Personal preventive protocols and travel patterns during the COVID-19 pandemic

Introduction

With its rapid spreading, and high morbidity and mortality, COVID-19 has caused profound concern worldwide [1, 2]. Consequently, the World Health Organization (WHO) described this disease as a public health emergency of international concern [3, 4]. By July 7, 2022, nearly 558 million people were infected with the virus, and more than 6.3 million deaths occurred due to this disease worldwide [5].

The lack of effective treatment has led to the fact that the key strategy to control the disease and stop its rapid spread, along with vaccination, was to prevent transmission of the virus by following preventive protocols such as maintaining physical distance, avoiding crowds, wearing masks, washing hands and ventilating rooms [6-8]. Furthermore, most countries adopted relevant laws and regulations to reduce virus transmission including the closure of public places (universities, schools, and restaurants), distance education, reduced office hours, remote working, travel restrictions, etc. [9]. Since announcing the first coronavirus cases in the nation, Iran has struggled to contain the epidemic condition [10, 11]. At the beginning of the epidemic, protective behavior and non-pharmaceutical interventions were the best ways to prevent infection and stop the disease’s spread, because there was no effective treatment or vaccine for this infection [12]. Although, like most countries in the world, Iran has experienced multiple peaks of coronavirus infections during the COVID-19 epidemic, vaccination in Iran began in August 2021 and was on a small scale [13]. Therefore, non-pharmaceutical interventions were the best choice to contain the infection, especially before the vaccine was available. Meanwhile, in Western countries, the timing for starting vaccination of people on a large scale was generally earlier [13].

In the face of a global pandemic, travel restrictions have become a common strategy employed by governments worldwide to curb the spread of the virus. Travel restriction measures refer to various strategies and policies implemented by governments and organizations to limit or control the movement of people during the COVID-19 epidemic [7, 14]. These measures aim to reduce the spread of the virus by minimizing the potential for transmission across borders and within communities. The results of some studies showed that Implementing travel restrictions significantly reduced the number of trips and human mobility [15, 16]. While these measures aimed to limit the mobility of potentially infected individuals, it is crucial to recognize that travel restrictions alone may not completely hinder the spread of the virus. The COVID-19 changed travel preferences of people towards keeping oneself healthy. As people sought to avoid crowded areas, thereby reducing the risk of exposure to the virus, there has been a rise in interest in remote and isolated destinations. Some conducted surveys showed that responders preferred to choose natural and desolated places for their recreational trips [17]. Travelers must prioritize their health and safety during the pandemic. This includes following hygiene practices such as wearing masks, practicing social distancing, and frequently washing hands. Additionally, it is essential to be aware of, and comply with, local health guidelines and regulations in the travel area [18, 19]. Nevertheless, despite the established guidelines and recommendations, noncompliance with personal protective measures remains a persistent challenge. The findings of some studies showed that noncompliance with personal protective measures was high, especially in some population groups (including males, individuals with higher education, and people with higher socioeconomic status (SES) [20].

To develop effective disease management programs and develop policies to improve compliance with health protocols in places such as airports, railway stations, passenger terminals, recreational complexes, restaurants, gas stations, hotels, and inside transport vehicles such as airplanes, trains and buses, it is important to indicate the extent to which these protocols are followed in these places. This can effectively determine which areas should receive interventions and how. Therefore, our study aimed to measure and evaluate compliance with COVID-19 prevention protocols during travel using a validated tool, so that reliable information can be provided for programming and policy development.

Material and Methods

Questionnaire

This cross-sectional study was conducted in six provinces of Iran including Ardabil, East Azerbaijan, West Azerbaijan, Sistan and Baluchistan, Kerman, and Fars. The map of Iran highlighting the studied Provinces is shown in Figure 1.

Figure 1. The map of Iran and studied provinces.

