Abstract

This study aimed to evaluate the behavioral aspects and beliefs of the population of Ceará in the face of the COVID-19 pandemic. An online questionnaire was conducted on sociodemographic aspects and opinions related to the pandemic. Absolute and relative frequencies were calculated, the association between variables was performed with Chi-square, and the level of significance was 5%. The final sample had 2,259 participants, and an association was observed between females and perceiving themselves with a high risk of infection (p = 0.044) and males with non-performance of voluntary quarantine (p < 0.001). People aged 80 years and over were partially quarantined due to the flow of people at home (p < 0.001). Participants with elementary school education had a lower risk of infection than participants with a higher level of education (p < 0.001). This group includes people who did voluntary quarantine the least (p < 0.001). Participants living in the inland region of the state had less direct contact with someone tested positive for the Coronavirus (p = 0.031) and are less reclusive (p < 0.001). We can conclude that the approach to the COVID-19 pandemic varies by social aspects, such as gender, age, education, and place of residence, as well as the belief system of the population of the State of Ceará.

Key words
Pandemics; Coronavirus; Social behavior

Introduction

An outbreak of a new coronavirus disease (COVID-19, caused by Severe Acute Respiratory Syndrome Coronavirus 2-SARS-CoV-2) has been reported in Wuhan, China Since the end of December 2019, and has subsequently affected 26 countries worldwide¹1 Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L, Tai Y, Bai C, Gao T, Song J, Xia P, Dong J, Zhao J, Wang FS. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; 18.pii:S2213-2600(20):30076-X.^,22 Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, Hu Y, Tao ZW, Tian JH, Pei YY, Yuan ML, Zhang YL, Dai FH, Liu Y, Wang QM, Zheng JJ, Xu L, Holmes EC, Zhang YZ. A new coronavirus associated with human respiratory disease in China. Nature 2020; 579(7798):265-269.. In general, COVID-19 is an acute respiratory disease, with a 2% mortality rate²2 Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, Hu Y, Tao ZW, Tian JH, Pei YY, Yuan ML, Zhang YL, Dai FH, Liu Y, Wang QM, Zheng JJ, Xu L, Holmes EC, Zhang YZ. A new coronavirus associated with human respiratory disease in China. Nature 2020; 579(7798):265-269.. The onset of the disease can result in death due to massive alveolar damage and progressive respiratory failure¹1 Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L, Tai Y, Bai C, Gao T, Song J, Xia P, Dong J, Zhao J, Wang FS. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; 18.pii:S2213-2600(20):30076-X.

2 Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, Hu Y, Tao ZW, Tian JH, Pei YY, Yuan ML, Zhang YL, Dai FH, Liu Y, Wang QM, Zheng JJ, Xu L, Holmes EC, Zhang YZ. A new coronavirus associated with human respiratory disease in China. Nature 2020; 579(7798):265-269.^-33 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 95(10223):497-506..

COVID-19 arrived in Latin America on February 25, 2020, when the Brazilian Ministry of Health confirmed the first case of the disease, a 61-year-old Brazilian man who traveled from February 9 to 20, 2020 to Lombardy, northern Italy, where a significant outbreak is occurring⁴4 Rodriguez-Morales AJ, Gallego V, Escalera-Antezana JP, Méndez CA, Zambrano LI, Franco-Paredes C, Suárez JA, Rodriguez-Enciso HD, Balbin-Ramon GJ, Savio-Larriera E, Risquez A, Cimerman S. COVID-19 in Latin America: The implications of the first confirmed case in Brazil. Travel Med Infect Dis 2020; 29:101613.. Until March 26, 2020, Brazil had 2,915 confirmed cases of COVID-19 and 77 deaths, according to official data from the Ministry of Health⁵5 Brasil. Ministério da Saúde (MS). Ministério da Saúde declara transmissão comunitária nacional. Brasília: MS; 2020. [acessado 2020 Mar 22]. Disponível em: https://www.saude.gov.br/noticias/agencia-saude/ 46568-ministerio-da-saude-declara-transmissao-comunitaria-nacional
https://www.saude.gov.br/noticias/agenci... . Meanwhile, the number of cases and deaths in the world hiked, reaching 526,006 infected people, with 23,720 deaths⁶6 Worldometer. Real time world statistics. [acessado 2020 Mar 22]. Disponível em: https://www.worldometers.info/coronavirus/
https://www.worldometers.info/coronaviru... .

