F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.79534.1 Research Article Articles Beliefs on social distancing and face mask practices during the COVID-19 pandemic in low- and middle-income countries: a cross-sectional study

[version 1; peer review: 1 approved, 1 approved with reservations]

 Harapan Harapan Conceptualization Data Curation Formal Analysis Funding Acquisition Methodology Project Administration Resources Software Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-7630-8413 a 1 2 3 Yufika Amanda Conceptualization Methodology Project Administration Resources Validation Writing – Review & Editing 4 Anwar Samsul Conceptualization Formal Analysis Methodology Project Administration Validation Writing – Original Draft Preparation https://orcid.org/0000-0003-3165-2151 5 Ophinni Youdiil Conceptualization Funding Acquisition Resources Validation Writing – Review & Editing https://orcid.org/0000-0001-9443-1538 6 7 Yamada Chika Conceptualization Funding Acquisition Resources Validation Writing – Review & Editing 8 Sharun Khan Data Curation Investigation Resources Validation Writing – Original Draft Preparation https://orcid.org/0000-0003-1040-3746 9 Gachabayov Mahir Data Curation Investigation Resources Validation Writing – Review & Editing https://orcid.org/0000-0002-9200-1304 10 Fahriani Marhami Conceptualization Methodology Project Administration Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-0452-3485 1 Husnah Milda Methodology Project Administration Validation Writing – Original Draft Preparation Writing – Review & Editing 1 11 Raad Rawan Data Curation Investigation Validation Writing – Review & Editing https://orcid.org/0000-0003-4060-3378 12 Khiri Namareg ME. Data Curation Investigation Project Administration Validation Writing – Review & Editing 13 Abdalla Rashed YA Data Curation Investigation Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0002-7841-4807 14 Kacem Wajdi Data Curation Investigation Validation Writing – Review & Editing 15 Teyeb Zeineb Data Curation Investigation Validation Writing – Review & Editing https://orcid.org/0000-0003-2871-9773 16 Aloui Khaoula Data Curation Investigation Validation Writing – Review & Editing https://orcid.org/0000-0002-1594-3429 17 Ferjani Manel Data Curation Investigation Validation Writing – Review & Editing https://orcid.org/0000-0003-1039-0500 17 Deeb Dalia A. Data Curation Investigation Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0002-4434-947X 18 Emad Dina Data Curation Investigation Project Administration Supervision Writing – Review & Editing 19 Abbas Kirellos S Data Curation Methodology Project Administration Validation Writing – Review & Editing 20 Panchawagh Suhrud Data Curation Investigation Validation Writing – Review & Editing https://orcid.org/0000-0002-8606-4202 21 Anandu Sunil Data Curation Investigation Project Administration Validation Writing – Review & Editing 22 Haque Md Ariful Data Curation Investigation Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0003-4632-5153 23 Ferreto Lirane ED. Data Curation Investigation Methodology Validation Writing – Review & Editing 24 Briones María FC. Data Curation Investigation Methodology Validation Writing – Review & Editing 25 Morales Rocío BI. Data Curation Investigation Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0003-3473-4654 25 Lazcano-Díaz Sebastián Data Curation Investigation Methodology Validation Writing – Review & Editing 25 Durosinmi Abiodun Formal Analysis Investigation Methodology Supervision Writing – Review & Editing https://orcid.org/0000-0002-5382-5108 26 Adejumo Esther N. Data Curation Investigation Project Administration Validation Writing – Review & Editing 27 Babadi Elham Data Curation Methodology Project Administration Validation Writing – Review & Editing 28 Kakemam Edris Data Curation Investigation Project Administration Validation Writing – Review & Editing 29 Ullah Irfan Data Curation Investigation Project Administration Validation Writing – Review & Editing 30 Malik Najma I. Data Curation Investigation Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0002-3521-1014 31 Rosiello Francesco Conceptualization Methodology Project Administration Supervision Validation Writing – Review & Editing https://orcid.org/0000-0002-6532-1185 32 Emran Talha B. Data Curation Investigation Methodology Project Administration Validation Writing – Review & Editing https://orcid.org/0000-0003-3188-2272 33 Nainu Firzan Methodology Project Administration Resources Supervision Validation Writing – Review & Editing https://orcid.org/0000-0003-0989-4023 34 Wendt Guilherme W. Conceptualization Methodology Project Administration Resources Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-9014-6120 35 Arab-Zozani Morteza Conceptualization Methodology Project Administration Resources Validation Writing – Review & Editing https://orcid.org/0000-0001-7223-6707 36 Wagner Abram L. Conceptualization Methodology Resources Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-4691-7802 37 Mudatsir Mudatsir Conceptualization Methodology Resources Supervision Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-5643-9384 1 2 3 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Department of Family Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Department of Statistics, Faculty of Mathematics and Natural Sciences, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Ragon Institute of MGH, MIT and Harvard, Cambridge, 02139, USA Laboratory of Host Defense, WPI Immunology Frontier Research Center (IFReC), Osaka University, Osaka, 565-0874, Japan Department of Environmental Coexistence, Center for Southeast Asian Studies, Kyoto University, Kyoto, 606-8304, Japan Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, 243122, India Department of Abdominal Surgery, Vladimir City Emergency Hospital, Vladimir, 600014, Russian Federation Master Program of Biology, Faculty of Mathematics and Natural Sciences, Universitas Syiah Kuala, Banda Aceh, 23111, Indonesia Faculty of Medicine and General Surgery, Sudan University of Science and Technology, Khartoum, 407, Sudan Faculty of Medicine, University of Khartoum, Omdurman, 11111, Sudan Faculty of Medicine, University of Bahri, Khartoum, 11111, Sudan Department of Emergency Medicine, Faculty of Medicine of Tunis, University Tunis el Manar, Tunis, 2074, Tunisia Department of Internal Medicine, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, 2074, Tunisia Faculty of Dental Medicine Monastir, University of Tunis El Manar, Monastir, 5000, Tunisia Faculty of Medicine, Zagazig University, El-sharkia, 44519, Egypt Faculty of Medicine, Ain Shams University Nasr City, Cairo, 1181, Egypt Faculty of Medicine, Alexandria University, Alexandria, 21131, Egypt Department of General Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, 516599001, India Division of Veterinary Parasitology, ICAR-Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, 243122, India Department of Orthopedic Surgery, Yanan Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, 650000, China Department of Public Health and Postgraduate Program in Applied Health Sciences, Faculty of Medicine, Western Paraná State University, Francisco Beltrão, 85601-970, Brazil Faculty of Medicine, University of La Frontera, Temuco, 4781218, Chile Covenant University Medical Center, Ijebu Ode, Ogun, 120101, Nigeria Department of Medical Laboratory Science, Babcock University, Ilishan-Remo, Ogun State, 121103, Nigeria Research Fellow, Mayo Clinic, Rochester, 14604, USA Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, 516599001, Iran Department of Internal Medicine, Kabir Medical College, Gandhara University, Peshawar, 25000, Pakistan Department of Psychology, University of Sargodha, Sargodha, 40100, Pakistan Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, 00185, Italy Department of Pharmacy, BGC Trust University Bangladesh, Chittagong, 4381, Bangladesh Department of Pharmacy, Faculty of Pharmacy, Hasanuddin University, Tamalanrea, Makassar, 90245, Indonesia Department of Life Sciences, Faculty of Medicine, Western Paraná State University, Francisco Beltrão, 85601-970, Brazil Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, 97, Iran Department of Epidemiology, University of Michigan, Ann Arbor, MI, 48109, USA harapan@unsyiah.ac.id

No competing interests were disclosed.

