COVID-19 outbreak in Brazil: adherence to national preventive measures and impact on people’s lives, an online survey

Background The first case of COVID-19 infection was diagnosed in Brazil 26th February 2020. By March 16th, physical distancing and confinement measures were implemented by the Brazilian government. Little is known about how these measures were followed up by the Brazilian people and their impact on daily routine. Methods In early April 2020, using an online platform, we organized an online survey among adults living in Brazil about their COVID-19 preventive behavior and impact on their daily routine. Results Data from 23,896 respondents were analyzed (mean age: 47.4 years). Due to COVID-19 restrictions, half (51.1%) of the professionals reported working from home. Regular handwashing was practiced by 98.7% of participants; 92.6% reported adhering to the 1.5-2 m physical distancing rule, but only 45.5% wore a face mask when going outside. While 29.3% of respondents found it relatively easy to stay at home, indoor confinement was extremely difficult for 7.9% of participants. Moreover, 11% of participants were extremely worried about their health during the COVID-19 epidemic. Younger people, male, persons living in a rural area/village or popular neighbourhoods, students and workers reported less preventive behaviour. Conclusion Restrictive measures markedly affected the daily and professional routines of Brazilians. Participants showed a satisfactory level of adherence to national COVID-19 prevention guidelines. Qualitative and follow-up studies are needed to monitor the impact of COVID-19 in the Brazilian society. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10222-z.


Background
On December 31st 2019, the World Health Organization (WHO) received a notification of an unknown viral pneumonia outbreak in the Hubei Province of China. This outbreak was later found to be caused by the Severe Acute Respiratory Syndrome Coronavirus 2 [1,2]. The disease, now called Coronavirus Disease 2019 , has quickly spread to most countries of the world, affecting almost 5 million individuals and causing more than 320,000 deaths. Until May 22, 492,124 cases were registered in the South America, with 55,3% being in Brazil [3].
COVID-19 is primarily transmitted by respiratory droplets with a similar incubation time and development time as the previously known Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) [1,4]. The rapid international spread of COVID-19 pressured the WHO to declare the COVID-19 epidemic as a public health emergency of international importance in late January 2020. Such a decision is taken when an event with major public health implications crosses the borders of the country initially affected, demanding immediate international action [5]. In the absence of antivirals and while awaiting the large-scale introduction of COVID-19 vaccination [6], various public health strategies to contain the infection have been implemented around the world. These strategies commonly consist of enforced or semienforced "lockdowns" and closure of national and/or intra-national borders, as well as promotion of respiratory hygiene (masking, coughing/sneezing etiquette) and hand hygiene. The package of containment measures for COVID-19 around the world probably represents the largest global public health intervention in human history, though the societal and individual impact of these measures is not yet well-understood.
The population-level adherence to such measures may determine to a considerable extent the national magnitude and duration of the COVID-19 pandemic [7,8]. However, little is known on population-level adherence to the various containment measures implemented worldwide, with most studies focusing on adherence to hygiene measures among healthcare workers [9][10][11]. Indepth documentation of adherence to containment measures is nonetheless essential, on the one hand to feed into initiatives attempting to model outbreaks [7,12], and on the other hand to adapt and target health promotion messages to sub-populations that may be struggling to adhere to specific measures [13], such as specific age groups.
In Brazil, the first case of COVID-19, reported by the Ministry of Health (MOH) on February 26th, was a 61year-old man who had traveled to Italy between February 9 and 21 of 2020. Two tests were positive for COVID-19 infection. Since then, the number of infected persons in Brazil has increased dramatically [14]. Physical distancing and confinement measures were implemented by the Brazilian government after COVID-19 was declared a pandemic on March 16th [5]. Events expected to attract large numbers of people were cancelled, universities and schools were closed, and only services considered essential to the population remained functional, such as markets, pharmacies and bakeries. However, traveling between Brazilian states remained possible. To document how the containment measures affected the lives of the Brazilian people, and to understand which containment measures were best adhered to by which strata of the population, we conducted an online survey on the adherence of the Brazilian people to individual public health measures and impact of the COVID-19 outbreak on people's lives. A particular emphasis was placed on age as a stratifying factor, considering the clear association of COVID-19 severity with age, and the general need for adapting health messaging to specific age groups.

