The aim of this research was to examine how individuals’ understanding of information regarding COVID-19 and their use of reliable sources of information affected their level of adherence to key sanitary measures in the long term. We used latent trajectories to model adherence levels over the first year of the pandemic and generally found that there was one group of individuals who presented a significantly lower level of adherence to the measures throughout time. This low adherence group included between 2.6% and 6.5% of the population depending on the specific measure considered (5.7% for social distancing, 6.5% for contacts’ limitation and 2.6% for mask wearing). Thus, we start by acknowledging that only a very small proportion of the Canadian population showed extremely low adherence to sanitary measures. However, this small proportion is enough to hinder the impact of preventive measures [47], which is why it is so important to understand what influences some individuals to ignore them. Moreover, many studies up to date have focused on sociodemographic variables to detect population differences in adherence levels. Thus, it is important to keep in mind that all results were controlled for variables such as age, gender, education level, political identity, immigrant status and region of Canada.
First, we postulated that individuals who don’t understand information related to COVID-19 and preventive sanitary measures would be less likely to follow said measures. Our results show that a low level of understanding makes it between 3 and 34 times more likely to have a globally low adherence to sanitary measures. Although a high understanding does not guarantee a perfect adherence, a lack of comprehension regarding COVID-19 and associated preventive measures hinders adherence. This is not surprising considering that good knowledge and understanding of an epidemic outbreak was proved to be important in encouraging adherence to quarantine compliance in other cases of outbreak of H1N1, SRAS or Ebola in various countries [48]. Although there is little literature on situations comparable to COVID-19, these results are also coherent with what is known to affect patients’ adherence to preventive measures for health concerns in general. Indeed, it is well documented that patients are much less likely to adhere to preventive measures relevant for their specific ailments (whether it is cancer, diabetes, recovering for physical injuries, etc.) when they don’t understand their disease or the role that the preventive measures they are encouraged to implement is supposed to play in the management of their illness [25]. This relation between level of understanding and adherence prompted many medical practitioners, researchers, and associations to advocate for better health literacy in the general population [25] [26] [27] [28]. Health literacy, considered as the capacity to understand, access, and use health-related information, is the primary predictor of understanding an illness and the impact of related preventive measures or treatment, regardless of other factors such as education [13] [16] [29]. Our results simply suggest that this relation holds true in the case of COVID-19, meaning that better health literacy would improve individuals’ level of understanding and thus have a positive influence on adherence to preventive measures. Although this is clearly not something that can be implemented quickly, policies that enhance health-related education in school and in public communications by the government should be a priority not only to improve individuals’ understanding in the case of personal illness, but for matters of public health such as future epidemics. For a more immediate effect, governments and public health agencies should strive to provide clear and coherent communication regarding sanitary measures if they want to ensure a higher level of understanding and improve adherence.
Furthermore, we believed that use of unreliable sources of information would be associated with lower adherence. Regarding the increase of fake news and misinformation issues since the beginning of the pandemic, it was logical to assume that individuals using primarily unreliable sources such as friends and family, unverified sources on the internet and religious leaders to get information regarding COVID-19 would be more likely to have a low adherence level. As the results showed, we did find some significant link between the use of unreliable sources and low adherence to social distancing and contacts’ limitation, but not as much for mask wearing. This is coherent with the results of many other studies that showed reliance on sources such as the government or health agency encouraged adherence while the use of social medias could decrease adherence [14] [18] [19] [21] [24]. Furthermore, for all three measures, the effect of unreliable sources on low adherence was much less important than that of the understanding level, being only significant in distinguishing the lowest from the highest adherence trajectories, with odds ratio around 2.
It is also interesting to note that a low understanding level remained an important predictor of low adherence regardless of used sources levels of reliability and education level, two factors that are much more highlighted in public and political discourse. This goes to show that while the use of unreliable sources can be problematic, its effect is usually not as important as the actual level of understanding. While some research demonstrated that individuals with higher education level showed better knowledge and understanding of various issues [13], in our study, education was shown to be less relevant to promoting adherence than knowledge and understanding level. This could potentially be explained by the interaction between education and choices of sources, affecting knowledge together [13] [14] [18], an interaction that could be explored in further studies.
Finally, we also include some control variables that despite not being the main subject of this article, offer interesting insight into other factors that could affect adherence. Confirming what had been found by many other studies, we noted that being younger and being more to the right of the political spectrum increased risk of following a low adherence trajectory [15] [32] [49] [50] [37] [51] [52] [53] [54]. We also found significant differences in adherence to mask wearing depending on the Canadian region, which is coherent with the fact that mask wearing was imposed at different moments and at different speeds throughout the country [55].
This study has significant strengths, most importantly its longitudinal design. We used 11 times of measurement to construct latent trajectories, which gives an accurate and detailed portrait of the evolution of adherence levels during the first year of the pandemic in Canada. This longitudinal design also allowed us to examine the influence of initial level of understanding and reliability of sources used at the beginning of the pandemic over the long-term. The use of six control variables also allowed for a more comprehensive insight in the mechanism hindering adherence.
This study also has limitations. First and foremost, adherence and understanding were both measured based on participants’ perception of their own adherence and understanding. Although results are coherent with previous studies, external measures of adherence and understanding would have been a more accurate reflection of people’s behaviour during the pandemic. Moreover, the construction of the variable representing the use of reliable sources was very complex and necessitated many discretionary decisions on the part of our research team, which may limit replicability. The lack of standardized ways to assess these concepts is an important limitation to the development of consensus in the literature.
In this study, we found that over the long-term, there is usually a group of people representing around 5% of the population that displays significantly lower adherence to sanitary measures. This low adherence group distinguishes itself by its lower level of understanding and to a lesser extent its use of unreliable sources. Although the COVID-19 pandemic is coming to its end, similar global health crises may still arise in the future. This study highlights the importance of clear and coherent communication on the part of governments to allow a good level of understanding of the population when faced with new and sometimes complex guidelines. In the near future, it would be interesting to explore the temporal dynamics that exist between predictive factors and sanitary measures, as some factors may change over time and their effect on adherence may also vary. Understanding the effect of this evolution on adherence would inform public policy that could be generalized to other health crises.