 17 2 2022 2022 11 206 3 2 2022 Copyright: © 2022 Harapan H et al. 2022 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction: Social distancing and wearing a face mask are highly recommended to mitigate the transmission of coronavirus disease 2019 (COVID-19). However, the success of these strategies relies on individuals’ adherence and public compliance. This study was conducted to assess the level of belief in social distancing and face mask practices in communities in low- and middle-income countries (LMICs) and to identify their possible determinants.

Methods: A cross-sectional study was conducted in ten LMICs countries in Asia, Africa, and South America from February to May 2021. A questionnaire was used to assess the belief, practice, and their plausible determinants. Identification of the associated determinants was performed using a logistic regression model.

Results: Our data revealed that only 62.6% and 66.9% of the participants had good beliefs in social distancing and good face mask practices, respectively. Residing in the Americas, having a healthcare-related job, knowing people in immediate social environment who are or have been infected and exposure to information of COVID-19 cases on social media or TV were factors significantly associated with good belief in social distancing. Residing country, gender, monthly household income, type of job and exposure to information of COVID-19 cases were significantly associated with face mask wearing practice.

Conclusion: The proportion of participants having good beliefs in social distancing and good face mask practices is relatively low (<75%). Hence, sustained health campaigns regarding social distancing benefits and face mask-wearing practices during COVID-19 are critical in LMICs.

 COVID-19 face mask social distancing preventive measure practice Universitas Syiah Kuala 169/UN11/SPK/PNBP/2021 This study was funded by Universitas Syiah Kuala, Ministry of Education, Culture, Research and Technology, H-Index Scheme 2021 (169/UN11/SPK/PNBP/2021). The APC was funded by Grant-in-Aid for Scientific Research (KAKENHI) from the Japan Society for the Promotion of Science (grant number 19K17925). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction

The coronavirus disease 2019 (COVID-19) pandemic is continuing to affect millions of people globally following the initial emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China. 1 , 2 The COVID-19 pandemic has massively impacted existing health care systems worldwide and in particular in low- and middle-income countries (LMICs). 3 , 4 A syndemic of COVID-19 and other endemic infections could be particularly burdensome to tropical countries. 5 , 6 In the present scenario, strict adherence to social distancing (maintaining a physical distance of at least 2 meters), wearing a face mask, and regular handwashing are essential practices that are highly recommended for preventing human-to-human transmission of SARS-CoV-2. 7 , 8

Social distancing plays a critical role in slowing the rapid transmission of SARS-CoV-2 within the community. 9 , 10 Government-imposed social distancing measures have been found to be associated with a significant reduction in the cumulative incidence of COVID-19 worldwide. 11 Furthermore, people living in communities with better social distancing practices had a lower predicted risk of COVID-19 than those living in poor social distancing situations. 12 Accordingly, strict social distancing policies – prohibiting large gatherings and close social interactions between individuals from different households – could help mitigate the spread of SARS-CoV-2. 13 Achieving a high degree of compliance in social distancing behaviors is essential for preventing the spread of disease within the community. 10 Therefore, public health campaigns have to be conducted to improve the acceptability and adherence to the social distancing policies within the community. 13 , 14 Similarly to social distancing, mask-wearing will help slow down the spread of SARS-CoV-2, which is essential to allow health care facilities to continue functioning. 10 Wearing masks could also reduce SARS-CoV-2 transmission even in settings of poor social distancing. 12

Studies from European countries indicate that mandatory stay-at-home orders directly impacted population mobility and subsequently decreased the COVID-19 case growth rate during the pandemic. 9 Compliance of the public to the directives given by the governments and public health agencies will decide the effectiveness of these directives. Therefore, understanding beliefs in social distancing benefits and face mask practices among community members will help us formulate targeted public health campaigns that focus on specific subgroups to improve their acceptability and adherence to various prosocial behaviors.

This study sought to determine: (a) the level of beliefs in social distancing benefits and face mask practices; and (b) the possible determinants associated with belief in social distancing benefits and face mask practices among community members in ten LMICs in Asia, Africa, and South America.

 Methods Study design and setting

We conducted a cross-sectional study among community members in Asia (Bangladesh, India, Iran and Pakistan), Africa (Egypt, Nigeria, Sudan and Tunisia) and South America (Brazil and Chile) from February to May 2021. Community members were defined as all residents who have lived in one of these areas for at least three months prior to the study.

 Study population and sampling

Adults aged over 18 years old living in one of the studied countries and able to respond each question in the survey were considered eligible for the study. Illiterate individuals or those who needed help to complete the survey were considered ineligible. To recruit the minimal sample size, we sought a 5% margin of error, 95% confidence level and a 50% conservative estimate of respondents having good beliefs in social distancing benefits and face mask practices. The samples were recruited using a non-probability sampling method, convenience sampling approach.

 Data collection

The platform SurveyMonkey was used to host the anonymous online survey and the links to the survey were distributed on social media platforms such as Twitter, Facebook, and WhatsApp. A copy of the survey can be found under Extended data. 37 The invitation to participate in the survey was posted on Twitter and Facebook and shared on WhatsApp and the invited individuals were requested to share the invitation to their phone contacts. The survey consisted of an introduction page where information on the study was provided; an informed consent page where respondents had to provide consent to participate; and the main survey where respondents answered questions about their demographic background and their beliefs regarding social distancing and face mask practices. Approximately 15 minutes was required to complete all the questions. The questions within the questionnaire were tested and validity was confirmed prior to being used in the study.

 Study variables

Response variables

There are two response variables of the study: belief in the benefits of social distancing and face mask practices during the pandemic. To assess belief in social distancing benefits, the participants were asked to respond to three statements: (1) “Social distancing can protect yourself from COVID-19”; (2) “Social distancing can protect your child or children from COVID-19”; and (3) “Social distancing can protect your parents from COVID-19”. The possible responses and the scores were: “Strongly agree (score 5)”, “Agree (4)”, “Neither agree nor disagree (3)”, “Disagree (2)”, and “Strongly disagree (1)”. For each participant, the score from each statement was summed and the total score ranged from 3 to 15, in which the higher score indicates better belief in the benefits of social distancing. Those with a score of more than 80% (i.e., 13 or more) were classified as having a good belief in social distancing benefits while those with a score of less than 80% (i.e., 12 or less) were classified as having a poor belief. The 80% cut-off has been used to dichotomize the variables into good and poor previously. 15 , 16

The respondents were asked two questions to assess the face mask practices during the pandemic. These questions were about whether the respondents would: (1) wear a mask at work/school; and (2) wear a mask at the grocery store or other food vendors. The possible responses and the given score were: “Yes, during whole time (score 2)”, “Yes, for part of the time (score 1)”, “No (score 0)”, and “Not applicable (not going out for a whole week)”. The total score ranged between 0 to 4 and those wearing face masks during the whole time in both activities (score 4) were classified as having a good practice of face mask use, whereas those who did not (i.e., the score was less than 4) were classified as having poor practice. All participants who stated “not applicable" for one of the questions (they did not go to school/work or to a grocery store or other food vendor for the whole week) were excluded.

