Association between supportive attitudes and adoptive practice of control strategy against COVID-19 among college students in China, a cross-sectional study

Background: This study aimed to explore college students’ attitudes and compliance toward the prevention strategy of using non-pharmaceutical interventions (NPIs) in containing coronavirus disease 2019. Methods: We conducted a cross-sectional online survey in four universities in Guangdong Province (China) based on purposive sampling. We used a self-made questionnaire to measure the supportive attitude towards outbreak control strategy and adoption of NPIs in respondents. Results: A total of 44,446 college students participated between 31 January and 10 February 2020; 92.7% of respondents supported the outbreak control strategy. 94.8% would avoid public places, 92.8% would wear a facemask, 91.2% would avoid of gatherings and 86.9% would wash hands more frequent. 76.5% respondents adopted all four measures. Supportive attitude was associated with NPI adoption. Students who were female, postgraduate, anxious, and not depressed tended to have higher supportive attitude and higher NPI adoption rate. Conclusions: Higher supportiveness towards the disease control strategy for public may lead to higher adoption rate of NPIs for individuals. Psychosocial factors are related to supportive attitude and adoption of the NPIs. We believe that our �ndings are instructive about the prevention and control of emerging infectious diseases like COVID-19.


Background
Coronavirus disease 2019 (COVID- 19) is caused by a new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which was rst reported in Wuhan (Hubei Province, China) in December, 2019 [1].COVID-19 is an acute respiratory infectious disease that ranges from mild symptoms to severe illness and death.The virus was spread rapidly and caused 1,279,010 con rmed cases and 72,603 deaths in 118 countries between December 2019 and 7th April 2020,the outbreak soon developed into a globalized pandemic that had already infected over 14 million people and killed about 600 thousand people in 7 months while both number were still skyrocketing [2].
For emerging infectious diseases, due to a lack of e cacious antiviral agents and vaccine, nonpharmaceutical interventions (NPIs) are the most effective interventions to prevent and control their spread [3,4].During the epidemic of in uenza A (H1N1) in 2009, NPIs helped to decrease transmission [5].Community participation is very important for any NPI strategy to be successful [6][7][8][9].Negative public perception and practice can impede successful campaigns against the spread of infectious diseases [10,11].
At the early stages of the COVID-19 outbreak, the National Health Commission of China quickly launched a control strategy containing several measures to prevent and control disease spread: free treatment to con rmed patients; quarantine for people who was likely exposed to SARS-CoV-2 (separation from the rest of the population); restriction of travelling in and out of Wuhan city; closing down entertainment facilities for public; extended the Spring Festival holidays and delayed time of returning to school [12].In addition to the strategy for public, Chinese government and its healthcare departments also gave recommendations and guidelines of NPIs for individuals to follow, such as use of a facemask, washing hands frequently.Since COVID-19 is an emerging infectious disease, the public had little knowledge about it.NPI messages were propagated vigorously through television, mobile-telephone messages, social media (e.g., WeChat™), the Internet, and newspapers to all community members.Under these circumstances, the response and implementation by the public for a new NPI strategy are key elements for epidemic control.Also, timely feedback of this information is very important for health authorities to improve the overall control strategy.
College students (CSs) are important members of the community.They represent the younger, more receptive part of a population.We evaluated CSs' support and practice towards the NPI strategy against COVID-19 created by the Chinese government.The relationship between their support and practice in the initial period of the COVID-19 outbreak in China was also evaluated.

Study design
From 31 January to 20 February 2020, we provided a cross-sectional online survey for CSs.A purposive sampling method was employed to all CSs from four universities (one medical university and three comprehensive universities) in Guangdong Province, China.The questionnaire used in our study was selfdesigned and composed of three parts: socio-demographic characteristics, supportive perception, and adoptive action towards an NPI strategy of prevention and control of COVID-19 [13].(see Additional File 1).The questionnaire was sent through online communities at Southern Medical University and was collected by the website of the latter.The validity of the questionnaire was assessed by experts in public health and epidemiology.All questions were mandatory.The survey was anonymous and consent to participate was not required.Report of this study follows the STROBE statement.

Measures and de nitions
The questionnaire consisted of sociodemographic characteristics, Knowledge, Attitude and Practices (KAP) questions, Center for Epidemiologic Studies Depression Scale (CES-D) for depression testing, and Self-Rating Anxiety Scale (SAS) for anxiety testing.The cutoff points of these scales were based on those described previously [14-16].All participants were required to answer if they had any chance of being exposed to SARS-CoV-2.
In the questionnaire, we de ned supportive perception towards control of the outbreak by asking "Do you agree with the country's prevention and disease control policies?"and accordingly the respondents stated "agree" or "disagree".Adoption of NPI measures included washing hands frequently, using a facemask followed by recommendations, avoidance of gatherings, and avoidance of public places.Participants were required to answer "complied" or "not complied" to each question.In addition, we de ned respondents who adopted all four interventions as "high compliance" and those who did not as "not high compliance".The outbreak-control strategy and self-protection guidelines were announced on 25 January 2020.Before investigation, we con rmed that participants were aware of the content of the NPI strategy.
We ascertained whether participants had a history of potential exposure to SARS-CoV-2 by asking three questions.That is, whether: (i) they travelled to or through Wuhan in the previous 2 weeks; (ii) their family members had been diagnosed with COVID-19 or quarantined; (iii) their family members had travelled to or through Wuhan in the previous 2 weeks.If the answer to all of these questions was negative, the respondents were de ned as having "no exposure history".

