Our study shows that, during the survey period, Brazilians were following the COVID–19 preventive measures relatively well. Hand hygiene measures were adhered to most, followed by physical distancing and respiratory hygiene. In all categories of measures, a clear age effect was observed, with younger individuals (18–25 years old) scoring lowest and people >65 years old showing the highest preventive adherence score. This effect was most pronounced for respiratory hygiene.
Overall, only 45.5% reported wearing a face mask when going out. This is much lower than in Asian countries, where most people wear face masks once the COVID–19 epidemic was introduced in their country [14,15,16]. This is however higher than in several European countries where initially wearing facemasks was initially advised, following WHO recommendations, only to be used in health care settings [17,18,19]. Checking one’s temperature for the early detection of a COVID–19 infection at least twice a week was only practiced by 10.8% of the respondents. This may be a point of concern, as WHO reported that temperature screening was able to detect the majority of exported cases during the COVID–19´s expansion [20].
When assessing the profile of individuals with poor general adherence, men were less adherent compared to women, which mirrors findings from a Knowledge, Attitudes, and Practices study conducted in China (16). People living in rural areas and poor neighborhoods were also less adherent: in rural areas people may not perceive themselves at high risk of COVID–19, and therefore may not respect the national restriction measures and not practice individual hygiene measures [21]. Therefore, extra communication and health education may be needed to change the risk perception in rural areas and popular neighborhoods [22]. Brazilian students reported difficulties to stay home, which may be related to a need to travel to their original homes in periods when schools and universities were closed [23] or could be related to differing social habits among this population. Encouragingly, respondents with underlying diseases followed the preventive measures well, which is important considering their higher risk for more severe disease.
Taken together, these observations suggest that tailoring of the public health messages may be indicated. A reinforcement of specific messages, such as mask use and temperature taking, may be beneficial, and using delivery methods tailored to the specific age groups could allow higher uptake. Especially communication methods to the younger age group could benefit from such tailoring, and possibly approaches relying on social media and including influencers to spread public health messages could be considered [24]. Of note, the observation that most respondents’ concern was higher for their loved ones than for themselves could be incorporated in such health messages; possibly by emphasizing how adhering to measures protects one’s close environment.
In general, our results indicate that following an intensive COVID–19 prevention campaign [25] the Brazilians gradually became aware of the importance of adopting simple methods to prevent COVID–19 transmission. For only 7.9%, of the interviewees, the incorporation of “new habits” was extremely difficult. Initially the MOH of Brazil expected a peak of COVID–19 infections during the second half of April. However, it did not happen. According to a new estimate from the MOH, the peak is now expected by the end of May [26]. The satisfactory adherence to the preventive measures may have delayed the peak of the epidemic.
COVID–19 associated mortality is highest Brazil, in the North region (Amazonas, 178) and in two states in the Northeast (Ceará and Pernambuco) [27]. Our study showed that the Northeast region had less difficulty to adhere the restrictive measures. This difference between regions may have been influenced by the adoption of restrictive measures to varying degrees by the governors of the Brazilian states. Indeed, 11 states have decreed lockdown for at least one municipality in their state. Only the state of Amapá decreed a lockdown for all your municipalities.
Currently there is a lot of confusion about how to deal with the COVID–19 epidemic in Brazil. The president has minimized the actions of the MOH, downplaying the importance of quarantine, and is defending vertical isolation to avoid financial collapse. Vertical isolation or shielding means, most people return back to normal life and people with underlying diseases, older adults and pregnant women continue to respect physical distance and reduce their social activities. Regarding this vulnerable group, 29.4% stated to have underlying diseases in our survey. This is a concern, as older age and the presence of (an) underlying health condition(s) are associated with increased COVID–19 related mortality [28,29] On the other hand, Brazilian respondents with underlying diseases adhered better to the containment measures.
The lack of unified actions against COVID–19, by the federal government, led to the resignation of the health minister on April 16 [30,31]. From that moment on, there was a relaxation of quarantine measures, opening of part of the trade, and consequently less physical distancing. This increased the number of COVID–19 cases and associated deaths [28,31]. At the end of April, the COVID–19 death toll in Brazil had already exceeded that of China [3] (more than 5,000 deaths) and this scenario is getting worse, not reaching the flattening of the curve and overloading the Brazilian health system [32]. As of May 22th 2020, 291,579 cases had been confirmed in the country, causing 18,859 deaths [2,5]. Currently South America is the new epicenter of the pandemic and Brazil is the country most affected [3]. Our findings suggest a considerable initial willingness of the Brazilian people to follow the quarantine and other containment measures, and it remains to be investigated whether this willingness has been irrevocably subverted through the political stance against the public health measures, or whether it can still be harnessed to achieve better control of the national situation.
Our study had several limitations. The number of respondents was relatively small compared to the entire Brazilian population, and respondents were unevenly spread over the national territory. Indeed, only 2,6% of the participants reported residing in rural areas. In addition, 71,8% of the respondents were female, similar to other studies on COVID–19-related practices (16). Participants were more likely to be higher educated individuals living in cities and in the Southeast region. The latter may be explained by the fact that since the beginning of the pandemic, this region recorded the largest number of COVID–19 infections. Moreover, broadband internet quality is best in the Southeast region [33]. Our survey was also not able to reach vulnerable populations, such as the homeless, prisoners, older adults, migrants and people with mobility problems. Such populations may be at increased risk for COVID–19 infection and should be considered as priority key groups in the prevention and control of Covid–19 [23,34].