Explanatory variables

Several explanatory variables were included such as age, gender, urbanicity, monthly household income in USD, religion, occupation sector (healthcare- and non-healthcare-related), type of occupation, and the presence of COVID-19 comorbidities based on self-report, such as hypertension, diabetes, heart disease and pulmonary disease. The respondents were also asked whether they knew any people in their immediate social environment who are or have been infected with SARS-CoV-2. Respondents were also questioned about their exposure to information about individuals infected with the SARS-CoV-2 on TV or social media.

The perceived risk towards COVID-19 was also assessed for all respondents using two questions: (1) “What do you think are the chances that you will get COVID-19 in the next month?” and (2) “What do you think is your risk of dying from COVID-19 if infected? Response were assessed on a continuous scale of 0% to 100%. For each question, the respondents were classified into two: those with a perceived risk score equal to or less than 50% and those who had a score of more than 50%. In addition, the scores from both questions were summed and those who achieved more than 50% of the total score (i.e., 100 scores out of 200) were classified as having high perceived risk; conversely, those with less than 50% were classified as having a low perceived risk.

 Statistical analysis

A logistic regression was used to identify the explanatory variables associated with belief in benefits of social distancing and face mask practice in respondents. The analyses were conducted into two steps. First, in unadjusted logistic regressions, the associations of all explanatory variables with belief in benefits of social distancing and face mask practice were calculated separately. In this step, the crude odds ratio (OR) and 95% confidence interval (95%CI) of each explanatory variable for a good social distancing belief or good face mask practice were calculated. In the second step, those variables with p-values less than 0.25 at unadjusted logistic regression step were included in adjusted logistic regressions to calculate adjusted OR (aOR) and the 95% CI. The significance of OR and aOR were assessed at α=0.05. All analyses were conducted using SPSS version 24 (SPSS Inc., Chicago, IL, USA).

 Ethics and consent

This study was approved by Institutional Review Board of Universitas Syiah Kuala & Zainoel Abidin Hospital (approval number: 129/EA/FK-RSUDZA/2021) and Indonesian National Health Research and Development Ethics Commission (#1171012P). An introduction page consisting of information about the objectives, the benefits, and risks of the study was provided. All respondents provided consent by ticking a box before the survey could be opened. The survey account could only be accessed by the principal investigator to ensure the anonymity and confidentiality of participants.

 Results Demographic characteristics

During the study, 1,849 responses were received. In this present study we excluded 203 respondents due to incomplete data. A total of 1,646 respondents were included in the analysis of belief in social distancing benefits, where more than 20% of them were from India. The characteristics of the respondents are presented in Table 1. The full dataset can be found in the Underlying data. 37 Approximately 56% of the respondents were aged between 21-30 years old, and 58% were female. Out of the total, more than a third of the respondents earned less than USD500 monthly. During the time of this study, 1,139 (69.2%) of the respondents reported to know people in their immediate social environment who were or had been infected with SARS-CoV-2 and 352 (30.9%) of them reported that these individuals had serious presentations of illness. In addition, 1,525 (92.6%) had seen or read about individuals infected with SARS-CoV-2 on social media or TV of which 48.7% (802 out 1,525) believed that the cases were very serious. In total, 36.4% and 22.5% of the respondents believed that they had more than a 50% risk of getting COVID-19 and dying from COVID-19 if infected, respectively ( Table 1).

Participants’ characteristics included in the assessment of determinants associated with belief in social distancing ( n=1646) and face-mask practice ( n=1306).

Variable Belief in social distancing ( n=1646) Face-mask practice (n=1306)
n (%) n (%)
Country
Pakistan 262 (15.9) 181 (13.9)
Brazil 107 (6.5) 62 (4.7)
Chile 106 (6.4) 44 (3.4)
Egypt 98 (6.0) 88 (6.7)
India 337 (20.5) 302 (23.1)
Iran 141 (8.6) 121 (9.3)
Nigeria 161 (9.8) 142 (10.9)
Bangladesh 131 (8.0) 107 (8.2)
Sudan 174 (10.6) 141 (10.8)
Tunisia 129 (7.8) 118 (9.0)
Age group (year)
<20 279 (17.0) 185 (14.2)
21-30 926 (56.3) 744 (57.0)
31-40 268 (16.3) 231 (17.7)
41-50 119 (7.2) 103 (7.9)
>51 54 (3.3) 43 (3.3)
Gender    
Male 691 (42.0) 570 (43.6)
Female 955 (58.0) 736 (56.4)
Urbanicity    
Rural 314 (19.1) 254 (19.4)
Urban 1332 (80.9) 1052 (80.6)
Monthly household income (USD)    
<500 616 (37.4) 495 (37.9)
500-999 289 (17.6) 225 (17.2)
500-999 192 (11.7) 151 (11.6)
2,000-2,999 148 (9.0) 108 (8.3)
3,000-4,999 127 (7.7) 96 (7.4)
5,000-7,999 100 (6.1) 75 (5.7)
≥8,000 174 (10.6) 156 (11.9)
Religion    
Islam 914 (55.5) 745 (57.0)
Christian/Protestant/Methodist/Lutheran/Baptist 178 (10.8) 151 (11.6)
Catholic 127 (7.7) 87 (6.7)
Hindu 238 (14.5) 211 (16.2)
Atheist or agnostic 87 (5.3) 43 (3.3)
Others 102 (6.2) 69 (5.3)
Healthcare-related job    
No 907 (55.1) 662 (50.7)
Yes 739 (44.9) 644 (49.3)
Occupation    
Self-employed 155 (9.4) 138 (10.6)
Employed for wages 415 (25.2) 360 (27.6)
Out of work for less or more than 1 year 73 (4.4) 50 (3.8)
Homemaker 34 (2.1) 24 (1.8)
Student 947 (57.5) 716 (54.8)
Retired or unable to work 22 (1.3) 18 (1.4)
Have hypertension    
No a 1099 (66.8) 893 (68.4)
Yes b 97 (5.9) 80 (6.1)
Do not know 450 (27.3) 333 (25.5)
Have diabetes    
No a 1188 (72.2) 962 (73.7)
Yes b 58 (3.5) 50 (3.8)
Do not know 400 (24.3) 294 (22.5)
Have heart disease    
No a 1090 (66.2) 883 (67.6)
Yes b 55 (3.3) 47 (3.6)
Do not know 501 (30.4) 376 (28.8)
Have pulmonary disease    
No a 1041 (63.2) 845 (64.7)
Yes b 90 (5.5) 76 (5.8)
Do not know 515 (31.3) 385 (29.5)
Know people in immediate social environment who are or have been infected with COVID-19    
No 507 (30.8) 366 (28.0)
Yes 1139 (69.2) 940 (72.0)
Have you seen or read about individuals infected with the COVID-19 on social media or TV?    
No 121 (7.4) 101 (7.7)
Yes 1525 (92.6) 1205 (92.3)
What do you think are the chances that you will get COVID-19 in the next month?    
<50% 1047 (63.6) 800 (61.3)
≥50% 599 (36.4) 506 (38.7)
What do you think is your risk of dying from COVID-19 if infected?    
<50% 1276 (77.5) 1017 (77.9)
≥50% 370 (22.5) 289 (22.1)

Have been tested or examined by a doctor but negative.

Have been diagnosed by a doctor.

There were 340 respondents who did not go to school/work or did not go out to a grocery store or other food vendors for the week prior to the study and therefore were excluded. A total of 1,306 respondents were included in the analysis to assess the factors associated with face mask use practices, whose characteristics are similar to the total respondents ( Table 1).

