Three themes emerged related to how the participants perceived and acted on health risk information related to COVID-19: virus transmission, exposure to risk and consequences of COVID-19 (Table 3). Quotes are displayed in Additional file 2.
Table 3 Themes and sub-themes
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Virus transmission
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Exposure to risk
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Consequences of COVID-19
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Comprehending modes of virus transmission
Understanding words differently
Acting on the uncertain evidence
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Affecting exposure to risk
Being driven by values
Learning about mitigation in different ways
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Imposing new models for a novel virus
Building situational awareness
Perceiving personal health consequences differently
Emphasising secondary consequences.
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Virus transmission
The first theme, virus transmission, was further divided into three sub-themes: comprehending modes of virus transmission, understanding words differently and acting on the uncertain evidence.
Comprehending modes of virus transmission
Many of the participants reported uncertainty regarding the information from the government about modes of virus transmission. The participants had high trust in the government’s advice related to virus transmission and believed in the national measures to be based on expert advice. However, some felt they lacked knowledge regarding virus transmission, and some felt confused due to the mixed health risk information received from the government.
Given the existing evidence for transmission at the time of data collection, NIPH singled out droplet transmission as the most important mode of transmission and communicated that airborne transmission and contact transmission existed but were non-significant ways of transmission. However, in the interview data, we found five different mental models of how the coronavirus transmitted, two of which did not even contain droplets. The participants described transmission in ways that could be categorised as either a) mainly droplet transmission or b) mainly through air (aerosol) transmission, c) a combination of droplet and contact transmission d) a combination of airborne and contact transmission, or e) a combination of droplet/air/contact transmission (Figure 2).
The participants expressed uncertainty related to what happened in the “airspace” with respect to the time the virus survived in the air and the distance it travelled. Few of the participants described that the distance the virus or the aerosols travelled through the air depended on dynamic conditions such as wind, ventilation, and normal breath versus sneezing. Some of the participants believed the risk of being exposed to the coronavirus depended on static and categorical measures, such as talking to someone within a one-metre distance for more than 15 minutes, while 10 minutes conversations was considered safe.
Furthermore, many of the participants expressed uncertainty related to how long the coronavirus could survive on different surfaces, such as metal, clothes, and food.
Pre-symptomatic and asymptomatic transmission were acknowledged by some of the participants. Some of the participants noted that it took some time to develop visible symptoms of COVID-19 (pre-symptomatic transmission), and some of the participants described virus transmission from people without symptoms (asymptomatic transmission). This knowledge was important for their understanding of why they had to keep distance even from their family members and why people had to quarantine. However, the participant did not necessarily receive this information from the government but rather from friends.
Understanding words differently
The words used by the NIPH to describe droplet, airborne and contact transmission were not used in everyday language by most of the participants when explaining virus transmission, who rather emphasised the behaviours transmission occurred, e.g., spitting, hugging, kissing, touching, talking. Half of the participants did not use either of the terms “droplet transmission”, “airborne transmission” or “contact transmission”. The participants also often understood the terms differently from the formal NIPH definitions. Some of the participants understood droplet transmission as saliva transmitted through physical contact with another person by kissing or touching but did not include droplets emitted from the diseased person’s mucous membranes. Furthermore, the participants’ separation between droplet and airborne transmission was not conceptually clear. Both droplet transmission and airborne transmission were described as droplets or aerosols travelling through the air, which led to conceptual confusion.
Droplet transmission was mainly described as transmission to people in close proximity through coughing, sneezing, talking or physical contact with other people. Although the NIPH additionally included hugging and kissing in their definition of (direct) contact transmission at the time of data collection, these behaviours were not associated with the term “contact transmission” by any of the participants but rather with the term “droplet transmission”. Contact transmission was mainly described as the transmission of droplets from the infected person to surfaces (e.g., shared public contact points) and then again from the hand to the mouth of another person.