A validated travel behavior questionnaire was employed to assess compliance with health protocols during the COVID-19 pandemic [21]. The questionnaire has been developed by our research team. The final version of the questionnaire included 10 items scored on a Likert scale (Suppl. 1 and 2) and was validated using 285 samples from capital cities of six provinces including Fars, Kerman, East Azerbaijan, West Azerbaijan, Ardabil, and Sistan and Baluchistan. The content validity ratio (CVR) and Item-level content validity index (I-CVI) were acceptable for all 11 items. The mean CVI for the entire scale S-CVImean (i.e., the mean of all I-CVIs) was equal to 0.977; and scale-level CVI based on the universal agreement method (S-CVI/UA) was 0.9. Also, the Cronbach’s alpha was 0.81 [21].

The questionnaire consists of two sections: demographic and behavioral. The behavioral section comprises two parts: individual behavior and behavior of other people. The section on individual behavior measures the person’s own travel behaviors during the COVID-19 pandemic and includes 6 questions scored on a Likert scale. The section on the behavior of other people measures travel behavior of others during the COVID-19 pandemic and includes 10 questions, four of which are scored on a Likert scale. In total, the questionnaire contains 10 questions on a Likert scale out of 16.

Sampling and data collection

A total of 589 individuals representing capital cities of six provinces were included in the study. They were selected using the cluster sampling method. Two to 10 clusters in each capital city (40 clusters in total) and 16 individuals in each cluster accounted for a total of 640 randomly selected individuals.

Two educated interviewers in each province conducted the questioning during two months. The population of the surveyed area was approximately 5.5 million people.

At the time of the study (May and June 2021), Iran experienced the fourth wave of the epidemic with nearly 300 daily deaths, on average. Most of the cities were on the red (very dangerous) or orange (dangerous) positions. The public vaccination had recently been initiated and a very low percentage of people had been vaccinated with two doses. Most cities were in the red (very dangerous) or orange (dangerous) positions. Vaccination of the population has recently begun, and a very small proportion of people have received two doses of the vaccine.

Ethical approval and consent to participate

This study was registered by the Ethics Committee of the National Institute for Medical Research Development with the approval ID of IR.NIMAD.REC.1399.120. Throughout the entire study process, our actions complied with the Declaration of Helsinki. Before que they were assured that the information obtained would remain confidential and would be used solely for research purposes.

Data analysis

For the analysis, the mean value of responses of each individual was calculated separately for every section (Individual Behavior and Behavior of Others). Therefore, two new variables were obtained and their correlation with contextual variables were investigated. The correlation of these new variables with categorical contextual variables was examined using Mann-Whitney and Kruskal-Wallis tests, depending on the variable type. To examine the correlation between these new variables and continuous variables, the Spearman’s correlation coefficient was employed. Normal distribution of continuous variables was assessed using the Kolmogorov-Smirnov test. Multivariate analysis was conducted via multiple linear regression. The variables that were statistically significant in the univariate analysis at the level of P<0.1 were included into the ordinal regression model. Hence, we computed the behavioral index by categorizing responses in three groups including never or rarely (score range of 1 to 2), occasionally (scores of 2.1 to 3), and often or always (scores ranging 3.1 to 5). The data were processed using SPSS 16 and STATA 14.

Results

A total of 589 individuals from six provinces participated in the study. The response rate was 92% (589/640). Of all participants, 309 (52.5%) were women. The largest number of participants (142) was from East Azerbaijan province (24.1%), while the fewest participants (28) were from Sistan and Baluchistan (4.8%). The mean age of participants was 42.84 years (SD=16.59) with a minimum of 16 years and a maximum of 89 years. Of all participants, 355 people (60.3%) had a travel history during the COVID-19 pandemic, while 234 individuals (39.7%) had no travel history. The demographic characteristics of participants are presented in Table 1. According to the distribution of the study population based on socioeconomic status, it was shown that the highest percent belonged to the high level (Figure 2). The distribution of travel purposes findings determined that recreational travel has the highest percentage of travel among the study population (Figure 3). The findings showed that more than 34 percent of the study population stated that they “rarely” or “never” follow the health protocols (Figure 4).

