COVID-19 measures in Belgium: how perception and adherence of the general population differ between time periods – BMC Public Health – BMC Public…

To our knowledge, our study was the first to assess the perceptions of and adherence to COVID-19 measures in Belgium at multiple times, on a large total sample of nearly 4000 respondents representative of the adult population in terms of gender, age, region and socio-economic status,. The results of the surveys revealed that both reported understanding of the preventive measures and their perceived usefulness were higher at the second survey in April/May 2021 than at the first one in September 2020. This was particularly the case for measures that were implemented at both survey periods, namely wearing a face mask in public spaces and shopping with maximum one other person. At the time of the second survey, these measures had been in place for a long time, which may explain the fact that they were better understood and that citizens were more likely to consider them as useful. However, it is important to note that most measures differed between the two periods. The better understanding and perceived usefulness of the preventive measures at the time of the second survey could therefore also be due to other factors, such as a clearer and less ambiguous formulation or overall better communication about the reasons for the measures.

In contrast, both past adherence to the measures and (intended) future adherence were lower at the second survey period, compared to the first. For the two recurring measures, the decrease of the score for future adherence was rather small, especially with regard to shopping with maximum one other person. Since at the time of the second survey all measures had been in place for more than 6 months, it is likely that this caused a certain level of fatigue amongst citizens. This may especially apply to the measures involving a reduction of social contacts, which were the ones that received the lowest scores in the second survey. This is in line with reports from other Belgian studies, showing a lower motivation to adhere to COVID-19 measures in April and May 2021 than in September 2020 [27], and also indicating that people had more contacts outside their household in April/May 2021 than in September 2020 [28]. Being confined also had a negative impact on mental health of affected populations [29], particularly among women and younger age groups [7]. A study in the US showed a negative relationship between having mental health problems such as a social distance burn-out and depressive symptoms on the one hand, and adherence to COVID-19 measures on the other hand [30]. A survey from the National Institute of Health in Belgium showed high levels of anxiety and depression among the general population since the start of the COVID-19 pandemic, especially among people aged 1829 [26]. Since in our study mental health was not assessed, we were not able to investigate the relationship between individual mental health and adherence.

Between the first and the second survey, there was a strong increase in the proportion of respondents that had experienced a confirmed COVID-19 infection. This is an expected finding, since, like most European countries, Belgium was confronted with an increasing number of cases between the two study periods [24]. Yet, while there was no difference in the perceived health consequences of COVID-19 for those who had had an infection, the expected health consequences reported by those who had not yet been infected at the time of the second survey was significantly higher than for the first survey. This may be related to the fact that at the second survey period, more people knew someone who had been infected: almost twice as many respondents knew someone who had been hospitalised with COVID-19, an important indicator of infection severity.

On the other hand, the respondents perceived risk of getting infected with COVID-19 was lower in the second survey than in the first, which may be explained by the fact that in April/May 2021 nearly a third (30%) of them had been vaccinated at least once. An unexpected finding however, is that the expected risk of older family members (parents and grandparents) being infected was higher in the second than in the first survey, especially since mainly older people had been vaccinated in Belgium at that time. Possibly, the fact that a larger proportion of respondents knew someone close who had been infected, sometimes with severe illness, might have made them more concerned about their own (vulnerable) relatives. However, this cannot be substantiated on the data from this study.

A difference was also observed in the support for the COVID-19 measures between the two study periods. The lower percentage of respondents who agreed with the statement that the government should recommend, but not oblige the COVID-19 measures and the higher agreement with the statement that the government should control the COVID-19 measures in the second survey suggests that citizens find it increasingly important to have clarity on what is expected from them, and that it should not be left up to the individual to decide this. Since COVID-19 had been part of peoples lives for more than a year in April/May 2021, less importance was given to reminders or nudges for preventive action compared to September 2020. Arguably, this may be because these actions became habits that were integrated in everyday life, so that nudges became less necessary.