Study design
An online questionnaire survey was organized in Brazil between April 3 to April 9. At the time of the survey Brazil counted 9056 confirmed COVID-19 cases, 1769 hospitalizations and 359 deaths. Data were collected on the ICPcovid website (www.icpcovid.com), which is a secure web-based platform developed by the University of Antwerp, Belgium.
The link for the survey was disseminated using What-sApp, email, and social media such as Facebook, Instagram, LinkedIn and ResearchGate. Furthermore, we had support from national organizations such as the Research Support Foundation of the State of Goiás, the Regional Council of Biology of the First Region, and the Faculty of Public Health of the University of São Paulo who actively disseminated the survey link. Everybody in Brazil, regardless their nationality could participate in the study: the only exclusion criteria for participation were being younger than 18 years (as we considered that approval from one of the parents was needed) and not living in Brazil at the moment of the survey.
The structured questionnaire consisted of 60 questions about socio-demographic characteristics, individual preventive measures (such as hand and respiratory hygiene, physical distancing and isolation) and daily living practices (such as impact on working conditions, difficulties to adhere to the preventive measures and COVID-19 health concerns); See supplemental information. We used Likert scores for questions concerning health risk perception and the level of difficulty to observe the preventive measures.

Data analysis
Statistical analysis was performed using IBM SPSS version 25 for Windows. Containment measures were grouped into three main categories: hand hygiene, respiratory hygiene, and physical distancing/isolation. A composite adherence score was generated for each of these categories using specific questions from the survey, with empirical weights (Table 1). Subsequently an overall adherence score was generated by combining the sub-scores using equal weights (1:1:1 ratio).
Descriptive statistics were presented using means with standard deviation (SD) for continuous outcomes, and percentages (%) for categorical variables. The Wilcoxon test was used to compare the number of days of work per week before and after the epidemic.
Multiple linear regression was performed to analyze factors associated with adherence to national prevention restrictive measures; the composite adherence score (Table 1) served as dependent variable. Variables with p < 0.10 in bivariate analysis were included in the adjusted model, and the final model was selected via a backward stepwise process of eligible covariates. Covariates that were investigated included: age, gender, state and area of residence, education, marital status, living alone, profession, working in the health sector, and existing comorbidities. The significance level adopted was 5% for all hypothesis tests.

Characteristics of respondents
A total of 25,266 persons participated in the survey. After excluding respondents younger than 18 years (n = 163) and people with inconsistent responses (1207), 23, 896 respondents (94.6%) were included for analysis. Participants were from all parts of the country. The median age of participants was 48.0 years (IQR 37.0-58.0 years); 71.8% were women ( Table 2). 7020 (29.4%) reported a chronic underlying disease such as diabetes, cancer, HIV infection or tuberculosis and 2177 were smokers of cigarettes.

Impact of COVID-19 restrictive measures on working arrangements
At the time of the survey, 44.6% of professionals were working from home. For those who were not working from home, 66.1% were not able to do so because of the type of job, 9.1% were not allowed by their employer, 5% had to leave the house to make money to support the family, and 1.3% left the home because they considered this to be without a risk (Table 3). Due to COVID-19 restrictions, participants reported going to work less often (mean number of days of work per week: 0.8) compared to the period before the epidemic (mean number of days of work per week: 3.2; p-value< 0.001; Wilcoxon test).