Through a state decree effective from March 20, 2020⁷7 Governo do Estado do Ceará. Decreto nº 33.519, de 19 de março de 2020. Intensifica as medidas para enfrentamento da infecção humana pelo novo coronavírus. Diário Oficial do Estado do Ceará 2020; 19 mar., the Government of the State of Ceará established more robust measures to contain the spread of COVID-19, which, at the time, totaled 20 notified cases, and was the State of the Northeast with the highest number of infected patients, ranking fourth among all Brazilian States⁵5 Brasil. Ministério da Saúde (MS). Ministério da Saúde declara transmissão comunitária nacional. Brasília: MS; 2020. [acessado 2020 Mar 22]. Disponível em: https://www.saude.gov.br/noticias/agencia-saude/ 46568-ministerio-da-saude-declara-transmissao-comunitaria-nacional
https://www.saude.gov.br/noticias/agenci... . On March 26, 2020, the Covid-19 positive cases rose to 235 people, with three deaths, and the State climb to the third spot in the country⁵5 Brasil. Ministério da Saúde (MS). Ministério da Saúde declara transmissão comunitária nacional. Brasília: MS; 2020. [acessado 2020 Mar 22]. Disponível em: https://www.saude.gov.br/noticias/agencia-saude/ 46568-ministerio-da-saude-declara-transmissao-comunitaria-nacional
https://www.saude.gov.br/noticias/agenci... . COVID-19’s high dissemination rate has aroused the curiosity of the scientific community, given that one of the most critical factors in assessing the threat of an infectious disease epidemic is the pathogenic transmissibility⁸8 Lodge EK, Schatz AM, Drake JM. Protective Population Behavior Change in Outbreaks of Emerging Infectious Disease. bioRxiv 2020; 01.27.921536..

Many factors can affect the speed with which effective disease control practices are implemented, such as information campaigns, local health practices, social behavior, and belief systems⁹9 Freimuth V, Linnan HW, Potter P. Communicating the threat of emerging infections to the public. Emerg Infect Dis 2000; 6(4):337-347.^,1010 Feigenbaum JJ, Muller C, Wrigley-Field E. Regional and Racial Inequality in Infectious Disease Mortality in U.S. Cities, 1900-1948. Demography 2019; 56(4):1371-1388.. Person-to-person transmission occurs mainly by direct contact or by droplets spread by the cough or sneeze of an infected individual¹¹11 Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun 2020; 26:102433.. Thus, the fight against the spread of COVID-19 recommends washing hands frequently, avoiding hugs, kisses, and handshakes and adopting social distancing measures, such as quarantine¹²12 Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19):The epidemic and the challenges. Int J Antimicrob Agents 2020; 55(3):105924..

Although Ceará is regularly affected by endemic diseases such as Dengue¹³13 Vasconcelos PFC, Lima JWO, Rosa APAT, Timbó MJ, Rosa EST, Lima HR, Rodrigues SG, Rosa JFST. Epidemia de dengue em Fortaleza, Ceará: inquérito soro-epidemiológico aleatório. Rev Saude Publica 1998, 32(5):447-454.^,1414 Oliveira RMAB, Araújo FMC, Cavalcanti LPG. Aspectos entomológicos e epidemiológicos das epidemias de dengue em Fortaleza, Ceará, 2001-2012. Epidemiol Serv Saúde 2018; 27(1):e201704414., Chikungunya¹⁵15 Campos RKGG, Vieira RC, Maniva SJFC, Morais ICO. Manejo clínico da suspeita de febre de chikungunya: conhecimento de profissionais de saúde da atenção básica. Rev Fun Care Online 2020; 12(1):236-241., and Zika¹⁶16 Duarte NFH, Alencar CH, Cavalcante KKS, Correia FGS, Romijn PC, Araujo DB, Favoretto SR, Heukelbach J. Increased detection of rabies virus in bats in Ceará State (Northeast Brazil) after implementation of a passive surveillance programme. Zoonoses Public Health 2020; 67(2):186-192., as well as historical reports of epidemics¹⁷17 Reis NRB. Rodolfo Teófilo e a luta contra a varíola no Ceará, 1905. Hist Cienc Saude-Manguinhos 2001; 8(1):286-289., the characteristics of contagion and dissemination control measures are profoundly different from COVID-19¹1 Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, Liu S, Zhao P, Liu H, Zhu L, Tai Y, Bai C, Gao T, Song J, Xia P, Dong J, Zhao J, Wang FS. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020; 18.pii:S2213-2600(20):30076-X.. Understanding how to delay and control the spread of pathogens is a priority in predicting and preventing epidemics of infectious diseases⁸8 Lodge EK, Schatz AM, Drake JM. Protective Population Behavior Change in Outbreaks of Emerging Infectious Disease. bioRxiv 2020; 01.27.921536.. Thus, this study aimed to assess the behavioral aspects and beliefs of the population of Ceará in the face of the COVID-19 pandemic.