Our study identified several characteristics associated with lower levels of adherence in both surveys. The finding that men adhere less than women, and younger age groups less than older ones, are similar to those of studies in other countries that studied characteristics of lower adherence [7, 8, 16, 17]. Yet while previous research in Belgium also identified disadvantaged or lower socio-economic background as a risk factor for low adherence [8, 19], educational level and annual income were not found to be significant contributors for past or (intended) future adherence in our study. In terms of occupational status, the only group that differed significantly from the reference group of workers were those who were incapacitated, and their adherence levels were actually higher. Since those who are incapacitated to work have likely underlying health problems, they might feel more vulnerable to becoming infected with COVID-19, and as such adhere stricter to the measures in order to protect themselves. On the other hand, French-speaking citizens were less adherent and intent on future adherence than Dutch speakers, and inhabitants of Wallonia less than inhabitants of Flanders or the Brussels Capital region. These findings are highly correlated, as Wallonia is a French-speaking region of Belgium, Flanders is Dutch-speaking, and Brussels is both French- and Dutch-speaking. The reasons for these findings are not clear, but since almost 40% of Belgians have French as their native language [31], this important difference warrants further investigation. It does suggest, however, that adherence to measures against COVID-19 does not only depend on what is being decided on a national level, but that cultural and linguistic differences within the population have an impact as well.

The last group that had lower adherence levels consisted of those with a symptomatic, confirmed COVID-19 infection. We see three potential explanations for this: either this group feels protected against COVID-19 due to their previous infection, and therefore feels that they do not have to adhere to the rules; or this group consists of individuals that are less likely to adhere (because of lack of motivation or faced with environmental barriers that make measures more difficult to adhere to), and are therefore more prone to an infection; or this group has perceived milder symptoms, and the perceived severity of a COVID-19 infection is therefore lower for them. A qualitative study among those who have been previously infected could potentially provide more insight into this.

Of all the measures that were investigated in the second survey, the two measures related to social contact (having one close contact and limiting close contact to one per household) were seen as the most difficult to adhere to, both in the past and in terms of (intended) future adherence. These two measures are arguably the ones that are most restrictive for peoples daily lives. Since these measures had already been in force for over 6 months at the time of the second survey, the difficulty to adhere to them is not surprising. This is also in line with the result of a multi-country study that showed potential pandemic fatigue, and as a result lower adherence, over time for high-cost measures such as social distancing [23]. In contrast, a measure that received overall high scores in terms of understanding, perceived usefulness, ease to adhere and past and future adherence is the use of a face mask in public spaces. In fact, the scores for this measure even became more positive compared to the first survey, implying that this measure has been well implemented in Belgian society. The same is also observed for testing and quarantining for those who have symptoms, indicating the perceived importance of this measure by citizens.

The second survey also allowed to investigate the perceptions regarding vaccination. High scores were given in support of the statements that COVID-19 vaccines are important to protect yourself and others and it is important that everyone is vaccinated against COVID-19, indicating that most people accept vaccines as an important protective measure. Nonetheless, scores for the statements COVID-19 vaccines are safe and COVID-19 vaccines are effective in preventing infection were much lower. Since the perceived safety of vaccines has been identified as an important predictor of vaccination intention [32], effective risk communication on vaccine safety is a crucial issue to improve actual uptake.

Our study had some limitations. First, while the samples from both surveys matched the predefined targets well in terms of gender, age, region and socio-economic group, there was a slight underrepresentation of respondents from the lowest socio-economic group. Obtaining an equal number of respondents from this group is often problematic, as they are less likely to participate in surveys. Secondly, citizens of Belgium who do not speak French or Dutch could not participate, since the survey questionnaire was only available in those two languages. However, this represents not more than 5% of the countrys population [31]. Thirdly, due to the anonymity of our questionnaire, we could not ascertain whether certain individuals participated in both surveys, which would have required a correction in the analytical approach. However, due to the methodology used by the market research and opinion poll company, this probably concerns only a marginal number of respondents, if any. Fourthly, although we obtained information on vaccination status, we could not include this as a potential predictor for adherence in the multivariate models. This is partly due to the fact that vaccination status was only relevant during the second survey (vaccines were not administered yet in Belgium during September 2020), and partly because only selected populations had been invited to get vaccinated at the time of the second survey (mainly elderly, healthcare professionals and chronically ill). As such, it is unlikely that vaccination status measured at that time would serve as a predictor for adherence. It is possible, however, that it would become a factor at a later stage, after everyone older than twelve years has received an invitation to get vaccinated.

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COVID-19 measures in Belgium: how perception and adherence of the general population differ between time periods - BMC Public Health - BMC Public...