 Belief in social distancing benefits and associated determinants

In total, 1,031 (62.6%) respondents had a good belief in social distancing benefits during the COVID-19 pandemic. The numbers were varied significantly among countries; the highest percentage was in Chile (91.5%), while the lowest was in Pakistan (50.4%). In general, countries in South America such as Chile and Brazil had a higher proportion of respondents who believed in social distancing benefits compared to those in African and Asian countries. In the univariate analysis, country, urbanicity, religion, type of job, having a pulmonary disease, knowing people in the immediate social environment who are or have been infected with SARS-CoV-2, and having seen or read about individuals infected with the SARS-CoV-2 on social media or TV were all factors associated with the belief in benefits of social distancing in some degree ( Table 2).

Unadjusted and adjusted logistic regression analyses showing factors associated with good belief in social distancing benefits ( n=1646).

Variable Good belief n (%) - 1031 Unadjusted Adjusted
OR (95% CI) p–value OR (95% CI) p–value
Country
Pakistan (R) 132 (50.4) 1   1  
Brazil 88 (82.2) 4.56 (2.63-7.92) <0.001 ** 3.01 (1.45-6.25) 0.003 *
Chile 97 (91.5) 10.61 (5.14-21.91) <0.001 ** 8.33 (3.55-19.54) <0.001 **
Egypt 60 (61.2) 1.56 (0.97-2.50) 0.067 1.07 (0.63-1.82) 0.793
India 193 (57.3) 1.32 (0.95-1.83) 0.093 0.69 (0.40-1.20) 0.190
Iran 88 (62.4) 1.64 (1.08-2.48) 0.021 * 1.13 (0.68-1.89) 0.633
Nigeria 98 (60.9) 1.53 (1.03-2.28) 0.036 * 0.95 (0.52-1.72) 0.865
Bangladesh 78 (59.5) 1.45 (0.95-2.22) 0.087 1.06 (0.66-1.71) 0.796
Sudan 119 (68.4) 2.13 (1.43-3.18) <0.001 ** 1.40 (0.87-2.25) 0.167
Tunisia 78 (60.5) 1.51 (0.98-2.31) 0.061 1.00 (0.60-1.69) 0.992
Age group (year)          
<20 (R) 161 (57.7) 1   1  
21-30 587 (63.4) 1.27 (0.97-1.67) 0.087 1.13 (0.81-1.58) 0.483
31-40 166 (61.9) 1.19 (0.85-1.68) 0.313 0.98 (0.61-1.58) 0.920
41-50 78 (65.5) 1.39 (0.89-2.18) 0.145 1.39 (0.78-2.47) 0.264
>51 39 (72.2) 1.91 (1.00-3.62) 0.049 * 1.65 (0.76-3.60) 0.209
Gender          
Male (R) 428 (61.9) 1      
Female 603 (63.1) 1.05 (0.86-1.29) 0.619    
Urbanicity          
Rural (R) 171 (54.5) 1   1  
Urban 860 (64.6) 1.52 (1.19-1.95) 0.001 * 1.12 (0.85-1.48) 0.404
Monthly household income (USD)          
<500 (R) 394 (64.0) 1      
500-999 178 (61.6) 0.90 (0.68-1.21) 0.491    
500-999 123 (64.1) 1.00 (0.72-1.41) 0.980    
2,000-2,999 95 (64.2) 1.01 (0.70-1.47) 0.959    
3,000-4,999 79 (62.2) 0.93 (0.63-1.38) 0.708    
5,000-7,999 59 (59.0) 0.81 (0.53-1.25) 0.340    
≥8,000 103 (59.2) 0.82 (0.58-1.15) 0.251    
Religion          
Islam (R) 538 (58.9) 1   1  
Christian/Protestant/Methodist/Lutheran/Baptist 111 (62.4) 1.16 (0.83-1.61) 0.385 1.05 (0.64-1.73) 0.850
Catholic 100 (78.7) 2.59 (1.66-4.04) <0.001 * 1.22 (0.66-2.27) 0.527
Hindu 149 (62.6) 1.17 (0.87-1.57) 0.295 1.60 (0.97-2.63) 0.064
Atheist or agnostic 64 (73.6) 1.95 (1.19-3.19) 0.008 * 0.88 (0.47-1.65) 0.698
Others 69 (67.6) 1.46 (0.95-2.26) 0.088 0.92 (0.54-1.58) 0.763
Healthcare-related job          
No (R) 540 (59.5) 1   1  
Yes 491 (66.4) 1.35 (1.10-1.65) 0.004 * 1.39 (1.10-1.77) 0.007 *
Occupation          
Self-employed (R) 89 (57.4) 1   1  
Employed for wages 284 (68.4) 1.61 (1.10-2.35) 0.014 * 1.49 (0.99-2.24) 0.058
Out of work for less or more than 1 year 43(58.9) 1.06 (0.60-1.87) 0.832 1.01 (0.56-1.84) 0.976
Homemaker 17 (50.0) 0.74 (0.35-1.56) 0.431 0.77 (0.34-1.71) 0.519
Student 586 (61.9) 1.20 (0.85-1.70) 0.291 1.23 (0.82-1.85) 0.327
Retired or unable to work 12 (54.5) 0.89 (0.36-2.18) 0.799 0.80 (0.31-2.11) 0.657
Have hypertension          
No a (R) 708 (64.4) 1   1  
Yes b 55 (56.7) 0.72 (0.48-1.10) 0.131 0.80 (0.48-1.32) 0.377
Do not know 268 (59.6) 0.81 (0.65-1.02) 0.072 1.09 (0.78-1.52) 0.615
Have diabetes          
No a (R) 759 (63.9) 1   1  
Yes b 36 (62.1) 0.93 (0.54-1.59) 0.778 1.45 (0.75-2.80) 0.269
Do not know 236 (59.0) 0.81 (0.65-1.03) 0.081 1.01 (0.71-1.43) 0.965
Have heart disease          
No a (R) 699 (64.1) 1   1  
Yes b 30 (54.5) 0.67 (0.39-1.16) 0.152 0.75 (0.39-1.46) 0.394
Do not know 302 (60.3) 0.85 (0.68-1.06) 0.140 1.13 (0.77-1.67) 0.523
Have pulmonary disease          
No a (R) 674 (64.7) 1   1  
Yes b 55 (61.1) 0.86 (0.55-1.33) 0.490 0.87 (0.52-1.48) 0.615
Do not know 302 (58.6) 0.77 (0.62-0.96) 0.019 * 0.81 (0.55-1.19) 0.282
Know people in immediate social environment who are or have been infected with COVID-19          
No (R) 284 (56.0) 1   1  
Yes 747 (65.6) 1.50 (1.21-1.85) <0.001 ** 1.41 (1.02-1.96) 0.038 *
Have you seen or read about individuals infected with the COVID-19 on social media or TV?          
No (R) 53 (43.8) 1   1  
Yes 978 (64.1) 2.29 (1.58-3.34) <0.001 ** 2.43 (1.60-3.69) <0.001 **
What do you think are the chances that you will get COVID-19 in the next month?          
<50% (R) 659 (62.9) 1   1  
≥50 372 (62.1) 0.97 (0.78-1.19) 0.735 1.00 (0.72-1.39) 0.996
What do you think is your risk of dying from COVID-19 if infected?          
<50% (R) 798 (62.5) 1   1  
≥50 233 (63.0) 1.02 (0.80-1.29) 0.879 1.17 (0.87-1.58) 0.297
Perceived risk (total score)          
Low (≤50) (R) 549 (63.5) 1   1  
High (>50) 482 (61.7) 0.93 (0.76-1.13) 0.463 0.78 (0.55-1.09) 0.142

Have been tested or examined by a doctor but negative.

