key: cord-268975-xzdh8yum authors: Huang, Jing; Liu, Fangkun; Teng, Ziwei; Chen, Jindong; Zhao, Jingping; Wang, Xiaoping; Wu, Ying; Xiao, Jingmei; Wang, Ying; Wu, Renrong title: Public behavior change, perceptions, depression, and anxiety in relation to the COVID-19 outbreak date: 2020-07-03 journal: Open Forum Infect Dis DOI: 10.1093/ofid/ofaa273 sha: doc_id: 268975 cord_uid: xzdh8yum BACKGROUND: The COVID-19 has spread rapidly and world-widely, which elicits public panic and psychological problems. Public protective behaviors and perception play crucial roles in controlling the spread of illness and psychological status. METHODS: We conducted a cross-sectional online survey in the hardest-hit Hubei province and other areas in China affected by COVID-19 outbreak. Questions about their basic information, the perception of the COVID-19 outbreak, recent preventive or avoidance behaviors, and self-reported mental health scales including the Patient Health Questionnaire (PHQ-9) and Self-Rating Anxiety Scale (SAS) were included. Binary logistic regressions were used to investigate the association between personal variables/perceptions and psychological distress. RESULTS: 6,261 people were included for analysis, with 3,613 (57.7%) in Hubei province (1,743 in Wuhan). A majority of people have adopted preventive and avoidance behaviors. People from Hubei, with contact history, and people who or whose family members were infected had much higher depression or anxiety prevalence. Providing truthful and sufficient information, informing the public about the severity of the disease, and perceptions that the outbreak will be control by protective behaviors were associated with lower depression and anxiety prevalence. CONCLUSIONS: Assessing the public response, perception, and psychological burden during the outbreak may help improve public health recommendations and deliver timely psychological intervention. Further researches can focus on the psychological status of a specialized group to identify ways for better support based on public response and psychological demand. In December 2019, a new virus caused pneumonia emerged in Wuhan, Hubei province, has rapidly and widely spread in China and other countries, which caused an exponential increase in patients with infection 1,2 . Within weeks, the numbers of confirmed cases, suspected cases, and deaths rose substantially. On Jan 29, Xizang raised its public health emergency response to level 1, which announced that all of the 31 provincial-level regions in mainland China have set up the highest level of emergency public health alerts and responses. On Jan 30, WHO declared the outbreak as a public health emergency of international concern (PHEIC). As of Feb 10, 2020, the number of During the outbreak, the government closed the schools, canceled the public activities, ordered everyone to stay at home and avoid outside activities as much as possible. The transmission of COVID-19 from human-to-human, a large number of confirmed cases, suspected cases, and the increasing number of deaths elicited public fear of being infected 4 . Meanwhile, people were flooded with various and uncertain information from numerous sources, which may increase public panic and potential psychological problems 5 . The uncertainty of the new virus outbreak, the A c c e p t e d M a n u s c r i p t extensive information or rumors, and the shortage of necessities may increase worries in the population. During the start of our survey on Feb 10, the outbreak seems to reach a full point. To this, the National Health Commission of China has launched several policies and notices to cope with the psychological burden due to the COVID-19 pandemic 6,7 . Previous studies suggested the importance of early assessment of anxiety and behavioral response to the spread of an infectious disease [8] [9] [10] [11] . However, no study has performed to assess the public response, protective behavior changes, the relationship between perception and psychological burden in the COVID-19 outbreak. Therefore, a timely and accurate measurement of public responses and psychological distress is extremely important 12, 13 . We conducted a large survey in the hardest-hit Hubei province and other areas affected by the COVID-19 outbreak, with 3,613 in Hubei province and 2,648 outside Hubei province. Due to the extensive internet coverage and more than 1.3 billion mobile Internet users in China, according to a recent report by the Ministry of Industry and Information Technology 14 , the survey was conducted through the Internet to avoid exposure and increase the response speed and participation 14 . This survey provided a snapshot of public adoption of preventive behaviors or avoidance behaviors, perception and the psychological status during the peak period of the outbreak. The cross-sectional online survey was designed to perform in Hubei province for about 3,000 participants, and outside Hubei province for 3,000 participants. The sample size was chosen to allow for sufficient power to analyze likely differences between subgroups such as confirmed cases, A c c e p t e d M a n u s c r i p t people with a history of recent contact with COVID- 19 They needed to answer questions about their basic information, the perception of the COVID-19 outbreak, recent