Methods

This cross-sectional study is a type of opinion survey with no identification of the participants, complying with the rules of Resolutions CNS/MS 466/12¹⁸18 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2013; 13 jun. and 510/16¹⁹19 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Resolução nº 510, de 7 de abril de 2016. Diário Oficial da União 2016; 24 maio.^,2020 Guerreiro ICZ. Resolução nº 510 de 7 de abril de 2016 que trata das especificidades éticas das pesquisas nas ciências humanas e sociais e de outras que utilizam metodologias próprias dessas áreas. Cien Saude Colet 2016; 21(8):2619-2629., and was carried out with residents in the State of Ceará, aged 18 or over, who could answer all questions through computers or smartphones. Partially answered questionnaires were excluded from the study.

An online questionnaire was conducted using Google® Forms and social media Instagram@, Facebook@, and WhatsApp@ were publicly used to disseminate the questionnaire. The instrument was available during the 24 hours preceding the governmental order to close all establishments that were not of public benefit and that the population remained quarantined in their homes. Thus, data were collected on March 19, 2020. The need for immediate observation of the population occurred due to possible changes in beliefs arising from the confinement period, as some individuals self-quarantined themselves.

Data collection

The questionnaire was built from closed-ended questions containing sociodemographic aspects and 12 questions dealing with beliefs about the pandemic. The following were investigated: gender (female, male, female transgender, male transgender), age group (18-19 years, 20-39 years; 40-59 years; 60-79 years; 80 years and over), place of residence (Metropolitan Region of Fortaleza-RMF, inland of the State of Ceará), marital status (married, separated/divorced, single, widowed), educational level (complete/incomplete elementary, complete/incomplete high school, complete/incomplete higher education, complete/incomplete postgraduate degree), area of activity (commerce, education, student, unemployed, management/legal/humanities, industry, health, technology, and other areas not mentioned).

The questions asked were as follows: P1- In your opinion, what is the level of your area of activity concerning Coronavirus infection? (high, medium, low); P2- Are you in direct contact with someone who tested positive for coronavirus? (yes, no); P3- Are you quarantined? (No; Partially. Going out sometimes; Partially. Receiving people such as housekeepers, caregivers, and other; reclusive); P4- Concerning the quarantine, you follow the information you receive: (from official governmental bodies; from what I see in the media; from religious leaders; from close health professionals; from friends or relatives; P5- You believe that infection in Brazil: (will be lower than in the rest of the most affected countries, will be similar to the most affected countries, will be higher than in the rest of the most affected countries); P6- You believe that infection in Ceará: (will be lower than in the rest of Brazil, will be similar to the rest of Brazil, will be higher than in the rest of Brazil); P7- You believe that infection in Fortaleza: (will be lower than in other Brazilian capitals, will be similar to other Brazilian capitals, will be higher than in other Brazilian capitals); P8- Do you believe that we have some protection against the virus different from other places? (yes, no); P9- Do you believe that our hot climate will favor the reduction of the pandemic in the State of Ceará? (yes, no); P10- Do you believe that the constant viruses to which we submit will favor the reduction of the pandemic in the State of Ceará? (yes, no); P11- Do you believe that the constant viruses to which we submit will favor a weaker action by the Coronavirus? (yes, no); P12- Do you believe that our most impoverished living in poor sanitary conditions will favor their contamination at what level? (higher than in the high-income population, lower than in the high-income population, all will be equally infected).