Have been diagnosed by a doctor.

Significant at 0.05.

Significant at 0.001.

In the adjusted analysis, having a healthcare-related job, knowing people in immediate social environment who are or have been infected with SARS-CoV-2, and having been exposed to information about individuals infected with the SARS-CoV-2 on social media or TV were factors associated with good belief in social distancing benefits. Those who were working in healthcare-related sectors had higher odds in believing that social distancing could prevent the SARS-CoV-2 infection compared to those who were working in non-healthcare-related sectors (aOR: 1.39; 95%CI: 1.10-1.77, p=0.007). Respondents who knew individuals in their immediate social environment who were or had been infected with SARS-CoV-2 (either mild cases or serious cases) had a stronger belief in benefits of social distancing (aOR: 1.41; 95%CI: 1.02-1.96) compared to those who did not. In addition, respondents who were exposed to COVID-19 cases from TV or social media (had seen or read about individuals infected) had almost 2.5 times higher odds of belief in the benefits of social distancing compared to those who had never been exposed to COVID-19 cases information (95%CI: 1.60, 3.69) ( Table 2).

 Face mask practices and associated determinants

Out of the total 1,306 respondents, 875 (66.9%) of them were considered to have good face mask practices. The percentage of good practices were varied among countries ranging from 46.1% in Sudan to 88.6% in Chile. Some determinants were identified in univariate analyses such as country, gender, income, religion, sector of workplaces, type of occupation, having COVID-19 comorbidities, knowing people in their immediate social environment who are or have been infected with SARS-CoV-2, exposure to information regarding COVID-19 on social media or TV, and the perceived risk of getting COVID-19 ( Table 3).

Unadjusted and adjusted logistic regression analyses showing factors associated with good face mask practice ( n=1306).

Variable Good practices n (%) Unadjusted Adjusted
OR (95% CI) p–value aOR (95% CI) p–value
Country          
Pakistan (R) 99 (54.7) 1   1  
Brazil 54 (87.1) 5.59 (2.52-12.42) <0.001 ** 5.68 (2.06-15.66) 0.001 *
Chile 39 (88.6) 6.46 (2.44-17.14) <0.001 * 8.17 (2.60-25.72) <0.001 **
Egypt 61 (69.3) 1.87 (1.09-3.21) 0.023 * 1.21 (0.65-2.22) 0.547
India 231 (76.5) 2.70 (1.82-4.00) <0.001 * 2.47 (1.24-4.94) 0.011 *
Iran 96 (79.3) 3.18 (1.88-5.40) <0.001 * 2.54 (1.34-4.80) 0.004 *
Nigeria 76 (53.5) 0.95 (0.61-1.48) 0.833 0.50 (0.25-1.00) 0.049 *
Bangladesh 77 (72.0) 2.13 (1.27-3.55) 0.004 * 2.34 (1.29-4.24) 0.005 *
Sudan 65 (46.1) 0.71 (0.46-1.10) 0.126 0.46 (0.26-0.79) 0.005 *
Tunisia 77 (65.3) 1.56 (0.96-2.51) 0.070 1.28 (0.70-2.33) 0.426
Age group (year)          
<20 (R) 121 (65.4) 1   1  
21-30 488 (65.6) 1.01 (0.72-1.42) 0.962 0.73 (0.48-1.10) 0.128
31-40 160 (69.3) 1.19 (0.79-1.80) 0.404 0.89 (0.50-1.58) 0.686
41-50 76 (73.8) 1.49 (0.87-2.54) 0.144 1.40 (0.70-2.83) 0.344
>51 30 (69.8) 1.22 (0.60-2.50) 0.586 1.11 (0.46-2.72) 0.812
Gender          
Male (R) 362 (63.5) 1   1  
Female 513 (69.7) 1.32 (1.05-1.67) 0.018 * 1.46 (1.11-1.92) 0.007 *
Urbanicity          
Rural (R) 163 (64.2) 1   1  
Urban 712 (67.7) 1.17 (0.88-1.56) 0.286 1.03 (0.74-1.44) 0.858
Monthly household income (USD)          
<500 (R) 320 (64.6) 1   1  
500-999 149 (66.2) 1.07 (0.77-1.49) 0.681 0.85 (0.59-1.23) 0.391
500-999 112 (74.2) 1.57 (1.04-2.36) 0.030 * 1.06 (0.67-1.67) 0.810
2,000-2,999 76 (70.4) 1.30 (0.83-2.04) 0.257 0.89 (0.53-1.48) 0.646
3,000-4,999 62 (64.6) 1.00 (0.63-1.58) 0.991 0.56 (0.33-0.95) 0.032 *
5,000-7,999 46 (61.3) 0.87 (0.53-1.43) 0.577 0.46 (0.26-0.82) 0.009 *
≥8,000 110 (70.5) 1.31 (0.89-1.93) 0.178 0.76 (0.47-1.25) 0.286
Religion          
Islam (R) 464 (62.3) 1   1  
Christian/Protestant/Methodist/Lutheran/Baptist 105 (69.5) 1.38 (0.95-2.02) 0.092 1.71 (0.96-3.04) 0.069
Catholic 62 (71.3) 1.50 (0.92-2.45) 0.102 0.70 (0.34-1.45) 0.339
Hindu 167 (79.1) 2.30 (1.60-3.31) <0.001 ** 1.23 (0.67-2.27) 0.513
Atheist or agnostic 27 (62.8) 1.02 (0.54-1.93) 0.947 0.43 (0.20-0.91) 0.028 *
Others 50 (72.5) 1.59 (0.92-2.76) 0.096 0.70 (0.36-1.36) 0.297
Healthcare related job          
No (R) 404 (61.0) 1   1  
Yes 471 (73.1) 1.74 (1.38-2.20) <0.001 * 1.84 (1.38-2.45) <0.001 **
Occupation          
Self-employed (R) 85 (61.6) 1   1  
Employed for wages 254 (70.6) 1.49 (0.99-2.25) 0.056 1.74 (1.09-2.78) 0.021 *
Out of work for less or more than 1 year 27 (54.0) 0.73 (0.38-1.41) 0.349 0.85 (0.41-1.76) 0.666
Homemaker 14 (58.3) 0.87 (0.36-2.11) 0.762 0.73 (0.28-1.94) 0.532
Student 482 (67.3) 1.28 (0.88-1.87) 0.193 1.63 (1.03-2.60) 0.039 *
Retired or unable to work 13 (72.2) 1.62 (0.55-4.81) 0.384 1.87 (0.54-6.42) 0.321
Have hypertension          
No a (R) 625 (70.0) 1   1  
Yes b 46 (57.5) 0.58 (0.36-0.92) 0.022 * 0.70 (0.39-1.27) 0.245
Do not know 204 (61.3) 0.68 (0.52-0.88) 0.004 * 0.85 (0.57-1.28) 0.444
Have diabetes          
No a (R) 667 (69.3) 1   1  
Yes b 28 (56.0) 0.56 (0.32-1.00) 0.050 * 0.62 (0.30-1.27) 0.190
Do not know 180 (61.2) 0.70 (0.53-0.92) 0.010 * 1.00 (0.65-1.52) 0.982
Have heart disease          
No a (R) 661 (69.2) 1   1  
Yes b 30 (63.8) 0.79 (0.43-1.45) 0.440 1.02 (0.47-2.22) 0.956
Do not know 234 (62.2) 0.73 (0.57-0.95) 0.016 * 1.03 (0.65-1.63) 0.888
Have pulmonary disease          
No a (R) 595 (70.4) 1   1  
Yes b 44 (57.9) 0.58 (0.36-0.93) 0.025 * 0.77 (0.43-1.37) 0.369
Do not know 236 (61.3) 0.67 (0.52-0.86) 0.002 * 0.81 (0.52-1.27) 0.358
Know people in immediate social environment who are or have been infected with COVID-19          
No (R) 215 (58.7) 1   1  
Yes 660 (70.2) 1.66 (1.29-2.13) <0.001 ** 1.25 (0.84-1.84) 0.268
Have you seen or read about individuals infected with the COVID-19 on social media or TV?          
No (R) 58 (57.4) 1   1  
Yes 817 (67.8) 1.56 (1.03-2.36) 0.034 * 1.69 (1.04-2.75) 0.036 *
What do you think are the chances that you will get COVID-19 in the next month?          
<50% (R) 519 (64.9) 1   1  
≥50% 356 (70.4) 1.29 (1.01-1.63) 0.040 * 1.07 (0.72-1.57) 0.748
What do you think is your risk of dying from COVID-19 if infected?          
<50% (R) 683 (67.2) 1   1  
≥50% 192 (66.4) 0.97 (0.73-1.28) 0.818 0.99 (0.69-1.42) 0.960
Perceived risk (total score)          
Low (≤50%) (R) 427 (65.1) 1   1  
High (>50%) 448 (68.9) 1.19 (0.94-1.50) 0.141 0.97 (0.65-1.44) 0.860

