Attitudes and practices regarding COVID-19 preventive measures in diverse settings of Mozambique: a qualitative study

Introduction

The new Coronavirus SARS-CoV-2 (responsible for the Coronavirus Disease 19 or COVID-19) emerged in December 2019 in Wuhan, China, and spread quickly to other countries, creating a global pandemic situation worldwide.¹ Many countries, high, middle, and low income alike, imposed several restrictions to prevent the disease from spreading quickly.² In response to this difficult situation, the World Health Organization (WHO) declared COVID-19 a global health emergency and called for collaborative efforts by all countries to reduce the spread of the pandemic.³ In response, several public health measures were put in place to reduce the virus’s transmission and minimize the disease’s impact.^2,3

Essential questions related to countries’ preparedness of the health systems in responding to patient demand were raised, particularly regarding low-income countries, which were already overburdened before the pandemic.⁴ In such countries, preventive measures should have been highly reinforced to reduce pressure on the health system. However, adequate enforcement of preventive measures requires governments to be able to provide support to the most vulnerable populations, including those living in poverty, and limited access to the required information to enable them to collaborate with the emergency public health response.^5,6 In such situations, the public is likely unable to comply with the imposed measures, even if enforcement is in place.

In Mozambique, the government registered the first case of COVID-19 officially confirmed on 22 March 2020.⁷ At that time, most patients comprised of people returning from international travel.⁸ When community transmission became a concern, the government adopted measures to contain the spread and to delay disease transmission peaks to gain time while a pharmacological solution was still being searched for globally.^9,10 At that point, Mozambique experienced a level three state of emergency, aligned with the following measures: closure of schools; limitation of international travel (cessation of visa issuance); a minimum physical distance of 1.5 meters between individuals; mandatory use of masks; encouragement of hand hygiene practices; banning of overcrowding; crucial turnover among on-site employees and; prohibition of all social and recreational and religions events, as well as sports activities.¹¹ The broad dissemination of these prevention measures triggered a negative population-wide response characterized by panic and confusion⁸ and unexpected patterns of reactions and behaviors such as migration to sites where law enforcement is poor.¹² These actions were perceived to increase resilience and subsistence in a poor country where most income-generating activities come from the informal sector.¹² Considering that Mozambique ranked as the third poorest country globally (based upon their 2020 GNI per capita in current USD), reflecting the above scenario.¹³ In additional, in this scenario, the subsequent extensions to the initial state of emergency continuously posed new challenges to ensure strict compliance with the guidelines for preventive measures.¹⁴ Earlier analysis on the issue of the feasibility of implementing COVID-19 risk reduction measures in impoverished communities had already acknowledged that the implementations of some measures would be a challenge in many cities and rural areas of middle and low-income countries.¹⁵ Indeed, Manjate and colleagues confirmed these challenges in Mozambique.¹⁶

The study assessed knowledge, attitudes, and practices regarding COVID-19 prevention and reported that more than 50% of participants claimed to take COVID-19 prevention measures because of the obligations established by government authorities.¹⁵ Therefore, exploring people’s attitudes and practices concerning COVID-19 are essential to understanding how the general population copes with abrupt behavioral change requirements in a public health emergency.¹⁴ Even though a state of emergency was declared with several imposed measures, studies are still scarce with methodological approaches and representativeness limitations for different contexts of Mozambique.

In the past, the present study results and recommendations significantly contributed to the decision-making process and development of effective public health communication strategies aiming at behavior change to reduce disease transmission at the community level.^7,14 The lessons learned from it are relevant to the current scenario—where the pandemic has reached a certain level of maturity —and for future occurrences of public health emergencies.

This study aimed to analyze the attitudes and practices related to COVID-19 prevention measures during first Mozambique’s state emergency period to contain the spread of COVID-19 in rural and urban settings.

Methods

Study participants and setting

Study participants were selected for convenience through the study team’s contacts on their mobile phones. During this process potential participants were contacted by phone and asked for an interview which was either scheduled for an in-person meeting (face-to-face interview) or a virtual, telephone-based interview.

The data collection was conducted in eight provinces, 13 municipalities, and 12 districts of Mozambique (all referred to as sites) (Figure 1). These locations were selected based on convenience sampling, as they represent the geographical areas where (i) the Centro de Investigação em Saúde de Manhiça (CISM) has active studies (i.e., Manhiça, Maputo, Xai-Xai, Quelimane, and Mopeia), (ii) are also residential areas of study team members, and (iii) are places where team members have contacts with people they know (e.g., Maputo, Matola, Moamba, Inhambane, Morrumbene, Beira, Mocuba). Study participants comprised a range of socio-cultural and economic backgrounds in 222 neighbourhoods.

Figure 1. Map of study sites.

