1. Background
Following the announcement of COVID-19 as an international concern by the World Health Organization (WHO) (1, 2), personal and social preventive measures were requested, including hand and face washing, wearing a mask, social distancing, and non-participation in meetings, as the most important ways to minimize virus transmission (3-7). Gradually, several months after the pandemic began, there were reports of the development and injection of the COVID-19 vaccine in various countries. According to previous studies, adherence to preventive measures has been reduced after receiving the vaccine in the general population or due to epidemic fatigue (8-12). However, the nature and extent of this change and reduction in adherence to preventive measures have been different in various populations. The current study was performed due to the importance of these data for health policymakers and regional managers (for both the current pandemic and potential future pandemics) and the lack of a study in the Iranian sociocultural context.
2. Objectives
The aim of this study was to investigate the intention of changing adherence to COVID-19 preventive health measures (ICA-COVID-19–PHM) after implementation of the COVID-19 vaccination program compared to when they had not received the vaccine. This study was performed at a time only medical staff had been vaccinated in Iran, and general population vaccination had not yet begun.
3. Methods
3.1. Participations
The study participations were the general population of Mazandaran Province, the age groups of 18 to 60 years old who are active in using virtual or social networks such as WhatsApp, ETA, Yes, Rubika, and Instagram. The sample size of the present study was 1000 participants [it was determined using the single population proportion formula with assumptions of 4% margin of error, 95% CI, 40% expected proportion of adherence, 1.5 for design effect (for cities), and 10% non-response rate], which was considered with a distribution almost proportional to the population of the cities of Mazandaran Province.
3.2. Data Collection
Data were collected using a researcher-made questionnaire (2 subscales: 10 questions for each scale). The questionnaire was developed by expert opinion (2 epidemiologists, 2 community medicine specialists, 1 public health specialist, 1 infectious diseases specialist, 1 health education specialist, and 1 health information management specialist). Its construct validity was evaluated by Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), and its reliability was evaluated by Cronbach’s alpha for internal consistency. Questions were asked about participants’ performance in adhering to preventive measures for COVID-19 under the current conditions (when they did not yet receive the vaccine) with Cronbach’s alpha of 0.89 and their intention to adhere to the preventive measures for COVID-19 after implementation of a COVID-19 vaccination program with Cronbach’s alpha of 0.92. The response options in the questionnaire were defined in a range of 1 (weakest compliance) to 5 (strongest compliance). In addition, socio-demographic characteristics such as sex/occupation/education were collected.
3.3. Statistical Analysis
The frequency and percentage of socio-demographic characteristics were computed. The Pearson correlation coefficient, intra-class correlation coefficient (ICC), and paired t-test were used to evaluate the intention of changing adherence to COVID-19 preventive health measures (ICA-COVID-19-PHM). An analysis was performed in Stata version 16. In all statistical tests, the significance level was considered 0.05.
4. Results
The demographic distribution of participants is shown in Table 1. Table 2 shows the significant relationship between current protocol compliance and intention to adhere to post-vaccination for each protocol and total. The correlation coefficient ranged from 0.58 for non-travel to 0.76 for personal hygiene. ICC ranged from 0.68 for non-traveling to 0.86 for personal hygiene and hand/face washing. The results of the paired t-test showed that there was a significant difference between the adherence at the present time and the intention to adhere to preventive protocols after receiving the vaccine.
