International citizen project to assess adherence to public health measures and their impact on the COVID-19 outbreak

In December 2019, an unknown viral pneumonia outbreak occurred in the Hubei Province of China. This disease was later found to be caused by the Severe Acute Respiratory Syndrome Coronavirus-2, which was declared recognized as a pandemic by the World Health Organization (WHO) in March 2020. The disease, now called Coronavirus Disease 2019 (COVID-19), has spread to 200 countries and caused more than 465, 000 infections and at least 21,000 deaths as of March 26th 2020. COVID-19 mostly causes benign symptoms in adults, although some cases may become severely ill and require hospitalization with respiratory support.

Human-to-human transmission of COVID-19 occurs through respiratory droplets and aerosol, contaminated objects, and direct physical contact with infected people. Once infected, both asymptomatic and symptomatic persons can transmit the disease. In the absence of effective treatments or vaccines, the WHO has strongly recommended countries to implement interventions to curb the rapid spread of COVID-19 through minimizing contact between infected and uninfected persons. Suggested measures include lock downs, closing schools, and public places, and stringent personal methods of hand hygiene and social distancing. Governments are increasingly implementing more stringent measures of social distancing to stall the transmission of COVID-19. For the first time on a global scale, people are faced with travel restrictions, school closure, and forbidance of social gatherings of any kind.

Because such measures had never been implemented before at this scale, it is unclear to what degree people will adhere to them, which factors determine adherence, what the durability of adherence is, and what the effectiveness of the combined intervention and its components is in reducing COVID-19 transmission. December 2020, the first COVID-19 vaccines have been approved and large-scale vaccination will start soon. 

We hypothesize that the level of adherence to the prescribed measures as recommended by the government will initially be high, that adherence will not be durable, and that the level of adherence is associated with the incidence of severe COVID-19 disease. The study aims are:

  1. To describe the level of adherence to the current measures recommended by governments and during the first 6 months following implementation
  2. To describe the determinants of adherence to the measures recommended by governments (baseline covariates and time-varying covariates)
  3. To assess the overall effectiveness of adherence to the measures recommended by governments on the incidence of severe COVID-19 disease
  4. To identify the most effective measure (or combination of measures) to reduce the incidence of severe COVID-19 disease
  5. Assess perceptions about COVID-19 vaccination and willingness to be vaccinated

Understanding the feasibility of adherence to, and durability of public health measures will be essential to public health officials in choosing the most effective strategy for reducing transmission, reducing the COVID-19 burden on the healthcare system, and “flattening the curve” until a vaccine or treatment is licensed. Moreover, if the current containment measures for the outbreak are successful, herd immunity will not be reached. Therefore lessons learned from the current outbreak will be important to tackle potential recurrent episodes and will better prepare us for future pandemics. By performing the study in different countries the most effective strategies will be identified. For objectives 3 and 4, the data obtained with the questionnaire will be combined with local COVID-19 incidence data. High COVID-19 vaccination coverage will be needed to stop the community distribution of COVID-19. Therefore to plan COVID-19 vaccination campaigns it is important to obtain information about the willingness of the population to be vaccinated (objective 5) and reasons for vaccine hesitancy.

What will be measured?

The primary outcome measure will be adherence to the interventions recommended by the government which include: staying at home, social distancing, hygiene measures, staying away from healthcare workers except for corona-related urgency, avoiding generation mixing, self-quarantine when experiencing symptoms, avoidance of unessential travel.

Information will also be obtaining concerning relevant covariates such as: rural/urban residence, housing details, age, education level, size and composition of household, gender, health condition (co-morbidities), pregnancy, smoking status, income, travel history, belief in science, belief in social responsibility, belief in government, and risk perception.

Questions will be asked about COVID-19 perceptions, willingness of the population to be vaccinated, and reasons for vaccine hesitancy.

How frequently will the measurement take place?

Participants will be asked to complete the survey at regular time intervals. Certain questions will be repeated but other questions may be modified and new questions may be added depending on the preliminary results.

How will the questionnaire be distributed?

The questionnaire will be distributed using a secure study website mainly by submitting answers using mobile phones.

What stimulates people to participate?

People contribute to science (a better understanding of virus outbreaks and pandemic management) and therefore have the feeling they can contribute positively to society (in a time when society is put under stress).

How will the information be used?

Indicators of poor adherence overall or in specific population groups will be communicated to the health authorities within the days after distribution of the questionnaire so that targeted interventions can be developed and implemented.

Who is organizing the study?