Adherence to the national COVID-19 restrictions
Most participants (92.6%) reported adhering to the 1.5-2 m social distancing rule; 69.5% covered their mouth and nose when they sneeze and washed their hands afterwards; 45.5% wore a face mask when going outside; Staying at home was found to be extremely difficult for 7.9%, but 29.3% considered it not difficult at all (Table 4).
Difficulty to adhere to the COVID-19 preventive measures and health concerns While 29.3% of respondents found it relatively easy to stay at home, indoor confinement was extremely difficult for 7.9% of participants (Table 3). When queried about their health concerns as a consequence of COVID-19, respondents were more concerned about the health of their loved ones (29.9% very concerned and 22.2% concerned) than their own health (11.0% very concerned and 13.9% concerned) (Fig. 1).
Multiple linear regression analysis was carried out to identify factors associated with higher overall adherence. Older age, being female, having at least an undergraduate degree, being a health care worker, having comorbidities, not living in the rural area/village, not being a student, not working in the private sector, and not smoking were all independently associated with a higher overall score (Table 5). Adherence scores for the specific measures were all significantly lower in the younger age group (18-25 years). Respiratory hygiene and physical distancing adherence scores were significantly lower in the 26-65 years old than in the > 65 years oldconfounding of the other covariates was controlled for through multiple linear regression (Fig. 2).