Data analyses
First, collected data were cross-checked and imported into Excel™ (Microsoft, Redmond, WA, USA) in simpli ed Chinese, coded and translated into English, and analyzed using R 3.6.0(R Foundation for Statistical Computing, Vienna, Austria).The basic characteristics of respondents were rst presented as a number (percentage) for categorical variables.
Second, the difference in supportive attitude to the COVID-19 control strategy and the difference in the prevalence of adoption of this strategy in different subgroups was presented.The number need to treat (NNT) and its 95% interval con dence (CI) were also calculated.
Third, the association between a supportive attitude towards the COVID-19 control strategy and its adoption was examined.
The signi cance of differences was assessed by the χ² test for categorical variables and z-ratio for independent proportions.Multivariable logistic regression was carried out to test the association between a supportive perception towards the NPI strategy and adoption of its measures.Multi-collinearity was ruled out for all covariates based on the collinearity test.Covariates (age, sex, degree course (undergraduate or postgraduate), primary degree (medicine or non-medicine), anxiety score, and depression score were adjusted.Matching of the propensity score based on logistic regression was undertaken to minimize the potential bias in all subgroups, and age, sex, degree course, primary degree, anxiety score, depression score and history of exposure were adjusted accordingly.P < 0.05 was considered signi cant.Missing data were tested by margin plots and considered to be "missing at random".All missing data were excluded during each analysis.

Results
This section may be divided by subheadings.It should provide a concise and precise description of the experimental results, their interpretation as well as the experimental conclusions that can be drawn.

Supportive perception towards the non-pharmaceutical intervention strategy in different subgroups
Female and postgraduate students showed a slightly higher percentage of supportive perception towards the NPI strategy against COVID-19 compared with male and undergraduate students (adjusted absolute risk reduction (aARR) of 2.0%, and 1.8%, respectively).Respondents with no sign of depression had a more supportive attitude towards strategies than those who were depressed (94.2% vs. 90.5%,aARR = 3.7%).However, respondents who felt anxious were much more approving towards the NPI strategy (95.8% of respondents) than those who did not feel anxious (23.3%).Those who had been exposed to SARS-CoV-2 tended to have less of a supportive attitude than those who had no exposure history (95.8% vs. 91.5%,aARR = 4.3%).
We compared the adjusted number need to treat (aNNT) in subgroups.The smallest value of aNNT was 4 and was found in the anxiety group, which suggested that anxiety was the most important factor in uencing the supportive attitude of respondents.The second most important factor was exposure history(aNNT = 23).(Table 2)

Adoption of non-pharmaceutical intervention measures in different subgroups
The measure adopted by most respondents was avoidance of public places (94.8%), followed by use of a facemask (92.8%), avoidance of gatherings (91.2%) and hand washing frequently (86.9%) (Table 2).

