 283 infection risks and required containment/mitigation measures. The need for public 284 engagement and hygiene intervention, behaviour change, and consideration of socio-cultural 285 aspects in public awareness initiatives in India and South Africa has been noted in the 286 literature [10-14]. The volume of news media dedicated to the pandemic may also have 287 served to provide education and awareness among the public. Conversely, it may have fuelled 288 confusion and panic, particularly on the diverse online channels where unbridled and 289 unverified evidence and opinions compete for attention with information from local and 290 global health authorities. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 15 291 Survey respondents demonstrated awareness of the pandemic, with most identifying the 292 primary routes of transmission, incubation period, symptoms of infection, and recommended 293 measures for infection prevention and management of mild conditions, including the reason 294 for and duration of isolation. Information on the pandemic was generally gained from 295 traditional and social media, family and friends, and government websites. Respondents’ 296 reliance on general and social media as sources of pandemic-related information highlights 297 the role played by the media in pandemic containment and mitigation. 298 The information landscape has changed extensively in the last three decades, prompting the 299 need to address not only the SARS-CoV-2 pandemic but also its related infodemic [15]. While 300 the main aspects of an infodemic refer to inaccurate and misleading information shared 301 through digital and physical environments during disease outbreaks, disinformation refers to 302 the deliberate spread of false information. In this pandemic, we are increasingly witnessing a 303 growing infodemic driven by misinformation, including a worrying trend in the escalation of 304 disinformation through traditional and social/digital media [16-18]. The role of the media, 305 traditional and digital alike, in framing and rapidly disseminating information is evident in this 306 pandemic, particularly when related to influencing behaviours and empowering individuals 307 with the accurate information to make informed decisions regarding IPC [15, 19-21]. 308 Family and friends were noted as sources of SARS-CoV-2 information by respondents in the 309 survey. Word of mouth presented face-to-face or through various communication channels 310 within families and among friends, though not specifically a media source, is an essential 311 source of information. It is also a key route for spreading misinformation, mainly because of 312 the trust between the source and the recipient. Thus, the prominence of influencers (in the 313 community and on digital platforms alike) in disseminating pandemic-related information is 314 highlighted. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 16 315 The findings of this study underscore the importance of various media as sources of 316 information for informed decision-making among the public. It also draws attention to the 317 relevance of social media, and family and friends, as sources of pandemic-related information 318 for the public. Given the infodemic that has trailed the SARS-CoV-2 pandemic on all media 319 [21, 22], there is a need for evidence-informed and timely communication in continually 320 addressing pandemic-related misinformation and disinformation. Infodemic management is 321 multifaceted, requiring different disciplines to address it. Beyond communication, factors 322 influencing an individual’s behaviours may relate to external pressures, including the 323 economy, politics, education, health literacy and religious or cultural beliefs. 324 Some respondents in this study considered SARS-CoV-2 to be food- or water-borne. Such 325 beliefs may impact infection prevention measures; while there has been research into 326 transmission by these routes [23, 24], they have not been noted as primary transmission 327 routes for the viral infection. Droplet and airborne transmission have been noted as some 328 primary transmission routes, with the use of face masks a significant intervention in reducing 329 the spread of the infection [25, 26]. 330 Across both countries, some respondents expressed somewhat reluctance to mask-wearing, 331 despite their concern about contracting the infection, which may be related to the stigma or 332 discomfort of masks. Stigma, known to influence/compromise infection prevention 333 behaviours [27, 28], needs to be addressed, locally and globally, not only for the current 334 pandemic but also for future ones, and improved adherence to optimised infection 335 prevention practices. 336 Among other options to reduce infection risk, hand hygiene has been prioritised in public 337 health messages for pandemic mitigation [29]. Access to clean water is critical for hand 338 hygiene and is among the tools to address and mitigate the impact of the pandemic, as . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 17 339 highlighted in the literature [29, 30]. While water supply did not affect hand hygiene 340 frequency among respondents, it highlighted a difference between study participants in the 341 two countries. Infection prevention measures such as hand hygiene and physical distancing 342 may pose a challenge in some LMIC (India and South Africa are examples), especially in under- 343 resourced sections of rural areas or densely populated urban settings [29, 30]. 