preventive or avoidance behaviors, and self-reported mental health scales. After a complete description of the survey to the subjects, electronic informed consent was obtained. The basic information of the participants includes gender, age, job, marriage status, education level, and address. The survey also asked people seven questions about preventive behaviors (public mask-wearing, increases in handwashing and the frequency, surface sterilization) and avoidance behaviors (such as avoid crowded places or public transport or people with contact history, personal protective, and social distancing behavior, urge their family members or friends for these The perception of the COVID-19 outbreak includes the severity of the disease, the attitude towards the disease, information, support, the worries of being infected and for their families. Each question had five response options: strongly agreeing (scored as 5), tend to agree, neither agree nor disagree, tend to disagree, or strongly disagree (scored as 5). One question was related to the concern level about the outbreak to see whether participants have paid much attention to the COVID-19 epidemic news. Eight questions were about the understanding of the disease, timely and true information, basic supplies and support received from outside. One of the items assessed whether participants believed that recommended behaviors reduced their risk of being infected. Six questions evaluated participant's worries and attitudes towards the outbreak, including worries about being infected, worries for their families or friends, worries for contacting an infected but symptomless individual, worries when get COVID-19 related symptoms, and attitude of the disease. It should be noted that two questions related to worries about the infection of the participants or their loved one had six response options, five options were the worrying levels, the last option was confirmed infection, which means the participant/ his family has been confirmed infection. The nine-item depression module from the Patient Health Questionnaire (PHQ-9) was employed in the survey to evaluate the depression level. Each of the nine questions inside corresponds to one of the DSM-IV criteria scored as "0" (not at all) to "3" (nearly every day). People with PHQ-9 score ≥10 had high sensitivity and specificity for major depression 15 . People who scored 10 or A c c e p t e d M a n u s c r i p t more were defined as having depression about COVID-19. Anxiety was assessed using the Self-Rating Anxiety Scale (SAS), which was well-validated and widely used for anxiety screening and severity measurement. Participants were asked about their feelings over the past week concerning the COVID-19 outbreak. Previous studies showed the upper limit for the Chinese general population was an index score of 50. In this study, people who scored 50 or more were defined as having anxiety about COVID-19, and those with scores 60 or more were defined as having moderate to severe anxiety 16, 17 . SPSS 25.0 software was used for the analyses. We used binary logistic regression to investigate the univariate association between personal variables and psychological distress (prevalence of depression or anxiety), the association between public perceptions and psychological distress. Another set of binary logistic regression was applied to assess the multivariate associations between personal variables and psychological distress after adjusting for significant personal variables. Odds ratios were used to assess these associations. Data were weighted to gender, age, marriage, and working status based on the data from the National Statistics Institute of China. The prevalence of public behaviors, perceptions, depression, and anxiety changed less than 1% or marginally 1% after weighting procedure, therefore the unweighted data were used for analysis in this study. Overall, 6,523 completed the survey in five days at the peak of the Table 1 lists the public behavior changes in response to COVID-19 outbreak. The most commonly (96.3%) adopted preventive behavior was to wear a mask when going outside and the most commonly (95.0%) adopted avoidance behavior was reducing the frequency of going out, dining together, and visiting others. A majority of people (99.5%) had adopted at least one of these things. A c c e p t e d M a n u s c r i p t In total, 17 (Table 3) , even after adjusting the other significant personal variables. Next, we examine association between perceptions and psychological status. (Table 4 ). Our results suggested that Chinese general public had obvious responses and behavior changes after about two weeks that 31 provincial-level regions in mainland China activated level 1 public health emergency responses. People showed high adoption rates of various protective behaviors, such as mask-wearing, disinfection, and social distance maintenance. The most affected province, Hubei, is still been engulfed by the outbreak. Most restaurants, hotels, malls, cinemas and other public place of entertainment have been closed. Several ways of restrictions on access have been adopted by the communities and villages including locking all unused doors or blocking roads to limit access, restricting all unauthorized individuals, distributing cards for