Statistical analysis

The data were tabulated in an Excel spreadsheet and analyzed using SPSS software version 24.0®. Absolute and relative frequencies were calculated for all study variables. The association between variables was verified using the Chi-square test. A significance level of 5% was adopted for inferential procedures.

Results

A total of 2,364 people answered the questionnaire. However, following the exclusion of the incomplete questionnaires, the final sample had 2,259 participants. Of these, most were female (68.1%). The single (49%), aged 20-39 years (61.6%), with complete or incomplete higher education (47.3%), working in the health field (29.5%) and residing in the Metropolitan Region of Fortaleza (80.4%) were prevalent.

Regarding the questions asked to the whole group, 61.4% considered that the risk of infection by the coronavirus in their area of operation was high; 98.1% had no direct contact with someone who tested positive for the coronavirus; 52.5% were in partial quarantine, sometimes leaving home; and 65.8% followed information from official government agencies.

Regarding infection with the coronavirus in Brazil, 43.4% believed that it would be similar to the most affected countries in the world. Likewise, they considered as similar the infection of Ceará when compared to other Brazilian states (53.6%) and Fortaleza when compared to other Brazilian capitals (59.9%).

A total of 79.2% of respondents do not believe that we have any protection from the virus, unlike elsewhere. Concerning the local warm climate favoring the reduction of the pandemic, 57.3% do not believe in this protection, nor do they accept the assumption that the constant viruses to which we are submitted will favor the reduction of the pandemic in the State (84.5%), or that such viruses favor a weaker action of the coronavirus (82.4%). As for the most impoverished population living with poor sanitary conditions, 60.5% stated the belief that their infection will be higher than the high-income population.

When the questions asked had their answers compared between males and females, an association was observed between females and perceiving themselves at high risk of infection (p = 0.044) and males with the non-performance of voluntary quarantine (p < 0.001). When compared to men, women do not believe that: we have some protection from the virus different from other places (p = 0.013); our hot climate will favor the decrease of the pandemic in the State of Ceará (p < 0.001), the constant viruses to which we submit will favor the decrease of the pandemic in the State of Ceará (p = 0.014), and also do not believe that the constant viruses to which we are exposed will favor a weaker action of the coronavirus (p < 0.001) (Table 1).

Concerning the answers and their relationship with the age groups proposed in the study, we observed that people aged 80 and over consider that what they do has a medium risk of infection with COVID-19, while the group aged 20-39 years considers it high (p < 0.001). This same group with 80 years and over is the one performing quarantine partially because of the flow of people at home (p < 0.001), and whose information is less concentrated as in all other groups, as they listen a lot to the health professionals with which they have bonds (p = 0.008). These people believe that the pandemic level will be lower in Brazil than in the rest of the most affected countries (p < 0.001), that we are protected against the virus differently from other places (p = 0.002), that the climate of Ceará will favor the decrease of the pandemic in the State (p < 0.001), and that poor sanitary conditions will lead the most impoverished population to a higher level of infection than in the high-income population (p = 0.042) (Table 2).

In the association between the responses to the questionnaire and the level of education, participants with primary education considered that they are at a lower level of risk than participants with a higher level of education (p < 0.001). In this group are people who did voluntary quarantine the least (p < 0.001) and receive information mainly from social media (p < 0.001). Individuals with primary education also believe that the level of infection in Brazil will be lower than in the rest of the countries most affected (p < 0.001), that it will be lower in Ceará than in other states (p < 0.001), and that it will be lower in Fortaleza than in other capitals (p < 0.001). Those with postgraduate degrees consider that they have no protection against the virus, unlike other places (p < 0.001), our climate will not favor the reduction of the pandemic in the State (p < 0.001), the constant viruses that affect us will not favor the decreased pandemic in Ceará (p < 0.001), and will not even favor a weaker action of the coronavirus (p < 0.001). People with elementary education also believe that the health situation of most of the most impoverished populations will entail a lower level of infection by COVID-19 than in the high-income population (Table 3).