Have been tested or examined by a doctor but negative.

Have been diagnosed by a doctor.

Significant at 0.05.

Significant at 0.001.

In an adjusted analysis, country, gender, monthly household income, having occupation related to healthcare sectors, types of occupation, and having seen or read about individuals infected with the SARS-CoV-2 on TV or social media were all significantly associated with practicing face mask use ( Table 3). Females had 1.46 times greater odds of having good practices compared to males (95%CI: 1.11-1.92, p=0.007). Compared to those who earned less than $500, respondents who earned $3,000-$4,999 and $5,000-$7,999 had lower odds of face mask-wearing when going out to workplaces or school or other places with aOR: 0.56; 95%CI: 0.33-0.95 and aOR: 0.46; 95%CI: 0.26-0.82, respectively. Those who were working in a healthcare-related job had almost two-fold odds (aOR: 1.84) of having good practice compared to those working in non-healthcare workplaces. Employees working for wages and students also had better face mask use practices compared to those who were self-employed (entrepreneurs). Our data also shows that exposure to coverage of COVID-19 cases in the media was associated with good face mask practices with OR: 1.69 and 95%CI: 1.04-2.75 ( Table 3).

 Discussion

In addition to a massive vaccination campaign, public health measures such as social distancing and face mask use will still continue to play a pivotal role in reducing COVID-19 transmission. Social distancing and face mask use are still highly recommended 12 even after COVID-19 vaccination since vaccines cannot fully prevent SARS-CoV-2 infection, 17 and vaccines are still difficult to access throughout much of the world. 18 Our data suggests that less than 70% of the participants had good beliefs in social distancing (62.6%) and good face mask practices (66.9%).

Our study found that individuals with healthcare-related jobs and who had seen or read about COVID-19 cases on social media or TV had good beliefs in social distancing benefits and face mask practices. In general, healthcare-related workers have better knowledge of COVID-19 than the general population 19 and therefore might know better the benefits of public health measures such as social distancing and face mask-wearing in preventing COVID-19. Similarly, people who often get exposed to news related to COVID-19 might also have better knowledge about the disease, 20 , 21 which might lead to a more positive attitude towards social distancing and better practice of face mask-wearing. A positive association of good knowledge with social distancing and face mask-wearing practices have also been captured in previous investigations. 22 , 23 This highlights the importance of continuous knowledge dissemination through health campaigns to enhance beliefs in social distancing benefits and mask-wearing among the general population.

Our results suggest that participants who knew people in their immediate social environment who were or had been infected with COVID-19 was significantly associated with good belief in social distancing benefits. Individuals who have had first-hand experience of the pandemic, either by contracting COVID-19 themselves or knowing people who are or have been infected with COVID-19, are more likely to agree and comply with health measures such as social distancing. 24 Having friends or relatives who are or have been infected with COVID-19 might increase awareness of serious health consequences of the pandemic 24 and increase motivation to protect themselves or the community, resulting in better beliefs and adherence to social distancing recommendations. 25 Knowing others with COVID-19, particularly those with a severe course of illness could also impact the perceived risk of disease, which itself could motivate healthy behaviors, as postulated by the Health Belief Model. 26

Our study found that females had better face mask practices compared to their male counterparts. This supports previous studies revealing that females had better knowledge on COVID-19 and better practice of preventive measures, e.g., face mask-wearing, compared to men. 19 , 27 , 28 Gender differences in COVID-19 attitudes and behavior have also been observed in another study showing that women were more likely than men to agree and comply with restraining public health policy such as mask-wearing, since they were more likely to perceive COVID-19 as a serious health problem. 24 Existing literature also showed that women have better knowledge in emerging infectious diseases, 29 , 30 and are more favorable to government intervention than men. 31 , 32 Moreover, women are more likely to be the caregivers of the family, which might cause them to be more worried about getting infected with COVID-19 as they could subsequently transmit the virus to the other family members. 24

One interesting finding in our study was that individuals with a higher monthly income had poor face mask-wearing practice. Previous studies reported a positive association between higher income and knowledge on COVID-19 preventive measures 27 , 28 , 33 ; however, there are contradictory reports on the association between income and face mask practice. 34 , 35 A study conducted in China reported that the proportion of people wearing a face mask increased linearly with monthly income, 34 while another study reported no association between the compliance with face mask-wearing and monthly household income. 35 Such findings might be confounded by the fact that face mask-wearing in public places is strictly imposed in some countries, but not in others. 36 Moreover, respondents with a higher household income in this study might be more likely to work from home, and thus may not feel the same need to wear face masks as someone who more regularly goes out. Overall, our findings suggest that the government should emphasize public health campaigns targeting men and low-educated people to improve public beliefs and practice of COVID-19 prevention measures, such as social distancing and mask-wearing.

There are some limitations of this study. The use of an online survey excludes some people from lower social-economic classes, those with lower educational attainment, and those who were illiterate. Selection bias might also occur due to the variation in internet access across the countries where the study was conducted. Measurement of mask-wearing practice was based on questions of whether or not participants wore face mask at work/school and grocery stores/food vendors, which might be compulsory in some countries, and may not reflect the real practices of mask-wearing in the community. Participants may also respond in a certain way due to the social desirability bias.

 Conclusion

Our data suggested that there is a substantial percentage of community members in certain low- and middle-income countries who do not believe in social distancing benefits during the COVID-19 pandemic and do not have good face mask-wearing practices. Some determinants associated with negative beliefs on the benefits of social distancing and poor face mask practices have been identified through this study, and these could be used by the governments or other organizations to increase adherence to social distancing and face mask-wearing practices in the community.