Acting on the uncertain evidence
The participants acted on the uncertain evidence of virus transmission differently. For some of the elderly participants, the idea of airborne transmission and the possible severity of COVID-19 caused fear and isolation. One elderly woman described that early in the pandemic crisis, she had observed the size of the cloud of a person’s breath outdoors in the cold winter air and had thought that if there were any virus-containing droplets in that cloud, one metre of distance was too short. She had work experience from a surgical theatre and observed that people occasionally did not keep enough distance, did not wash their hands properly, and used face masks incorrectly. She had isolated herself for a year in her home due to a fear of death and the dreaded health consequences of COVID-19 and to prevent her elderly husband from being infected.
Through the government and health authorities’ risk communication, the participants had learned the importance of keeping distance and washing their hands; however, they mainly learned about virus transmission from non-governmental and informal sources.
While most of the participants acted on generic advice, such as keeping distance, washing their hands, and avoiding touching public surfaces, some described that they acted on information related to virus transmission gained through non-governmental media channels, despite acknowledging its uncertainty. One man avoided touching metal surfaces; a woman started disinfecting her mobile phone after watching a YouTube video that visualised contact transmission. A 79-year-old woman described washing her groceries and her clothes to avoid transmission of the virus after reading a news article about three-day virus survival.
Exposure to risk
The second theme, exposure to risk, was further divided into three sub-themes: affecting exposure to risk, being driven by values and learning about mitigation in different ways.
Affecting exposure to risk
All of the participants emphasised that being physically close to others increased the risk for exposure to the coronavirus. The participants variably emphasised that the risk for exposure could be affected by one’s culture (e.g., by participating in religious societies or regularly visiting pubs and cafés), hygiene knowledge or cognitive deficits (e.g., not understanding the severity of the risk, being a child or having dementia), attitudes (e.g., not caring about the risks for others and themselves), occupation (e.g., healthcare workers or bus drivers), activities (e.g., participating in parties, alcohol consumption, the use of buses) and geographical factors (i.e., population density or cities with overcrowded housing). Environmental factors were also emphasised by some of the participants as vital to prevent the spread of the virus (i.e., indoor/outdoor, large rooms, ventilation, climate). For example, a farmer explained that environmental factors prevented the spread of the virus in the agricultural context due to large buildings and ventilation.
All of the participants emphasised that they reduced their exposure to risk by keeping distance from other people and washing their hands/using anti-bacterial gel. In different ways, many participants explained how they made their own risk assessments for exposure to risk for being infected with the coronavirus. Some of the participants emphasised that receiving more information about risk activities and real-life information about infection locations, whether the activity was considered high risk, whether the outbreak was confined to a specific social environment, and whether it was under control could help them make better decisions in their daily lives.
One man aged 49 explained that receiving such information was important to be able to make his own risk assessment to make safe decisions in his daily life without necessarily locking down his personal life. He believed that the pandemic gives us waves on the sea all the way, we have to learn to navigate on the waves, emphasising the adaptation to a new normal. He felt that he had not been provided with such information by the local authorities due to privacy considerations that had been made for people who were infected.
Being driven by values
Simply understanding the importance of social distancing and hand washing was not always considered sufficient for the participants to protect themselves from the virus. Their daily decision making to reduce exposure to risk was in some conditions driven by personal values rather than a lack of knowledge. In the long term of the pandemic, some of the participants perceived that they specifically struggled to socially distance from friends and from family relatives. Some of the participants described making trade-offs between competing goals and values, i.e., reducing exposure to the virus and seeing their friends and family. A woman described that she regularly had her grandchildren over for visit, even if they had cold symptoms. She understood she exposed herself to risk, but she valued being physically close to them because those early years of childhood were of high importance for their relationships. She was afraid they would grow up not knowing her and not knowing how to hug another human being.
On other occasions, the participants’ mitigation behaviour was driven by symbolic values. The use of face masks and anti-bacterial gel in food stores were perceived as symbols of trust, i.e., ways to show others that they followed the mitigation rules, as well as symbols of distrust, as some people protected themselves due to a lack of trust in others complying with the infection control measures.