Table 1.Demographic Characteristics of the Study Participants
| Demographic Variables | No. (%) |
|---|---|
| Gender | |
| Female | 674 (67.4) |
| Male | 326 (32.6) |
| Marital status | |
| Single | 371 (37.1) |
| Married | 600 (60) |
| Divorce | 22 (2.2) |
| Widow | 7 (0.7) |
| Education level | |
| Under diploma | 77 (7.7) |
| Diploma | 265 (26.5) |
| Master diploma | 70 (7) |
| BS | 355 (35.5) |
| MSc | 156 (15.6) |
| Doctor | 77 (7.7) |
| Income | |
| Not enough | 497 (49.7) |
| Enough but without savings | 388 (38.8) |
| Enough and have savings | 115 (11.5) |
| Job | |
| Health workers | 251 (25.1) |
| Military | 8 (0.8) |
| Students | 216 (21.6) |
| Housewives | 180 (18) |
| Other organizations | 111 (11.1) |
| Other occupations | 234 (23.4) |
Table 2.Pearson Correlation, Intra-Class Correlation, Mean and SD, and Paired t-Test Statistics for Various Preventive Measures of COVID-19 a
| Preventive Measures | Pearson Correlation | Intra-Class Correlation b | Adherence (Pre-Vaccination) | Adherence (After Vaccination) | Difference | Paired t-Test Statistics | Reduction (%) |
|---|---|---|---|---|---|---|---|
| Keeping a safe distance of at least 6 feet (approximately 2 meters) | 0.71 c | 0.82 | 3.66 ± 1.14 | 3.50 ± 1.22 | 0.15 ± 0.91 | 5.34 c | 4.19 |
| Avoiding leaving home, except to go to essential work | 0.59 c | 0.72 | 3.52 ± 1.30 | 3.22 ± 1.31 | 0.30 ± 1.18 | 7.98 c | 8.47 |
| Personal hygiene | 0.76 c | 0.86 | 4.24 ± 0.96 | 4.16 ± 1.01 | 0.08 ± 0.69 | 3.47 c | 1.79 |
| Hand and face washing | 0.75 c | 0.86 | 4.18 ± 0.97 | 4.09 ± 1.03 | 0.09 ± 0.70 | 4.17 c | 2.22 |
| Wearing a mask | 0.64 c | 0.75 | 4.22 ± 1.04 | 3.88 ± 1.21 | 0.34 ± 0.96 | 11.27 c | 8.14 |
| Use of gloves | 0.73 c | 0.84 | 2.15 ± 1.28 | 2.22 ± 1.39 | -0.06 ± 0.98 | -2.03 d | -2.93 |
| Isolating myself at home when sick | 0.65 c | 0.78 | 4.32 ± 0.99 | 4.17 ± 1.06 | 0.15 ± 0.87 | 5.50 c | 3.49 |
| Avoiding any non-essential travel (domestic, international) | 0.58 c | 0.68 | 4.08 ± 1.16 | 3.59 ± 1.30 | 0.49 ± 1.14 | 13.56 c | 11.96 |
| Disinfection of hands | 0.72 c | 0.83 | 3.83 ± 1.24 | 3.57 ± 1.30 | 0.26 ± 0.95 | 8.51 c | 6.66 |
| Avoiding crowded places (concerts, conferences, arenas, festivals) | 0.62 c | 0.74 | 3.58 ± 1.23 | 3.26 ± 1.31 | 0.32 ± 1.12 | 9.12 c | 8.99 |
| Total | 0.76 | 0.84 | 37.78 ± 8.19 | 35.67 ± 9.10 | 2.12 ± 6.07 | 11.03 c | 5.60 |
a Values are expressed as mean ± SD.
b ICC below 0.50: Poor; Between 0.50 and 0.75: Moderate; Between 0.75 and 0.90: Good; Above 0.90: Excellent.
c P < 0.001.
d P < 0.05.
5. Discussion
The results of the present study showed that the intention of changing adherence to all COVID-19 preventive health measures (ICA-COVID-19-PHM) was reduced after vaccination of COVID-19 (except for using gloves); this the difference was not large, but it was statistically significant. This low reduction of preventive measures seems to be due to the pandemic fatigue or COVID-19 vaccination, which needs further investigation. This is because the ICC values of each preventive health measure and also total preventive measure showed moderate to good consistency. Also, the Pearson correlation between preventive health measures before vaccination and the intention to adhere after vaccination was strong. It seems that regarding the nature of COVID-19 and also the high probability of genetic mutations, the vaccination will be considered a repetitive action, and adhering to health protocols is a complementary strategy for this disease until the complete disruption of the pandemic chain.
5.1. Limitations
Although the large sample size and inclusion of all cities of Mazandaran Province are the strengths of this study, there are several limitations. First, the generalizability of the results to other provinces of Iran should be done with caution. Second, participants of this study are not a good representation of the general population. Third, the preventive measures of the government were not considered.
5.2. Conclusions
Considering the limitation mentioned above, it can be concluded that the intention of changing adherence to COVID-19 preventive health measures of the people of Mazandaran Province after implementation of a COVID-19 vaccination program compared to when they did not receive the vaccine is decreasing. The intention of changing adherence to preventive health measures (such as avoiding travel and crowded places and mask-wearing) had the most reduction. In addition, the results of the present study may implicitly reflect health literacy and post-vaccination concerns about the disease at regional and provincial levels.