Table 1. Demographic characteristics of study participants

Figure 2. Distribution of study population based on socioeconomic status.

Figure 3. Percentage distribution of travel purposes among the study population.

Figure 4. Percentage distribution of compliance with health protocols by the study population.

The t-test was used to compare the mean age of participants based on their travel history. The results of this analysis showed that the mean age of people with a traveling history was 40.64 years while for those without traveling history, it was 46.41 years. This difference was statistically significant (P<0.001). Also, the results of the ANOVA test showed that people with more education traveled more than people with less education (P<0.001). The chi-squared test confirmed that the difference in traveling history between provinces was significant as well (P<0.001). Also, the χ² test showed that the share of people with no traveling history in East Azerbaijan was 74.6%, while in Sistan and Baluchistan it was 17.9%. Thу numbers for West Azerbaijan, Fars, Ardabil, and Kerman were 43.5%, 32.6%, 26.1%, and 22.4%, respectively. У detected no significant difference between traveling history and SES, gender, or occupation subgroups (P>0.05).

Among the people who reported traveling history, 34.6% undertook a journey lasting for four days or more, 68.3% traveled by private car, and 12.4% by plane. Most travelers had recreational purposes (38.5%), while only 2.8% traveled for business. The cumulative number of travelers with the job, educational, business, and medical treatment purposes made up just 28.9% of the participants, and 39.7% of travelers stayed at the homes of their relatives and acquaintances during the trip. The results of the participants’ travel details are summarized in Table 2.

Table 2. Travel details of study participants

The results of the descriptive analysis of questionnaire items are shown in Table 3.

Table 3. Frequency and percent of options of each question

The mean value of participants’ responses was calculated for each section (Individual Behavior and Behavior of Others), and two new variables were created as a representative of the questions in that section, and their correlation with contextual variables was assessed. The results of t-test to compare the means of behavioral sections showed that, the mean (SD) for the individual behavior section was 3.39 (0.86), and for the behavior of others section it was 1.61 (1.05) (ranging 1-5); the difference was statistically significant (P<0.001).

Based on the ordinal regression, significant relationships were observed for variables of gender, education, and provinces (p<0.05) (Table 4).

Table 4. Results of ordinal regression to determine effective factors of behavior in the studied population

Discussion

This study was conducted to measure and evaluate the level of compliance with health protocols for the prevention of COVID-19 during travel using a valid and reliable tool. Given that the sample was randomly selected, the results of the study can be generalized to the entire population of the country.

Of all participants, 355 (60.3%) had a travel history during the COVID-19 pandemic, and only 234 (39.7%) had no travel history. Despite ongoing educational measures on how to prevent diseases using several means, especially avoiding unnecessary travel, it seems that this percentage of travel history (60.3%) is much higher than expected during the COVID-19 epidemic. This is at a time when the country has imposed various travel restrictions, and even during the waves of the disease, these restrictions were strict and there were large financial penalties. Since many establishments and activities such as schools, universities, sports competitions, congresses, etc. were closed or canceled, working from home replaced physical presence, and meetings and classes were held online, it was expected that the number of necessary work-related and educational trips would be much smaller.

A high percentage of participants (65.7%) reported that the purpose of their trip was leisure and family gatherings. This shows that people did not follow the avoidance of unnecessary travel as one of the most important prevention protocols very well. In a study by Horváth and Lopatny, which aimed to examine tourism safety, including health safety, during the COVID-19 pandemic in Hungary, 69.3% of respondents indicated their travel motivation as recreational trips. In addition, 19.2% of them mentioned visiting relatives and friends as their travel motivation. Only 4.7% of participants indicated that their travel motivation was business or education [22]. A study by Abu-Rayash and Dincer, which was conducted in different cities in several countries, showed that population mobility and the number of trips in all the cities studied decreased sharply due to the COVID-19 pandemic [23].