An international consortium of scientists from Asia, Africa, South America, the United States, and Europe. The protocol and questionnaire for this survey is largely based on the citizen science Corona survey first launched in Belgium by the University of Antwerp (team: Philippe Beutels, Niel Hens, Koen Pepermans & Pierre Van Damme) on 17th March 2020, which is repeated every Tuesday throughout the COVID-19 epidemic in Belgium. Collaborating institutions are listed below:

  • Brazil: Disease Control Coordination of the Secretary of State for Health, São Paulo, Brazil
  • Cameroon: Brain Research Africa Initiative (BRAIN)
  • Ecuador: Universidad de Cuenca, Facultad de Ciencias Medicas
  • Peru : Universidad Peruana Cayetano Heredia, Instituto de Medicina Tropical Alexander von Humboldt
  • Mali: University of Bamako, Faculty of Medicine and Odontostomatology, International Center of Excellence in Research
  • Ghana: University of Energy and Natural Resources, Sunyani, Ghana
  • The Gambia: MRC Unit The Gambia at LSHTM Fajara
  • Democratic Republic of Congo: University of Kinshasa, Department of Tropical Medicine
  • Uganda: Makerere University, College of Health Sciences, School of Public Health
  • Burundi: University of Burundi, Faculty of Medecine
  • Zambia: University of Zambia, School of Public Health, Tropical Diseases Research Centre
  • Malawi: UNC Project Lilongwe & University of North Carolina (USA), School of Medicine
  • Mozambique: Institutio Nacional de Saúde
  • South Africa: University of Witwatersrand, Ezintsha
  • India: Shiv Nadar University, School of Natural Sciences, Dept. of Mathematics
  • Thailand: Mahidol University, ASEAN Institute for Health Development
  • Taiwan: National Taiwan University College of Medicine, Taipei
  • Vietnam: Hue University of Medicine and Pharmacy, Faculty of Public Health, Institute for Community Health Research
  • Benin: Ecole Polytechnique d'Abomey-Calavi, Université d'Abomey-Calavi, Bénin
  • Belgium: Institute of Tropical Medicine, Antwerp
  • Belgium: Global Health Institute, University of Antwerp
  • Somalia: Mogadishu University
  • Tunisia: Direction des Soins de Santé de Base, Ministère de la Santé
  • Malaysia: School of Social Sciences, Universiti Sains Malaysia
  • Bangladesh: Public Health Foundation, Bangladesh



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Prof. Dr. Robert Colebunders, Prof. Dr. Jean-Pierre Van geertruyden, Dr Joseph Nelson Siewe Fodjo (GHI, Belgium); Prof. Marc-Alain Widdowson (ITM, Belgium); Dr. Bernardo Jose Vega Crespo (Ecuador); Prof. Dr. Edlaine Faria de Moura Villela (Brazil); Prof. Dr. Theresa Ochoa, Dr. Takashi Watanabe (Peru); Dr Philippe Sessou (Bénin); Prof. Dr. Alfred K. Njamnshi, Dr. Leonard Ngarka (Cameroon); Dr. Dolo Housseini (Mali); Dr. Kenneth Bentum Otabil (Ghana); Prof. Dr. Umberto Dalessadro (The Gambia); Prof. Dr. Hypolite Muhindo, Dr. John Ditekemena (DR Congo); Prof. Dr. Rhoda Wanyenze (Uganda); Dr. Zacharie Ndizeye (Burundi); Dr. Gershom Chongwe (Zambia); Prof. Dr. Mina Hosseinipour (Malawi & USA); Dr. Janet Dula, Dr. Jani Ilesh (Mozambique); Dr. Mohammed Majam (South Africa); Prof. Samit Bhattacharyya (India); Prof. Dr. Supa Pengpid (Thailand); Prof. Dr. Thang Vo Van (Vietnam), Dr Mohammed Ahmed (Somalia); Dr Hayet Hamdouni (Tunisia); Prof Dr Chien-Ching Hung (Taiwan); Prof Wah Yun Low (Malaysia); Dr M Tasdik Hasan (Bangladesh).

Team for statistical support:

Steven Abrams (GHI, University of Antwerp, CenStat, UHasselt); Thomas Neyens (L-BioStat, KU Leuven, CenStat, UHasselt); Jonas Crevecoeur (LRisk, KU Leuven); Katrien Antonio (LStat and LRisk, KU Leuven); Liesbeth Bruckers (CenStat, UHasselt); Lisa Hermans (CenStat, UHasselt); Anna Ivanova (L-BioStat, KU Leuven, CenStat, UHasselt).

Updated: February 2021