344 Isolation and quarantine of infected and exposed individuals are underlying measures for 345 infectious disease control, though this may prove challenging. Responses to SARS-CoV-2- 346 related isolation/quarantine duration reflect respondents’ perceptions of SARS-CoV-2 347 incubation. While there was an initial consensus on a 14-day isolation/quarantine period for 348 infected/affected individuals, there have been shifts and debates on the optimum incubation 349 period of the virus, hence, the duration of isolation and quarantine measures [31]. 350 Respondents’ responses reflected this, more so in India, where discussions about extended 351 isolation periods have been reported [32]. 352 Lockdown measures instituted in various parts of the world following the spread of SARS-CoV- 353 2 served as another infectious disease mitigation strategy. With the rise of infection 354 transmission and the attendant lockdown measures, it was expected that individuals would 355 have avoided visiting healthcare facilities. Some participants in this study, particularly in India, 356 reported avoiding healthcare facilities because of a fear of contracting the COVID-19 virus; 357 this was influenced by employment status, more in India than in South Africa. Employed 358 participants may be more likely motivated to maintain good health or hesitant to confirm 359 illness, for fear of losing money or work, resulting in fewer visits to healthcare facilities, than 360 those unemployed. While lockdown measures can reduce patient presentation to healthcare 361 facilities [33, 34], such a decline in presentation may also be associated with later 362 presentations with more severe consequences. Initiatives are required to address gaps in . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 18 363 patient care necessitated by public health promotion strategies such as lockdowns in this and 364 future pandemics. 365 Across the two countries, attitudes to the vaccination were positive. However, the country 366 analysis showed this was driven by higher vaccine acceptance in India, with respondents in 367 South Africa more cautious regarding COVID-19 vaccination. Reasons cited for hesitancy or a 368 negative attitude to SARS-CoV-2 vaccination were related to mistrust in the vaccine 369 development process and the futility of vaccines for what respondents considered a self- 370 limiting flu-like illness. 371 This survey was, however, conducted before SARS-CoV-2 vaccines were available. Hesitancy 372 towards the SARS-CoV-2 vaccine had been noted earlier in the pandemic, fuelled by infodemic 373 on communication channels and the public’s belief in SARS-CoV-2-related conspiracies [35, 374 36]. The notion that the pandemic has been grossly exaggerated and reported, with 375 unnecessary financial and other stresses on populations, was expressed by some participants 376 who provided additional free text information. As the pandemic evolves, research to better 377 understand infection and vaccine-related concerns among the general population is needed 378 to support targeted and contextually appropriate strategies promoting vaccine uptake and 379 optimised infection prevention behaviours. 380 Among individuals with opposing opinions about vaccination, using social science methods to 381 study underlying reasons and contexts for their views, along with highlighting the individual 382 rather than the collective advantages of vaccination, may provide helpful and relatable insight 383 [36, 37]. This could be particularly important when considered in light of recent research and 384 noted factors that may influence vaccine perception and uptake [38-40]. More recent 385 research has provided insight into dealing with vaccine-hesitancy as well as the challenges 386 associated with anti-vaxxers [41]. Public health campaigns and vaccination promotions should . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 19 387 therefore understand and leverage social listening techniques to comprehend public 388 perceptions concerning communication gaps. A similar method of social listening should be 389 developed for community and traditional settings to understand why various beliefs and 390 behaviours related to COVID-19 emerged. 391 392 STRENGTHS AND LIMITATIONS 393 Our study provides unique insights into the public’s attitudes and practices across two LMIC 394 during the early stages of this pandemic. The findings are subject to some limitations, which 395 should be considered in its interpretation. 396 First, being a cross-sectional study, the relevance of the findings may change over time and 397 with interventions, especially as subsequent waves of COVID-19 have been reported. Second, 398 the online distribution of the survey and the limited paper version may have limited its reach, 399 particularly under-representing individuals from diverse socio-economic levels. Third, data 400 collection across both sites did not rely on the same methods, given the COVID-19 restrictions 401 at the time of data collection, which likely influenced the sample sizes across the sites. Sample 402 size may also have been influenced by survey fatigue, challenges with Internet access in LMIC, 403 and other limitations associated with accessing and participating in the survey at the time of 404 the survey roll-out. 405 Survey respondents are therefore not representative of the public in either of the two 406 countries, limiting the generalizability of findings. In addition, this survey was conducted 407 between September and December 2020, when both countries were at different phases of 408 the SARS-CoV-2 pandemic. The differences in experiences across the countries may have 409 influenced the responses provided. . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 20 410 Nevertheless, this paper fills a gap in the knowledge, awareness and attitudes of the public in 411 India and South Africa towards IPC practices in the context of COVID-19 within the first year 412 of the pandemic. It will be beneficial for charting public understanding and perception of the 413 COVID-19 pandemic and provide informative data that can be employed for public 414 engagement in other infectious disease control and mitigation across both sites and similar 415 contexts. While this research presents the data for each country separately, it is not its 416 intention to make any statistical comparisons between participants in the two countries. 417 Despite that, the individual test on how employment affects water supply and the avoidance 418 of healthcare settings during lockdown provided some insight on differences between 419 participants in the two countries. Thus, the need for pandemic mitigation efforts to consider 420 differences in context and subjects for the delivery of context-specific and appropriate 421 interventions is highlighted. 422 423 424 CONCLUSIONS 425 This study presents socio-economic and demographic data, which may influence public 426 awareness and behaviour and further be explored in pandemic mitigation initiatives among 427 the public in both countries. Survey respondents correctly identified public health promotion 428 measures for SARS-CoV-2. Reported disinclination to mask-wearing and reported hesitancy 429 for the uptake of SARS-CoV-2 vaccination highlight gaps that can be addressed for improved 430 pandemic mitigation efforts. Further research to explore the outlook towards mask use and 431 vaccination across both countries can provide more insight on factors influencing infection 432 prevention and vaccine apathy. Vaccination campaigns should consider robust public 433 engagement and more targeted communication strategies using tactics like social listening, . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 21 434 with multimodal, participatory online and offline initiatives to address the infodemic that 435 drives public concerns. Furthermore, this can contribute to developing a better understanding 436 of the driving force behind vaccine hesitancy among different populations. 437 438 Acknowledgements 439 The authors express appreciation to all survey participants and members of the public who 440 participated in the review of or provided feedback on the survey tool, and to Ms Jean Fourie 441 for review and editing of the manuscript. 442 443 Author contributions 444 OM conceptualised and wrote the initial protocol for the study, with additional input and 445 revision from CB, VC, HL, RA, SSingh and overall oversight by EC and MM. OM, SSurendran 446 and EC coordinated the data collection with input from NZ, SSurendran, VN, and FE 447 contributed to data capturing; OM, FE and ES contributed to the data analysis. OM wrote the 448 first draft of the manuscript, with input from SSurendran and oversight from EC and MM. All 449 authors contributed to subsequent revisions and approval of the final draft. 450 451 Funding sources 452 The work was supported by the Economic and Social Research Council (ESRC) as part of the 453 Antimicrobial Cross Council Initiative supported by the seven UK research councils, the 454 Global Challenges Research Fund (GCRF) as part of the ASPIRES project 455 (https://www.imperial.ac.uk/arc/aspires/), the National Institute for Health Research, UK 456 Department of Health [HPRU-2012-10047] in partnership with Public Health England and . CC-BY 4.0 International licenseIt is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted August 26, 2022. ; https://doi.org/10.1101/2022.08.26.22279242doi: medRxiv preprint 22 457 the National Research Foundation of South Africa (Grant Number: 129755). The funders did 458 not have any role in the study design and conduct, review or approval of the manuscript, or 459 the decision to submit the manuscript for publication. 460 461 Declarations 462 Ethics approval and consent to participate 463 The study was approved by the relevant human research ethics committees at the Amrita 464 Institute of Health Sciences, Kerala, India (Ref: IRB-AIMS-2020-232) and the University of 465 Cape Town, South Africa (Ref: 311/2020). 466 467 Competing Interests 468 The authors declare they have no competing interests. 469 470 471 472 Patient and public involvement 473 A patient advocate and public engagement specialist/civil society champion was involved in 474 the design of the study material and also contributed as an author. Members of the public 475 participated in the review of the survey tool and provided feedback for its modification. 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