 Data availability Underlying data

Figshare: 'Beliefs on social distancing and face mask practices during the COVID-19 pandemic in low- and middle-income countries: a cross-sectional study'. https://doi.org/10.6084/m9.figshare.19105238 37

This project contains the following underlying data:

Master Table.xlsx [Table containing the raw data of the study]

 Extended data

This project contains the following extended data:

Study Questionnaire.pdf

 Reporting guidelines

STROBE_Checklist.pdf. STROBE checklist for 'Beliefs on social distancing and face mask practices during the COVID-19 pandemic in low- and middle-income countries: a cross-sectional study'. https://doi.org/10.6084/m9.figshare.19105238 37

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Acknowledgments

We would like to thank Universitas Syiah Kuala for funding this study. We would like to thank Narra Studio Jurnal Indonesia for its assistance during the manuscript preparation.

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Public Health 2021 2021-January-13;8(947). 33520918 10.3389/fpubh.2020.606635 Harapan H : Beliefs on social distancing and face mask practices during the COVID-19 pandemic in low- and middle-income countries: a cross-sectional study. figshare. Dataset. 2021. 10.6084/m9.figshare.19105238 10.5256/f1000research.83528.r290573 Reviewer response for version 1 Okoro Roland Nnaemeka 1 Referee https://orcid.org/0000-0002-6391-5000 Department of Clinical Pharmacy and Pharmacy Administration, University of Maiduguri, Maiduguri, Borno, Nigeria

Competing interests: No competing interests were disclosed.

 22 7 2024 Copyright: © 2024 Okoro RN 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The study is interesting and a show of a good teamwork, although I have identified some issues that need to be addressed by the authors.

Introduction:

Paragraph 1: As far as COVID-19 is concerned, it is not just “regular handwashing” but “regular handwashing with soap under running water”

Methods:

Paragraph 1: What informed the choice of counties selected for the study?

Paragraph 2: The minimum sample size calculated using the provided variables should be stated.

Paragraph 3:

Brief description of the study instrument should stand alone before data collection. Information on the study variables should be part of study instrument description. Information on how this instrument was validated is required.

How was cut-off of 50% used to categorize the perceived risk determined?

Data collection should be stated thereafter. The duration of data collection should be stated and how data collection was stopped in each country that was included in the study.

Paragraph 5: Nothing was mentioned about how the results were presented. All that was stated here was how factors were determined.

 Results:

Overall, how many people were invited to participate in the study? What was the response rate?

Authors stated that 203 respondents were exclude due to incomplete data, but this was not capture as an exclusion criterion in the method section.

 Discussion:

Well written

Conclusion:

Well written

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

Pharmacy Education and Pharmacy Practice, Tropical Diseases with emphasis on Malaria, and Pharmacotherapeutics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Harapan Harapan Syiah Kuala University, Indonesia

Competing interests: Authors has no competing interest.

 26 2 2026

Dear Reviewer,

Thank you for your constructive comments and suggestions on the first version of our article. We have revised the manuscript accordingly. Detailed point-by-point responses to each of your comments are provided below.

REVIEWER COMMENT:

The study is interesting and a show of a good teamwork, although I have identified some issues that need to be addressed by the authors.

Introduction: Paragraph 1: As far as COVID-19 is concerned, it is not just “regular handwashing” but “regular handwashing with soap under running water”

AUTHORS RESPONSE:

Thank you for this correction. We have revised the wording in the  Introduction accordingly.

ADDED/REVISED TEXT:

Replace: “regular handwashing”

With: “regular handwashing with soap under running water”

REVIEWER COMMENT:

Methods - Paragraph 1: What informed the choice of counties selected for the study?

AUTHORS RESPONSE:

Thank you. We have now clarified the rationale for country selection in the  Study design and setting section, including feasibility of online survey implementation, availability of local collaborators, and representation of LMICs across multiple regions.

ADDED/REVISED TEXT:

Methods – Study design and setting

“The participating countries were selected based on the feasibility of online survey implementation, availability of local collaborators in each country to support survey dissemination, and the intention to include LMIC settings from multiple geographic regions.”

REVIEWER COMMENT:

Methods - Paragraph 2: The minimum sample size calculated using the provided variables should be stated.

AUTHORS RESPONSE:

Thank you. We have now explicitly stated the minimum sample size and how it was calculated in the  Study population and sampling section.

ADDED/REVISED TEXT:

Methods – Study population and sampling

“The minimum sample size for estimating a proportion was calculated using a 5% margin of error, a 95% confidence level and a 50% conservative estimate of respondents having good beliefs in social distancing benefits and face mask practices, yielding a minimum required sample size of 385 participants.”

REVIEWER COMMENT:

Methods - Paragraph 3: Brief description of the study instrument should stand alone before data collection. Information on the study variables should be part of study instrument description. Information on how this instrument was validated is required.

AUTHORS RESPONSE:

Thank you for this helpful suggestion. We restructured the  Methods section to separate the  Study instrument description from the  Data collection subsection. We also added a clearer description of the questionnaire domains and a statement on instrument review/pretesting before implementation. Study variables section is now moved under directly under Study instrument.

ADDED/REVISED TEXT:

Methods – Study instrument  (new subsection before Data collection)

“Study instrument”

A structured questionnaire was developed to assess respondents’ demographic characteristics, belief in the benefits of social distancing, face mask practices, COVID-19-related exposures, comorbidities, and perceived risk toward COVID-19. The questionnaire included closed-ended items and Likert-type response options for the belief domain. A copy of the survey can be found under Extended data. 37 Before implementation, the questionnaire was reviewed by experts in the fields of virology and public health as well as the country collaborators for clarity and relevance. The questions within the questionnaire were tested and validity was confirmed prior to being used in the study. Wording and sequence were refined based on the validity assessment prior to data collection.

REVIEWER COMMENT:

Methods - Paragraph 3: How was cut-off of 50% used to categorize the perceived risk determined?

AUTHORS RESPONSE:

Thank you. We clarified in the  Study variables section that the 50% cut-off was used as a pragmatic midpoint threshold to dichotomize perceived risk scores for interpretation and analysis, rather than a universally validated cut-off.

ADDED/REVISED TEXT:

Methods – Explanatory variables 

“For analysis, responses were dichotomized using a pragmatic midpoint threshold (≤50% vs. >50%) to facilitate interpretation. In addition, the two scores from summed (ranges: 0–200) and respondents who achieved more than 50% of the total score (i.e., 100 scores out of 200) were classified as having high perceived risk; conversely, those with less than 50% were classified as having a low perceived risk.”

REVIEWER COMMENT:

Methods - Paragraph 3: Data collection should be stated thereafter. The duration of data collection should be stated and how data collection was stopped in each country that was included in the study.

AUTHORS RESPONSE:

Thank you. We revised the  Data collection subsection to clearly state the data collection period (February to May 2021), the dissemination process across countries, and how the online survey was closed at the end of the study period.

ADDED/REVISED TEXT:

Methods – Data collection

“Data collection was conducted from February to May 2021 for all countries. The survey remained open during this period and was closed at the end of the data collection window, after which no further responses were accepted.”

REVIEWER COMMENT:

Methods - Paragraph 5: Nothing was mentioned about how the results were presented. All that was stated here was how factors were determined.