Given the association between the responses of the participants with the place of residence, those who live in the inland region of State had less direct contact with someone testing positively for coronavirus (p = 0.031), are less totally reclusive (p < 0.001) and seek social media more to receive information (p = 0.009). They also believe that the infection level will be lower in Ceará than in the rest of the country (p < 0.001), that our climate is a decisive factor against the increase in cases (p = 0.049), and that the constant viruses that occur in the State will favor the decrease of the pandemic (p = 0.033) when compared to those living in the Metropolitan Region of Fortaleza (RMF).

Discussion

Started in the city of Wuhan, in the province of Hubei, located in southeastern China, COVID-19 first patients were diagnosed in November 2019 and spread quickly to the rest of the country²¹21 World Health Organization (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). [acessado 2020 Mar 22]. Disponível em: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf.
https://www.who.int/docs/default-source/... . Soon, countries close to and receiving large numbers of travelers from China, such as Japan and South Korea, showed their first cases. However, the highest spread occurred from east to west, reaching Asian countries and, later, European countries²²22 Zhuang Z, Zhao S, Lin Q, Cao P, Lou Y, Yang L, He D. Preliminary estimation of the novel coronavirus disease (COVID-19) cases in Iran: A modelling analysis based on overseas cases and air travel data. Int J Infect Dis 2020; 11(1):1-9..

The oceanic separation from the American continent further delayed infection, although the United States soon began to notify the presence of COVID-19 given the number of travelers they receive, which was the primary form of infection²³23 American College Health Association (ACHA). Guidelines. Preparing for COVID-19. [acessado 2020 Mar 22]. Disponível em: https://www.acha.org/documents/resources/guidelines/ACHA_Preparing_for_COVID-19_March-3-2020.pdf
https://www.acha.org/documents/resources... . Infection also occurred in Brazil, and the city of São Paulo recorded the first case in Latin America⁴4 Rodriguez-Morales AJ, Gallego V, Escalera-Antezana JP, Méndez CA, Zambrano LI, Franco-Paredes C, Suárez JA, Rodriguez-Enciso HD, Balbin-Ramon GJ, Savio-Larriera E, Risquez A, Cimerman S. COVID-19 in Latin America: The implications of the first confirmed case in Brazil. Travel Med Infect Dis 2020; 29:101613.. As the pandemic spread, it became evident that the necessary containment measures were delayed. In 2009, the influenza A (H1N1) pandemic had already shown the existence of several gaps in the global response capacity to public health emergencies²⁴24 Fineberg HV. Pandemic preparedness and response--lessons from the H1N1 influenza of 2009. N Engl J Med 2014; 370(14):1335-1342.. In the State of Ceará, the capital of which receives the most tourists in Brazil, including many foreigners, the wait for government measures to mitigate COVID-19 infection occurred amid behaviors and beliefs.

Community behavior is one of the crucial factors to avoid a higher number of cases and deaths from viral infections⁸8 Lodge EK, Schatz AM, Drake JM. Protective Population Behavior Change in Outbreaks of Emerging Infectious Disease. bioRxiv 2020; 01.27.921536.^,2525 Lemos DRQ, Neto RJP, Perdigão ACB, Guedes IF, Araújo FMC, Ferreira GE, Oliveira FR, Cavalcanti LPG. Fatores de risco associados à gravidade e óbitos por influenza durante a Pandemia de Influenza A (H1N1) 2009 em região tropical/semi-árida do Brasil. J Health Biol Sci 2015; 3(2):77-85.. South Korea and Japan had already shown a flat curve of disease progression through restrictive measures²⁶26 World Health Organization (WHO). Situation report - 63. Coronavirus disease 2019 (COVID-19). 23 March 2020. [acessado 2020 Mar 22]. Disponível em: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200323-sitrep-63-covid-19.pdf?sfvrsn = d97cb6dd_2
https://www.who.int/docs/default-source/... ^,2727 Day M. Covid-19: Italy confirms 11 deaths as cases spread from north. BMJ 2020; 368:m757.. On the other hand, Iran and Italy delayed taking these measures or had difficulty in controlling the people’s obedience, and started to count many sick or dead people²⁶26 World Health Organization (WHO). Situation report - 63. Coronavirus disease 2019 (COVID-19). 23 March 2020. [acessado 2020 Mar 22]. Disponível em: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200323-sitrep-63-covid-19.pdf?sfvrsn = d97cb6dd_2
https://www.who.int/docs/default-source/... ^,2727 Day M. Covid-19: Italy confirms 11 deaths as cases spread from north. BMJ 2020; 368:m757.. However, behavioral change depends on the context and is difficult to predict due to social characteristics, socioeconomic, and behavioral differences among people⁸8 Lodge EK, Schatz AM, Drake JM. Protective Population Behavior Change in Outbreaks of Emerging Infectious Disease. bioRxiv 2020; 01.27.921536.^,2828 Bauch CT, Galvani AP. Social Factors in Epidemiology. Science 2013; 342(4):47-49.. Unlike European and Asian countries, Brazil has little experience with catastrophes and calamities, with no local culture for preventing these situations. was a body responsible for civil protection created and acting in emergencies and public calamity, the Civil Defense was only in WW2, and has been active in specific situations since then²⁹29 Weintraub ACAM, Noal DS, Vicente LN, Knobloch F. Atuação do psicólogo em situações de desastre: reflexões a partir da práxis. Interface (Botucatu) 2015; 19(53):287-297..