Learning about COVID-19 mitigation in different ways
Health risk information related to COVID-19 was sometimes perceived as confusing, complicated, rapidly changing, and variably practised across regions. Some of the participants expressed their frustrations regarding the political debate about pandemic management. Nevertheless, the participants acknowledged the complexity and uncertainty related to pandemic management and expressed an overall high level of trust in the government and the health authorities’ (NIPH) risk communication, as they were believed to provide them with the best foundation for decisions for COVID-19 mitigation.
The participants expressed the need to comprehend the what, why and how of COVID-19 mitigation and expressed various ways of learning about this topic. They did, however, emphasise the what, why and how differently.
Most of the participants emphasised obtaining clear messages on the core rules or advice on what to do, from explanations using familiar words and facts. The core messages were to maintain social distance, to wash hands, and to use a face mask when not able to keep a distance. They experienced that the government and the NIPH managed to communicate these core messages successfully through mass media (e.g., press conferences, NIPH webpage).
Many of the participants further emphasised the importance of comprehending the why, the reasons behind the national and local restrictions and advice (e.g., why isolate, why vaccinate, why quarantine, why not wear a face mask, why one-metre distance and not two, why one activity is allowed and not another), as well as the effect of some of these measures, such as the effect of using facemask and getting the vaccine. Comprehending the reasons behind the restrictions and advice was emphasised as important to accept them and act on them, especially for restrictions and advice that changed over time. Although many of the participants perceived that the government and the NIPH managed to explain the reason for the advice and the restrictions. Some of the participants sought informal sources such as specific journalists, Snapchat, or YouTube videos where complex science information was translated into reasonable, actionable and clear messages. Others sought primary sources and scientific evidence verified by multiple sources (e.g., scientific articles, WHO and NIPH webpages) because they endeavoured to understand the foundational evidence for the decisions made by the government and thereby to comprehend the reason for the government’s restrictions and mitigation advice.
Some of the participants felt overloaded with information related to restrictions, and they were not able to remain updated, focusing on the information that was relevant for their daily lives or work situations, and expressed a need for practical yet correct information on how to implement the mitigation measures (e.g., how to keep distance on a bus, when to quarantine, how to interpret travel rules). Those participants emphasised a need for having easily accessible, updated online information available to comprehend the messages correctly, as well as having someone to communicate with to interpret how to act on the restrictions in their context. For example, one participant emphasised the importance of communicating with the workers’ organisation for farmers for their interpretation of the mitigation restrictions in the agricultural context.
Variability was found in the perception of video as a medium for learning about COVID-19. Videos were perceived as easy to learn from, memorable, and effectively speaking to emotions, but also as untrustworthy and presenting too simplistic information (mainly in the employed/recently laid off and retired groups).
Consequences of COVID-19
The third theme consequences of COVID-19 was further divided into four sub-themes: Needing new mental models for a novel virus, building situational awareness, perceiving personal health consequences differently and emphasising secondary consequences.
Needing new mental models for a novel virus
Establishing an early understanding that “this is not a seasonal flu” was mentioned as important by some participants to understand the severity of the risk. All of the participants believed that COVID-19 had more severe health consequences than a seasonal flu. The coronavirus was perceived as causing more deaths and serious illness for those at high risk and even for healthy individuals and as causing more severe long-term health consequences than the seasonal flu. Some of the participants also mentioned that lack of immunity, the potential for anyone to become severely sick, the lack of a vaccine and the global spread of the virus were reasons that made COVID-19 more severe than the seasonal flu.
Half of the participants believed the coronavirus was more contagious than a seasonal flu, while some of the participants believed its contagiousness was comparable to that of a seasonal flu, and still some felt they were unable to compare the coronavirus to a seasonal flu due to a lack of generic knowledge about viruses and their contagiousness. Many of the participants experienced high uncertainty related to the contagiousness of the British variant virus. They needed new mental models to understand this novel virus, and creating these was an ongoing process. Their beliefs were adjusted by the information they received from the government, health authorities and multiple other sources of information.
