Community responses during the early phase of the COVID-19 epidemic in Hong Kong: risk perception, information exposure and preventive measures

Background: Community responses are important for outbreak management during the early phase when non-pharmaceutical interventions are the major preventive options. Therefore, this study aims to examine the psychological and behavioral responses of the community during the early phase of the COVID-19 epidemic in Hong Kong. Method: A cross-sectional online survey was launched within 36 hours after confirmed COVID-19 cases were first reported. Councilors of all 452 district council constituency areas were approached for survey dissemination. Respondent demographics, anxiety level, risk perception, sources to retrieve COVID-19 information, actual adoption and perceived efficacy of precautionary measures were collected. Result: Analysis from 1715 complete responses indicated high perceived susceptibility (89%) and high perceived severity (97%). Most respondents were worried about COVID-19 (97%), and had their daily routines disrupted (slightly/greatly: 98%). The anxiety level, measured by the Hospital Anxiety and Depression Scale, was borderline abnormal (9.01). Nearly all respondents were alert to the disease progression (99.5%). The most trusted information sources were doctors (84%), followed by broadcast (57%) and newspaper (54%), but they were not common information sources (doctor: 5%; broadcast: 34%; newspaper: 40%). Only 16% respondents found official websites reliable. Enhanced personal hygiene practices and travel avoidance to China were frequently adopted (>77%) and considered effective (>90%). The adoption of social-distancing measures was lower (39%-88%), and their drivers for greater adoption include: being female (adjusted odds ratio [aOR]:1.27), living in the New Territories (aOR:1.32-1.55), perceived as having good understanding of COVID-19 (aOR:1.84) and being more anxious (aOR:1.07). Discussion: Risk perception towards COVID-19 in the community was high. Most respondents are alert to the disease progression, and adopt self-protective measures. This study contributes by examining the psycho-behavioral responses of hosts, in addition to the largely studied mechanistic aspects, during the early phase of the current COVID-19 epidemic. The timely psychological and behavioral assessment of the community is useful to inform subsequent interventions and risk communication strategies as the epidemic progresses.


INTRODUCTION
On 12 January 2020, the World Health Organization (WHO) declared the novel coronavirus which 54 caused unknown pneumonia cases in Wuhan, Hubei Province, China since December 2019 as "2019-55 nCoV", which was renamed by the International Committee on Taxonomy of Viruses as "SARS-CoV-2" 56 on 11 February 2020. In parallel, the WHO formally named the disease caused by SARS-CoV-2 as 57 "COVID-19", short for Coronavirus Disease 2019. Back in late December 2019, a cluster of 27 58 pneumonia cases associated with SARS-CoV-2 with a common link to the Huanan Seafood Wholesale 59 Market were reported [1], and the first death case attributable to SARS-CoV-2 occurred on 9 January 60 2020. Soon after the first global incidence was confirmed in Thailand on 12 January 2020, new cases 61 were reported in different countries and were mostly associated with Wuhan travel history or residency.  To control this COVID-19 epidemic, much effort has been paid to identifying the etiological agent, 77 epidemiological parameters such as incubation period [4], disease transmissibility [4,5], clinical 78 . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https: //doi.org/10.1101//doi.org/10. /2020, treatment options [8,9], and route of transmission [10]. Although these 79 information help devise optimal infection control strategies, such as contact tracing and follow-up 80 isolation [11], they center purely on the mechanistic aspect of the disease.  CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https: //doi.org/10.1101//doi.org/10. /2020  for survey dissemination. District councilors were invited to share our survey link and promotion 109 messages on their webpages, social media platforms or any channels which they usually use to convey 110 information to their targeted residents, but in general there was no restriction on their dissemination.

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Individuals who were aged 18 or above, understood Chinese and lived (on average) over five days per 112 week in Hong Kong in the last month are eligible to participate. Respondents were compensated with a 113 HKD10 cash coupon if they indicated willingness for receipt. To avoid duplicated responses from the 114 same respondent, the survey could only be taken once from the same electronic device. Respondents were asked about their demographics (including sex, age, living district, education 118 attainment, household income), self-perceived health status, travel history in the past month, occurrence 119 of respiratory symptoms in the past fourteen days and anxiety level using the Hospital, Anxiety and 120 Depression scale -Anxiety (HASD-A) (0-7 = Normal; 8-10 = Borderline abnormal; 11-21 = Abnormal).