Discussion
Our study shows that, during the survey period, Brazilians were following the COVID-19 preventive measures relatively well. Hand hygiene measures were adhered to most, followed by physical distancing and respiratory hygiene. In all categories of measures, a clear age effect was observed, with younger individuals scoring lower than older respondents on the adherence score.
Overall, only 45.5% reported wearing a face mask when going out. This is much lower than in Asian countries, where most people wore face masks once the COVID-19 epidemic was introduced in their country [15][16][17]. This is also lower than the 91.7% face mask use reported in a similar online survey in Ecuador in April 2020 and the 99.8% face mask use in a survey in Peru in June 2020 [18]. This is however higher than in several European countries where wearing face masks was initially advised only in health care settings, following WHO recommendations at the time [19][20][21]. Checking one's temperature for the early detection of a COVID-19 infection at least twice a week was only practiced by 10.8% of the respondents. This may be a point of concern, as WHO reported that temperature screening was able to detect the majority of exported cases during the COVID-19's expansion [22]. When assessing the profile of individuals with poor general adherence, men were less adherent compared to women, which mirrors findings from a Knowledge, Attitudes, and Practices study conducted in China (17). In our study, younger age was also associated with a lower  overall score. In another large online survey in Brazil conducted between April 24th and May 24th, assessing only the degree of adherence to physical contact restriction measures, greater adherence was found among females compared to males but it was mainly the 30 to 49 year old group that was less adherent and not the younger age group [23]. People living in rural areas and poor neighborhoods were also less adherent: in rural areas people may not perceive themselves at high risk of COVID-19, and therefore may not respect the national restriction measures and not practice individual hygiene measures [24]. Therefore, extra communication and health education may be needed to change the risk perception in rural areas and popular neighborhoods [25]. Brazilian students reported difficulties to stay home, which may be related to a need to travel to their original homes in periods when schools and universities were closed [26] or could be related to differing social habits among this population. Encouragingly, respondents with underlying diseases followed the preventive measures well, which is important considering their higher risk for more severe disease. Taken together, these observations suggest that tailoring of the public health messages may be indicated. A reinforcement of specific messages, such as mask use and temperature taking, may be beneficial, and using delivery methods tailored to the specific age groups could allow higher uptake. Especially communication methods to the younger age group could benefit from such tailoring, and possibly approaches relying on social media and including influencers to spread public health messages could be considered [27]. Of note, the observation that most respondents' concern was higher for their loved ones than for themselves could be incorporated in such health messages; possibly by emphasizing how adhering to measures protects one's close environment.
In general, our results indicate that following an intensive COVID-19 prevention campaign [28] the Brazilians gradually became aware of the importance of adopting simple methods to prevent COVID-19 transmission. For only 7.9% of the respondents indoor confinement was experienced as extremely difficult. Initially the MOH of Brazil expected a peak of COVID-19 infections during the second half of April. However, it did not happen. The satisfactory adherence to the preventive measures may have delayed the peak of the epidemic.
COVID-19 associated mortality during the study period was highest in the North region of Brazil (Amazonas) and in two states in the Northeast (Ceará and Pernambuco) [29]. Our study showed that the Northeast Fig. 1 Level of concern about COVID-19 consequences among participants of an online survey on COVID-19, Brazil, April 2020 (bivariate: selfversus loved ones) There has been a lot of confusion about how to deal with the COVID-19 epidemic in Brazil. The president has minimized the actions of the MOH, downplaying the importance of quarantine, and is defending vertical isolation to avoid financial collapse. Vertical isolation or shielding implies that most people return back to normal life and people with underlying diseases, older adults and pregnant women continue to respect physical distance and reduce their social activities. Regarding this vulnerable group, 29.4% stated to have underlying diseases in our survey. This is a concern, as older age and the presence of (an) underlying health condition(s) are associated with increased COVID-19 related mortality [30,31] On the other hand, Brazilian respondents with underlying diseases adhered better to the containment measures.
The lack of unified actions against COVID-19, by the federal government, led to the resignation of the health minister on April 16 [32,33]. From that moment on, there was a relaxation of quarantine measures, opening of part of the trade, and consequently less physical distancing. The lack of national coordination by the government in response to the pandemic reveal the conflictual positions between the federal government and governors from the 27 states of the country [34]. This increased the number of COVID-19 cases and associated deaths [30,31].
At the end of April, the COVID-19 death toll in Brazil had already exceeded that of China [3] (more than 5000 deaths) and this scenario got worse, not reaching the flattening of the curve and overloading the Brazilian health system [35]. As of December 31th 2020, more than 7,000,000 cases had been confirmed in the country, causing almost 200,000 deaths [3]. Our findings suggest a considerable initial willingness of the Brazilian people to follow the quarantine and other containment measures. However, this willingness seems to have been irrevocably subverted through the political stance against the public health measures with as a consequence that currently South America became the new epicenter of the pandemic with Brazil as the most affected country [3].
Our study had several limitations. The number of respondents was relatively small compared to the entire Brazilian population, and respondents were unevenly spread over the national territory. Indeed, only 2,6% of the participants reported residing in rural areas. The reason for this low number of participants from rural areas most likely is because in those areas people have less internet access and consequently are less linked to social media [24,25]. While 51.8% of the Brazilian population are women [36], 71,8% of the respondents in our survey were female. Such a higher proportion of female respondents was also observed in other studies on COVID-19-related practices [17]. Participants were more likely to be higher educated individuals living in cities and in the Southeast region. The latter may be explained by the fact that since the beginning of the pandemic, this region recorded the largest number of COVID-19 infections. Moreover, broadband internet quality is best in the Southeast region [37]. Our survey was also not able to reach vulnerable populations, such as the homeless, prisoners, older adults, migrants and people with mobility problems. Such populations may be at increased risk for COVID-19 infection and should be considered as priority key groups in the prevention and control of Covid-19 [26,38]. Our study findings are based on self-reports without a possibility to verify whether these responses corresponded with the real preventive behaviour of the respondents.
At the time of writing, the COVID-19 vaccination started in more than 30 countries [39], and in Brazil, it is scheduled to start at the end of January 2021. However, it will still be challenging to deal with the vaccine hesitance movements and the political polarization [40] that it is taking place in relation to vaccination.

Conclusion
In conclusion, most participants in this survey correctly followed the COVID-19 prevention guidelines, although staying at home was difficult for individuals who had to go out because of their job, and younger individuals tended to adhere less to containment measures. Larger follow-up surveys and in-depth qualitative studies about the preventive behavior of different groups in the Brazilian society are needed. The adherence to COVID-19 preventive measures will need to be monitored closely as restrictive measures are being relaxed and as the expectations concerning the COVID-19 vaccine may decrease the motivation of people to adhere to prevention measures.