Discussion
We found that 92.7% of respondents had a supportive attitude towards the NPI strategy for control of COVID-19.The time of the survey was in the winter vacation in China.All CSs were at home for the holidays, and they had the same access to information as the general population.A high prevalence of support indicates that the NPI strategy had been well publicized.About 5.5% of respondents reported that they disagreed with the NPI strategy.Compared with respondents who agreed with the NPI strategy, the respondents who disagreed tended to be male, have a low level of education and to suffer from depression.Studies have shown consistently that men express a lower level of concern towards health risks [17,18].This may be the reason why men had a lower supportive attitude than that of women in our study.Postgraduate students had a slightly higher supportive attitude about the NPI strategy than that of undergraduate students.Studies on Middle East respiratory syndrome (MERS)-related knowledge, preventive behaviors, and risk perception among nursing students during the MERS outbreak showed that senior nursing students and female students had a high perception and practice of measures to control MERS [19][20][21].That study suggests that intelligence has a positive effect on perception of a health strategy.
It is worth noting that the psychological of respondents was linked to a supportive perception of the NPI strategy.Depression was a negative in uencing factor in supportive perception of the NPI strategy, whereas anxiety had a positive in uence regardless of sex or level of education.This result may have been because people suffering from depression frequently lack interest in life [22].The reasons why anxiety was related to a supportive attitude to the NPI strategy may have been because: (i) anxiety was caused by COVID-19; (ii) COVID-19 caused anxiety in these respondents.Few studies have focused on anxiety and attitudes toward intervention measures to control and prevent disease.This suggests that people have the moderate anxiety caused by public health emergencies can enhance their implementation of relevant control strategies..
The measure adopted by most respondents was avoidance of public places (94.8%), followed by use of a facemask (92.8%), avoidance of gatherings (91.2%) and washing hands frequently (86.9%).Compared with the other three measures, the prevalence of adoption of handwashing was relatively low.
Implementation of this measure is related to sanitation facilities: in China, there are not enough facilities for outdoor handwashing.The inconvenience and di culty of maintaining a NPI measure is a potential obstacle to its adoption.During the epidemic of in uenza A (H1N1) in 2009, CSs and the general population had a low acceptance of NPI measures because they disrupted workplace and leisure activities [23,24].
We found that 76.5% of respondents adopted all four NPI measures.Zottarelli and colleagues showed that in the in uenza A (H1N1) epidemic in 2009, when evaluating CSs in the USA, 72.1% of the study cohort reported frequent hand-washing, yet only 10.7% avoided public gatherings [25].In another study conducted in a USA public university, the proportion of students who took any self-protective measure against in uenza A (H1N1) was 64.9% [9,23].Those results indicate that more CSs in China implement NPI measures than CSs in USA.
There was a positive correlation between supportive perception and adoption behaviors towards the NPI strategy during the COVID-19 epidemic (Table 4).People with a supportive attitude towards the NPI strategy indicated that they had a high perception of protection against and risk of COVID-19, so it is likely that they would be willing to adopt the measures.A study by Wang and colleagues on the factors that determine adoption of preventive behaviors during the in uenza A (H7N9) epidemic revealed that a protective perception positively in uenced an individual's willingness to take recommended actions [26].
Being female, having a high level of education, and being anxious meant that you were likely to adopt the measures of the NPI strategy.Importantly, respondents who reported having anxiety had a 28% higher chance of adopting the measures than those who were not suffering from anxiety.This nding suggested that the anxiety in students may have been caused by COVID-19.These results echo those from a study on perceived risk, anxiety, and behavioral responses in the early phase of the in uenza A (H1N1) epidemic in the Netherlands [10].Depression may negatively in uence adoption of NPI measures, which may because of depression made people less willingly to take action and more indifferent about safety.
Medical knowledge did not in uence adoption of measures.Interestingly, respondents who did not have an exposure history to COVID-19 patients or epidemic areas had less of a supportive attitude and adoptive behaviors to the measures compared with the ones who had exposure history (Table 3, Table 4).This nding may have been due to two reasons.First, if respondents had been exposed but did not develop COVID-19, their risk perception will be reduced, which is also known as optimistic bias.Parry and colleagues showed that, compared with people who had food poisoning due to Salmonella species, people who had not experienced food poisoning due to Salmonella species perceived their personal risk from food poisoning to be lower 26.Second, may be our respondents had reduced anxiety about COVID-19.Bults and colleagues showed that anxiety decreased over time in the in uenza A (H1N1) epidemic in 2009 [10].
Our study had two main limitations.First, it was a cross-sectional study and therefore weak in causation.
Second, there may have been an information bias because the study data were time-sensitive and selfreported.
Our study had three main advantages.First, this survey was done shortly after the outbreak, which might indicate how the respondents would actually react where interferences were little.Second, we analyzed the impact on supportive perception and adoptive action towards the NPI strategy by the social demographics and psychological status of CSs, which has been studied scarcely previously.Third, this is the rst study focusing on COVID-19-related supportive perception and adoption towards an NPI strategy.
These results can provide: (i) insights for public health decision-makers; (ii) helpful information on the NPI measures people are willing to adopt (and the factors affecting adoption) during an emerging epidemic.

Conclusions
Our results suggest that supportiveness towards the disease control strategy for public may lead to higher adoption rate of NPIs for individuals including more-challenging measures like social distancing.It also suggested that the policy maker should pay more attention on anxiety and depression people, who might be less likely to support the policy or prevention measures.Further research is needed to be done to understand differences in responses from other populations, what might affect the supportive perception and how these ndings will affect action in future outbreaks of infectious diseases.

Table 1
Characteristics of college students in the study, n = 44446 Note.Data are shown as number (%) unless otherwise stated.

Table 2
Supportive perception on the non-pharmaceutical intervention strategy to control COVID-19 among respondents by subgroup Percentage of supportiveness refers to the proportion of respondents who had a supportive attitude on the NPI strategy to control the spread of COVID-19.ARR, absolute risk reduction.NNT, number need to treat.P with is based on the z-ratio test, and P is two-tailed.†case was adjusted by propensity-score matching based on age, sex, degree course, primary degree, depression score, anxiety score, or exposure history.

Table 3
Adoption of the non-pharmaceutical intervention strategy to control COVID-19 among respondents by subgroup Percentage of adoption refers to the percentage of respondents who undertook all ve measures (hand hygiene, use of a facemask, avoidance of gatherings, and avoidance of public places.ARR, absolute risk reduction.NNT, number need to treat.P with is based on the z-ratio test, and P is two-tailed.†case was adjusted by propensity-score matching based on age, sex, degree course, primary degree, depression score, anxiety score, or exposure history