At these sites, the study targeted groups included young people (18–29 years old), adults (30–49 years old), and the older population (50 years and older). For this analysis, only participants aged 18 to 60 years old were included. Study participants were selected for convenience through the study team’s contacts on their mobile phones.

Results

Discussion

We investigated behaviors, attitudes, and practices related to COVID-19 preventive measures during the first state of emergency period of COVID-19 in rural and urban settings in Mozambique. Analysis of 295 interviews revealed that most participants changed their routine by (i) adopting a home office and (ii) reducing their mobility. However, home confinement was observed to be partially adopted due to the need for basic home supplies. The main context where COVID-19 preventive measures where adoped included (i) inside the house, (ii) when leaving or away from home, (iii) when returning home. Reported preventive measures included increased frequency of hand washing, wearing the mask, and physical distancing. While patterns and frequency of practice of these preventive measures vary with participants’ location and living conditions, it was partially driven by fear of infection and prosecution by the authorities. Some participants reported to follow preventive measures to ensure to access to essential public services such as transportation. Our findings show that the majority of communities followed most of preventive measures against COVID-19 infection as stated by the government. At the same time, the need to increase awareness concerning COVID-19 prevention at the community level and among users of public places was shown to be a necessary strategy for reducing the spread of the virus. This was also seen with an increase in positive cases in the country as one of the indicators of this low awareness of the need for prevention.²¹

We found that most participants (47.1%) reported to have changed their routine and reduced their mobility (e.g., adoption of home confinement, no travel) to avoid exposure to COVID-19, and thus, complying with most established preventive measures. Our findings is consistent with a study involving public workers in Mozambique conducted in the initial public health emergency declaration in March 2020, which showed that a large proportion of participants changed their routines, having remained confined at home to avoid exposure and contraction of the disease.²² Findings from our study are also in line with another study carried out in Nepal reporting that human mobility patterns as a measure of prevention behavioral responses during the COVID-19 pandemic was significantly reduced during the first wave of COVID-19.²³ This was notable when people started to be confined to their homes to avoid exposure to COVID-19 in the streets, stopped traveling to and from work (primarily through crowded transport) and stopped engaging in non-essential shopping.²³ In the present study, the observed higher compliance to home confinement as a preventive measure was linked to the need for avoiding COVID-19 exposure. We hypothesize that the higher adoption of home confinement is partially explained by the fact that it was the preventive measure mostly disseminated in media (e.g., newspapers, television and social midia) and was an enforcement in the public and private sector. However, these results show that in public health emergencies due to pandemic outbreaks like that of COVID-19, continuous monitoring of these practices at the community level to better understand the current trend of infections and case fatalities and inform strategic preventive planning is advisable. This may also include efforts to improve vaccine adherence behavior as one of the prevention strategies.

Although reporting reduced mobility and activities, the adoption of home confinement was notable partial to most participants and their family members for two reasons: (i) work for income and (ii) acquisition of essential supplies for family survival. These tendencies toward partial home confinement reflect the need of some heads of households to keep the routine considering the importance of work to guarantee the income for supporting the family needs. This is particularly because in Mozambique, most families live off small informal businesses, so regardless of the situation they feel forced to leave home to acquire income for the daily family's survival²⁴; an issue hard to reveal when using quantitative approaches in investigating attitudes and practices at the community level. These findings corroborate with a study from South India where participants, especially those who suffered a significant impact on income reduction, chose to keep their routine of working outside home as the primary source of income for the family.²⁵ It is worth noting that discourses of home confimenment were frequent and revealed an attitude to reduce dangers and thus protect “their home” environment. This may explain, even though partially, why there was a reduction in mobility over time mainly occurred during the first wave of COVID-19 pandemic despite the low number of positive cases and deaths from COVID-19 compared to the subsequent waves in Mozambique.²⁶ These results reveal an excellent starting point for implementing awareness-raising interventions to reinforce existing knowledge about, and practices adopted against COVID-19.

At the individual level, the most reported preventive measures against COVID-19 infection were increased frequency of hand washing (42.4%) and use of a mask (43.4%), particularly in public places. Attitudes towards these two measures can be considered positive as most participants mentioned practicing at least one. Nevertheless, some participants were fed up with following some mandatory measures, such as wearing a mask in public places and spaces. Most participants reported practicing at least one of the COVID-19 prevention measures, particularly when in public places and/or when seeking public services, and this can be noted by the frequency of wearing masks when they are leaving home (60.7%) and keeping their distance when away from home (65.8%). This reveals that participants comply with the mandatory individual preventive measures, but these attitudes and pratices varied depending on where the participants were located.