Building situational awareness
Understanding the consequences of COVID-19 was important for building situational awareness of the severity of the crisis and creating motivation to respond. The participants differently emphasised consequences for the individual or consequences for society as vital to their situational awareness.
Several of the participants perceived that the main danger of the virus was overload on the healthcare system and loss of control, and they described catastrophic scenarios from other countries. Half of the participants expressed that the basic reproduction number (R-value), which was repeatedly communicated in the media, helped them build situational awareness related to the risk of losing control of the outbreaks; however, they experienced a lack of knowledge for comprehending the full meaning of the R-value. Some misunderstood the term as a correlation coefficient or a number of people reinfected with COVID-19. The term “exponential growth” was perceived as a complex concept to comprehend and participants emphasised that communications about the rapidly growing spread of the virus and its consequences were more important than using the actual scientific term “exponential growth”.
Protecting the elderly and those individuals with underlying diseases were the participants’ main motivations for acting on infection mitigation measures. Everyone had a person in his or her family who was at high risk of becoming severely ill or dying due to COVID-19. The variable courses of illness, from asymptomatic to suffocation and death, even for healthy individuals, made some of the participants perceive the risk as severe for all age groups. One elderly woman was afraid that the entire population of sick and elderly people would be eliminated by the virus, and she isolated herself in her house as a result of this belief.
Situational awareness was vital for the motivation to act on mitigation rules, both in the response and in the long-term phase of the pandemic. However, many struggled to keep a sustained focus after living almost a year with mitigation measures. They struggled to keep up with the constant changes in local and national restrictions, felt disengaged when watching the same type of press conferences with the same spokespersons talking about infection numbers in front of the same backgrounds and felt fatigued by listening to the same messages that described maintaining social distance and using face masks. Many emphasised that the government needed to create awareness that the pandemic could last for a long time, and they needed emphatic messages from the government acknowledging citizens’ efforts and motivating them to sustain their motivation until the population has been vaccinated.
Perceiving personal health consequences differently
The participants’ need for information about individual health consequences and the disease varied. Some of the participants emphasised that they needed to understand their personal health risk better and wanted to know more about the disease and the long-term health consequences. For example, a 79-year-old woman described that she needed information about what happened if she was admitted to the hospital and what she could do to feel safe if she contracted COVID-19. She was afraid that she would not be able to cope with isolation, being alone and not being able to breathe, if she became infected with the virus.
On the other hand, some of the participants did not want information about the disease and health consequences because they believed that this information could cause panic and excessive worry for them as individuals. The variability in the need for information about the consequences of COVID-19 was illustrated by two participants who both described their reactions to the same documentary on elderly people hospitalised with COVID-19 (36). While watching the documentary had made one of the participants (woman, 65 years) so afraid that she had completely isolated herself in her home, it had helped another other person (male, 27 years) become more aware, rather than panicked of the consequences contracting the virus could have for the elderly people in his family.
Emphasising secondary consequences
The participants emphasised a broad spectrum of secondary consequences of COVID-19 mitigation strategies when discussing the major risks imposed by COVID-19. They worried about personal and global economic consequences due to the loss of income and jobs and the consequences for people’s social lives and mental health, especially for children, elderly people, and students. Many struggled with loneliness, isolation, and a loss of freedom, and they felt tired of living under strict infection control measures. They reported feeling that the government had communicated different narratives appealing to collective responsibility for protecting vulnerable individuals and groups at risk and to avoid the collapse of the healthcare system. At this stage, after nearly one year of mitigating the virus, participants needed acknowledgement of their efforts, messages to help create hope, narratives to help create mental visualisations of an end to the crisis, or realistic messages that they had to sustain their social distancing and lockdowns in society for a long time. A sense of control was needed to adapt to the situation and alleviate concerns about the secondary consequences of the pandemic.