temporary access. Community members need to take temperature and will only be allowed in with normal temperature. Newspapers, television, broadcast, Internet, magazines and other media take efforts to strengthen people awareness of protective behaviors and personal health to control virus infection. The high percentage of protective behavior adoptions proved the notable effects of these measures. The prevalence of psychological distress is associated with several personal variables. People from Hubei province, single, having contact history, being confirmed infection, whose family has been A c c e p t e d M a n u s c r i p t Further studies can be performed to explore the psychological status of people in a specialized group to understand their different demands and provide better psychological support. With more than 40,000 confirmed cases reported in China on Feb 10, the COVID-19 outbreak has developed into a serious public health problem. A majority of people have adopted various preventive and avoidance behaviors. People from Hubei, with contact history, and people who or whose family members were infected had much higher depression or anxiety prevalence which requires urgent psychological intervention. Providing clear and sufficient information, informing the public about the severity of the disease, and perceptions that the outbreak will be control by protective behaviors were associated with lower depression and anxiety prevalence. Further researches can focus on the psychological status of a specialized group to offer effective psychological counseling and support. The study is supported by the National Nature Science Foundation of China (Grant No. 81901401 and No.81622018). None declared. M a n u s c r i p t manuscript. JC, JZ, and XW revised the survey and the design. YW, ZT, JX, YW were involved in data collection. RW is the principal investigator of this clinical trial. All authors read and approved the final version of the manuscript. We also want to thank several anonymous reviewers for their valuable comments and suggestions to improve the quality of the paper. Data not publicly available. M a n u s c r i p t A c c e p t e d M a n u s c r i p t Table 1 Behavior response to COVID-19. Percentage of positive responses (n=6261) Preventive behavior Sterilize the surface of the floor, desktop, mobile phone and other objects more often than usual 81% Cover your mouth and nose with bent elbows when coughing or sneezing 81% Washed my hands with soap and water more often than usual 91% In the past 3 days, you certainly wear masks when you went out 96% Keep away from potential infected people 86% Try to keep at least one meter away from others, especially when going out 85% Reduce the frequency of going out, dining together, and visiting others 95% Avoid crowded places 93% Reduce the frequency of taking public transport 86% Have you advised your family and friends in the following areas during the epidemic Avoid crowded places 92% Wash hands with soap and water more often than usual 87% Wear masks when going out 97% Reduce the frequency of taking public transport 84% Reduce the frequency of going out, dining together, and visiting others In the past 24 hours, how many times have you washed your hands with soap 0-4 36% A c c e p t e d M a n u s c r i p t Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. The Lancet 2019-nCoV epidemic: address mental health care to empower society. The Lancet The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital Early assessment of anxiety and behavioral response to novel swineorigin influenza A (H1N1) Public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey Public response to the 2009 influenza A H1N1 pandemic: a polling study in five countries. The Lancet infectious diseases The public's response to the 2009 H1N1 influenza pandemic The 2014 Ebola outbreak and mental health: current status and recommended response Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed The PHQ-9: a new depression diagnostic and severity measure Chinese version of Zung's self-rating anxiety scale Behavioral Medicine Scale Manua Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers Medical management of radiation accidents Communicating with the public about emerging health threats: lessons from the pre-event message development project The dark side of information: overload, anxiety and other paradoxes and pathologies Pandemics: good hygiene is not enough We would like to acknowledge the valued contribution of the participants. RW, JH, and FL had the original idea for the study and designed the survey. FL carried out the analyses, JH wrote the A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t Adjusted odds ratio (95% CI) † I believe that taking protecting efforts will reduce risk of catching COVID- I am worried that I will be infected 3.8 (1.1), 6106 1.6 (1.5 to 1.7) 1.6 (1.4 to 1.7) 1.7 (1.6 to 1.9) 1.7 (1.5 to 1.8) I am worried that my family members or friends will be infected 4. *Scores from 1 to 5. Each question had five response options: strongly agreeing (scored as 5), tend to agree, neither agree nor disagree, tend to disagree, or strongly disagree (scored as 5). High scores indicate greater agreement with the statements. †Adjusting for gender, age, marriage, and working status.