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Although HADS-A is intended for screening clinically significant anxiety symptoms in clinical 122 populations, many studies have showed that it is valid for community populations [12,13]

Risk perception
128 . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020 susceptibility, and (ii) perceived severity. The first dimension was proxied by how likely one considered 130 oneself (his/her families) would be infected with COVID-19 if no preventive measure was taken. The 131 second dimension was proxied by how one rated the seriousness of symptoms caused by 132 their perceived chance of having COVID-19 cured and that of survival if infected with  Subjects were also asked to rate the relative severity of COVID-19 compared with common non-134 communicable diseases (NCDs) and previous outbreaks by novel pathogens in Hong Kong. Responses  Respondents were asked about the sources from which they obtained information about COVID-19, and 139 how much they trust those sources. They were also asked about the types of information that they 140 wanted to receive.   CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020 or dissemination plans of this research.

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The survey was conducted from 24 January 2020 to 13 February 2020 ( international concern, with Hong Kong activated the emergency response level. CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020 Many of the respondents are female (69%; 1176/1715), of young age (18-44 years) (80%; 1380/1715), 180 working population (68%; 1168/1715). The study sample is comparable to the population in terms of 181 residential district (effect size=0.27). Table 2 Table 3 shows the perceived susceptibility and perceived severity towards COVID-19 among 189 respondents. Most respondents regarded themselves as likely to be infected with  likely/likely: 89%), and most considered the symptoms of COVID-19 (if infected) as serious (very 191 serious/serious: 97%). Less than a quarter of the respondents thought that it was likely to have  19 cured (if infected) (15%), and only 18% thought that it was likely to survive through  When referencing to existing diseases (Table 4), almost all respondents (>98%) consider equivalent 194 disease severity between COVID-19 and SARS. This magnitude was similar to other deadly NCDs 195 (85%-94%), but much higher than the annual seasonal influenza (66%). CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020 Nearly all respondents were continuously alert to the disease progression of 205 1707/1715) and actively searched for related information (83%; 1431/1715). Table 5    The next two most trusted sources were broadcast (57%) and newspaper (54%), but they were used by 215 less than 40% of the respondents. On the other hand, the two most common information sources were 216 social platforms (94%; 1608/1715) and websites (regardless of official or unofficial) (90%; 1539/1715), 217 but they were rated as reliable or very reliable by only 26% and 16%-23% of the respondents 218 respectively. Only 16% (269/1715) of respondents found information from official websites reliable or 219 very reliable.  CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020   CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020 materials, such as masks, so that the blockage of local transmission chain can be sustained. This is in more sociable channels. This strategy is deemed more acceptable by the community than relying 279 solely on the official channel, given only 16% of respondents rates official websites as reliable or very 280 . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.02.26.20028217 doi: medRxiv preprint disease-related information during the early stage (Table 5).  (Table 6). 286 Interestingly, specific to this COVID-19 epidemic, residents in the NT were more likely to comply with 287 social-distancing precautionary measures than their counterparts in other areas of Hong Kong.   CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.02.26.20028217 doi: medRxiv preprint early start enables timely assessment of the community responses such that there is sufficient gap period 307 to inform intervention policies. Second, our recruitment method, online survey via dissemination by 308 DCCA councilors, is the first of its kinds to capture responses during public holidays while maintaining progresses. However, contact information were collected from this study cohort and follow-up surveys 321 will be carried out as the disease progresses.  CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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COVID-19 situation in the WHO European Region. In.: World Health Organization; 2020. 385 . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https: //doi.org/10.1101//doi.org/10. /2020  . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https: //doi.org/10.1101//doi.org/10. /2020 (15) a Cohen's w effect size b Data for 15 years old or above is extracted from 2016 by-census for comparison. c The "unemployed" category is excluded from comparison as it is unavailable from 2016 by-census. d The "monthly household income" category is excluded from comparison as it is unavailable from 2016 by-census.
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is the (which was not peer-reviewed) The copyright holder for this preprint . . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020  . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020  PH); the . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020  CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020  . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10. 1101/2020  . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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