Compliance with health authorities’ recommendations on wearing mask and frequent hand hygiene was perceived as the most essential preventive measure in mitigating the spread of COVID-19 infections over the country. Surprisingly, hand hygiene was reported with a marked preference of using ‘water and soap’ instead of disinfectants, such as sanitary alcohol, regardless of location. For participants, washing hands with soap and water makes it cleaner and ensures that the virus is eliminated. Similar results were reported in a study conducted in Ethiopia, revealing that around 78.5% of community members wash their hands while inside and away from home to prevent COVID-19.²⁷ These results show that frequent hand washing is one of the most common practice for preventing COVID-19 infection, and a positive attitude by household members in different scenarios, such as when they return home and when they are inside the home.

Expectedly, reporting wearing a mask was as frequent as hand washing in all scenarios (First most frequent when leaving home and second most frequent when inside and away from home). Further, as a physical barrier, it was perceived as one of the most critical and influential measures in preventing COVID-19, whether at home or in public spaces. The behavior of wearing masks particularly in public places observed in our study is similar to the reported in an online survey regarding the adherence to measures to prevent COVID-19 conducted in three main cities of Mozambique, which showed that more than 90% of respondents claimed wearing a mask when leaving home.⁷ Although reported as a challenging, participants mentioned that the use of masks inside the house is necessary to avoid infection among household members and also to avoid being infected by domestic workers often exposed in public transport and markets. These findings were contrary to two studies from Bangladesh and Ethiopia that were conducted with community members reported that less than a third of the participants wore masks every time they left home.^28,29

The rapid introduction of mandatory mask-wearing in public places for large-scale COVID-19 prevention was challenging. Our findings reveal that perception of discomfort, difficulty in communication and breathing were the most relevant barriers to wearing masks. Moreover, the participants claimed that compliance is motivated by the need to access public services and avoid complications with the police or inspection authorities. Our findings, however, corroborate with previous studies conducted in several settings reporting low mask-wearing due to difficulty in breathing, discomfort, communication and medical reasons.^28–30 This result calls for a reflection concerning recommendations given by the health authorities on the importance of using masks in public places. Some participants in this study reveal that they wear masks to comply with the authorities’ exigencies and not because of the risk perception of COVID-19 infection. In addition, clear messages about the importance of using a mask and complying with measures to prevent COVID-19 are needed.

Our data also highlight that at the community and family level, physical distance was one of the measures followed by community members, although it was hardly mentioned. Our results show that keeping physical distance was challenging in several locations. For example, inside the home physical distance between household members was considered to be challenging but necessary to avoid infection with COVID-19, including physical contact with objects. For instance, only 20% of participants mentioned complying with physical distancing at home. In contrast, a quarter of the same population perceives family proximity as a relevant challenge.³¹ Contrarily to our finding, Manjate and colleagues (2020) found a lower percentage of participants perceiving family proximity as a challenge for preventing infection from COVID-19.¹⁶ Family proximity probably suggests the existence of a feeling of trust between the same family members or of the same household, which influences the non-compliance with the measure of physical distancing at home. Previous studies show that this trust between people also extends to co-workers, friends and other people considered close.^7,32,33

We also found that maintaining physical distance in crowded public spaces to reduce the risk of infection was of concern but perceived as essential among study participants. Further, study participants perceived it to be extremely tough to comply with physical distancing when at home with the family. Our findings are in line with a previous study reporting the importance of maintaining distance in all environments to prevent COVID-19 infections.³² Physical distancing is widely reported as one of the most practiced methods for COVID-19 prevention, however, its compliance varies on several factors.^29,33,34 For instance, Benham and colleagues (2021) reported that compliance in maintaining safe distance for COVID-19 prevention was often found challenging in closed, public, and busy environments, such as supermarkets, shopping malls and elevators.³² Additionally, an international study reported that one-third of the adult population perceives crowded public spaces such as streets as a motivation against physical distancing. Thus they consider that in a public and open spaces the distance between people is guaranteed, and that other preventive measures, such as wearing masks for example, are also mandatory, which in a way ensures that everyone is well protected against COVID-19. These results suggest that public health policies with specific strategies such as affirmative action and public education still need to promote positive attitudes towards physical distancing.

Conclusions

This study suggests the introduction of awareness campaigns for community members and public place users, evidenced by structural and routine changes in households and the efforts of household members to adopt preventive measures. Attitudes and practices toward the COVID-19 preventive measures varied among participants’ locations and the concerns were dominated by widespread panic and insecurity. The compliance with preventive measures was partially driven by the need to access public services, which diverted the focus from the effort for people to put into practical measures to prevent and control COVID-19, especially concerning the use of masks and physical distancing practices in public places. Thus, in addition to monitoring compliance with the state of emergency measures to contain COVID-19, it is necessary to develop clear messages to encourage behavior change and increase adherence to health measures to reduce the transmission of COVID-19 among community members. Future studiesshould address barriers to public health measures that reduce COVID-19 transmission in communities.