In the current study, travel history varied significantly across the studied provinces. The highest share of the population (79.6%) in East Azerbaijan and the lowest proportion (17.9%) in Sistan and Baluchistan had no travel history during the COVID-19 pandemic. One of the reasons may be the difference in the numbery and quality of COVID-19-related trainings in local media. It is likely that the more effective and better the training on COVID-19 prevention protocols, the higher the compliance with the protocols.

A significant association was found between travel history and the age of the participants. The mean age of people with a travel history was approximately six years younger than people without travel history. This means that young people traveled more during this period and followed the travel avoidance protocol less than older adults. Similar results were found in another study confirming that older people were more health conscious when traveling than younger people [22].

We found a significant direct association between travel history and education, such that people with higher education levels traveled more during the COVID-19 pandemic. In contrast, another study showed that people with higher education were more health conscious when traveling [22]. We observed no significant associations of travel history with SES levels or different jobs. This shows that adherence to the protocol of avoiding unnecessary travel was similar among different SES groups.

 In our study, 68.3% of people who had a travel history used a private car. Similarly, a study by Torrisi et al. in Italy showed that most people preferred to travel by private car during the COVID-19 pandemic [24]. In a study in Chicago, USA, 86% of people said that traveling by private car was a low-risk or very low-risk way to travel [25]. In our study, a total of 87.6% used land transportation, while 12.4% traveled by aircraft. In the pre-COVID-19 era, 92% of transportation flows in Iran were by land and only 8% by air; hence, the use of airplanes increased from 8% to 12.4% during the COVID-19 pandemic. This may be due to concerns about staying on trains and buses with high passenger density for a long time, which would increase the chance of contact with others and disease transmission. A study conducted in Seoul, South Korea, showed that travel behavior has changed due to COVID-19: public transportation users switched to private car mode [26].

Regarding the place of accommodation while traveling, the study results showed that approximately 40% of travelers stayed at the homes of relatives and friends. This situation may lead to an increased chance of contact and disease transmission. Other studies have shown that the fear of COVID-19 transmission greatly affected the reduction in hotel occupancy rates [27]. In addition, travel has become one of the main factors in the spread of COVID-19 worldwide [28, 29].

The mean scores for the questions on individual behavior and the behavior of others were 3.39 and 1.61, respectively. Both of these scores ranged from 1 to 5, and the observed difference was statistically significant. This means that the participants stated that their compliance with the protocols was better than compliance of others. It is likely that the respondents did not answer the questions related to themselves quite honestly, and there may be a prestige bias; hence, they could easily overestimate their behavior regarding the compliance with health protocols while traveling. We therefore think that the results of others’ behavior regarding the compliance with health protocols are closer to reality.

One of the limitations of our research is related to the possibility of social desirability bias, which may have occurred in our study.

Conclusion

The results of the study showed that during the COVID-19 pandemic in Iran, unnecessary travel was not avoided. Although travel restrictions and compliance with health protocols during travel were among the major strategies to control COVID-19, most study participants who traveled during the COVID-19 pandemic did not comply with the relevant protocols. Therefore, we need to consider some important issues such as cultural factors, varying levels of risk tolerance among the human population, law enforcement measures, and more serious monitoring by policymakers.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study has been registered by the Ethics Committee of the National Institute for Medical Research Development with the following approval ID: IR.NIMAD.REC.1399.120. Before questioning, the objectives of the study were clarified to the participants, verbal consent was obtained from all participants, and they were assured that the information obtained would remain confidential with the research team and would be used exclusively for research purposes.

Acknowledgments

The authors express their sincere gratitude to the National Institute for Medical Research Development for funding this project.

Conflict of interest

The authors declare that they have no competing interests.

Funding

This study was funded by the National Institute for Medical Research Development (grant number: IR.NIMAD.REC.1399.120).

Supplement 1. English version of travel questionnaire

Supplement 2.

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