AUTHORS RESPONSE:

Thank you. We have revised the  Statistical analysis section to clearly state how the results were summarized and presented, in addition to how associated factors were analyzed.

ADDED/REVISED TEXT:

Methods – Statistical analysis

“The responses were downloaded from SurveyMonkey into Microsoft Excel, cleaned, coded, and then exported to the Statistical Package for Social Sciences (SPSS) for analysis. Descriptive statistics for respondents’ sociodemographic characteristics, beliefs in the benefits of social distancing, and face mask practices were summarized and presented as frequencies and percentages. The numbers and proportions of respondents with good belief in the benefits of social distancing and good face mask practice were calculated.”

REVIEWER COMMENT:

Results - Overall, how many people were invited to participate in the study? What was the response rate?

AUTHORS RESPONSE:

Thank you. We clarified in the  Results that because the survey was disseminated through open online channels and snowball sharing, the number of individuals who received/viewed the invitation could not be determined; therefore, a conventional response rate could not be calculated.

ADDED/REVISED TEXT:

Results – Demographic characteristics (opening paragraph)

“During the study period, 1,849 responses were received. Because the survey was disseminated through open online channels and social sharing, the total number of individuals who received or viewed the invitation could not be determined; therefore, a conventional response rate could not be calculated. In this present study, a total of 203 respondents were excluded due to incomplete data, leaving 1,646 respondents for the analysis of belief in social distancing benefits, where more than 20% of them were from India.”

REVIEWER COMMENT:

Results - Authors stated that 203 respondents were exclude due to incomplete data, but this was not capture as an exclusion criterion in the method section.

AUTHORS RESPONSE:

Thank you for identifying this inconsistency. We have revised the  Methods (Study population and sampling) section to explicitly state that responses with incomplete data on variables required for analysis were excluded.

ADDED/REVISED TEXT:

Methods – Study population and sampling

“Responses with incomplete data for variables required in the analyses were also excluded.”

REVIEWER COMMENT:

Discussion - Well written

Conclusion - Well written

AUTHORS RESPONSE: Thank you.

ADDED/REVISED TEXT: NA

 10.5256/f1000research.83528.r141134 Reviewer response for version 1 Khader Yousef 1 Referee https://orcid.org/0000-0002-7830-6857 Department of Public Health, Community Medicine and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan

Competing interests: No competing interests were disclosed.

 27 6 2022 Copyright: © 2022 Khader Y 2022 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

This study interesting study was conducted to assess the level of belief in social distancing and face mask practices in communities in low- and middle-income countries (LMICs) and to identify their possible determinants. The manuscript is well written.

The following comments need to be addressed by authors:

Please show the calculated sample size. Is it calculated for each country? You should show the sample size calculation considering the logistic regression analysis and not only for estimating a single proportion. Please elaborate on how you recruited people from each country. Is there a focal person in each country to reach people in each country?

Please mention the limitations that are associated with the sampling approach you used?  

The 80% cut-off: Is it possible to cite a reference that is related to the establishing this cut-off value for any standard questionnaire?

Did you consider clustering within country in the analysis (Multilevel analysis)?

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Epidemiology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Harapan Harapan Syiah Kuala University, Indonesia

Competing interests: Authors have no competing interest.

 26 2 2026

Dear Reviewer,

Thank you for your constructive comments and suggestions on the first version of our article. We have revised the manuscript accordingly. Detailed point-by-point responses to each of your comments are provided below.

REVIEWER COMMENT: 

This study interesting study was conducted to assess the level of belief in social distancing and face mask practices in communities in low- and middle-income countries (LMICs) and to identify their possible determinants. The manuscript is well written.

AUTHORS RESPONSE:

Thank you for your constructive and encouraging comments. Point-by-point responses to each of your comments are provided below.

REVIEWER COMMENT: 

The following comments need to be addressed by authors:

1. Please show the calculated sample size. Is it calculated for each country? You should show the sample size calculation considering the logistic regression analysis and not only for estimating a single proportion. Please elaborate on how you recruited people from each country. Is there a focal person in each country to reach people in each country?

AUTHORS RESPONSE:

Thank you for this important comment. We have revised the  Methods section to explicitly report the minimum sample size calculation (95% confidence level, 5% margin of error, and 50% expected proportion), and clarified that this estimate was used as a minimum overall sample size, not a country-specific sample size. We also clarified that the final sample exceeded this minimum to support multivariable logistic regression and country-level comparisons. In addition, we expanded the recruitment procedure to explain that the survey link was distributed via social media and networks across participating countries, and that local collaborators/co-authors served as focal persons in each country to facilitate dissemination.

ADDED/REVISED TEXT:

Methods – Study population and sampling

“The minimum sample size for estimating a proportion was calculated using a 5% margin of error, a 95% confidence level and a 50% conservative estimate of respondents having good beliefs in social distancing benefits and face mask practices, yielding a minimum required sample size of 385 participants. This calculation was applied as the minimum overall sample size for the study; not for each country separately. Recruitment was continued beyond this minimum to improve precision and support multivariable logistic regression analyses and country-level comparisons.”

Methods – Data collection

“In each participating country, local collaborators/co-authors served as focal persons to facilitate dissemination of the survey link through their professional and community networks.”

REVIEWER COMMENT: 

2. Please mention the limitations that are associated with the sampling approach you used?

AUTHORS RESPONSE:

Thank you. Thank you for this important comment. We have revised the limitations paragraph in the Discussion to explicitly acknowledge the limitation related to the sampling approach. Specifically, we added that the use of a non-probability convenience sampling approach (including online and snowball dissemination) may have introduced selection bias and limited the generalizability of the findings to the broader population in each participating country.

ADDED TEXT:

Discussion – Limitations

“In addition, the use of a non-probability convenience sampling approach (including online and snowball dissemination) may have introduced selection bias and limited the generalizability of the findings to the broader population in each participating country.”

REVIEWER COMMENT: 

3. The 80% cut-off: Is it possible to cite a reference that is related to the establishing this cut-off value for any standard questionnaire?

AUTHORS RESPONSE:

Thank you for this important comment. We have revised the relevant sentence in the Study variables to clarify that the 80% cut-off was used as an operational (pragmatic) threshold, consistent with its use in previous studies cited in our manuscript [15,16], and not as a universally standardized cut-off for this questionnaire.

ADDED/REVISED TEXT:

Methods – Study variables (social distancing belief)

The 80% cut-off was used as an operational (pragmatic) threshold to dichotomize the variable into good and poor categories, consistent with its use in previous studies, 15 ,16  rather than as a universally standardized cut-off for this questionnaire.

REVIEWER COMMENT: 

4.  Did you consider clustering within country in the analysis (Multilevel analysis)?

AUTHORS RESPONSE:

Thank you for raising this point. We have clarified in the  Statistical analysis section that multilevel (hierarchical) modeling was not performed in the current analysis and that country was included as an explanatory variable in the regression models. We also added this as a limitation in the  Discussion.

ADDED/REVISED TEXT:

Methods – Statistical analysis

“Multilevel modeling to account for clustering by country was not performed in the present analysis; instead, country was included as an explanatory variable in the regression models.”

Discussion – Limitations

“Furthermore, in this study, multilevel modelling was not performed to explicitly account for within-country clustering. Although country was included as a covariate in the regression models, residual intra-country correlation may still have remained.”