The primary responsibility of the community in containing the progression of the pandemic was in the fact that many Health Systems could collapse, as they did in some countries. A study with 182 countries found that 33% had low capacity to respond to a public health event, and 24% had little available functional capacity, even with the support of funds coming from elsewhere. These events include infectious diseases³⁰30 Kandel N, Chungong S, Omaar A, Xing J. Health security capacities in the context of COVID-19 outbreak: an analysis of International Health Regulations annual report data from 182 countries. Lancet 2020; 395(10229):1047-1053..

In this study, females believed to have a high risk of infection by coronavirus (Table 1), which is explained due to the greater sense of self-care among women³¹31 Gomes R, Nascimento EF, Araújo FC. Por que os homens buscam menos os serviços de saúde do que as mulheres? As explicações de homens com baixa escolaridade e homens com ensino superior. Cad Saude Publica 2007; 23(3):565-574.. Moreover, the higher perception of greater risk of COVID-19 infection by women is perhaps because the study included many health professionals who are at higher risk since the health sector’s workforce is predominantly female. However, infection by COVID-19 seems to have a gender preference³²32 Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395(10223):507-513.^,3333 Cheng ZJ, Shan J. 2019 Novel coronavirus: where we are and what we know. Infection 2020; 48:155-163.. Chen et al. found a higher number of men infected by COVID-19 than women. In previous SARS and MERS epidemics, men were also more likely to be infected than women³²32 Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395(10223):507-513.. This may have to do with the vital role of women’s X chromosomes and sex hormones in the body’s immune system³⁴34 Jaillon S, Berthenet K, Garlanda C. Sexual dimorphism in innate immunity. Clin Rev Allergy Immunol 2019; 56(3):308-321.. While more susceptible to coronavirus infection, male participants were more negligent and did not voluntarily quarantine (Table 1). In social imagery, men see themselves as invulnerable beings, which contributes to them taking less care and exposing themselves more to risky situations³¹31 Gomes R, Nascimento EF, Araújo FC. Por que os homens buscam menos os serviços de saúde do que as mulheres? As explicações de homens com baixa escolaridade e homens com ensino superior. Cad Saude Publica 2007; 23(3):565-574..

Pandemics have already caused severe damage throughout history. At least ten significant pandemics have occurred in the last three centuries, which have had a significant impact on morbimortality in a few weeks, affecting mainly children and young adults and causing social disruption situations. The city of Fortaleza had a thousand deaths in a single day in a smallpox epidemic that occurred in 1868¹⁷17 Reis NRB. Rodolfo Teófilo e a luta contra a varíola no Ceará, 1905. Hist Cienc Saude-Manguinhos 2001; 8(1):286-289.^,3535 Brasil. Ministério da Saúde (MS). Grupo Executivo Interministerial. Plano de Contingência do Brasil para o enfrentamento de uma Pandemia de Influenza. Versão Preliminar - Parte I. Brasília: MS; 2005.. People of all ages can be infected with coronavirus³³33 Cheng ZJ, Shan J. 2019 Novel coronavirus: where we are and what we know. Infection 2020; 48:155-163.. In this study, the group aged 20-39 years considered having a high risk of infection (Table 2). Approximately 72% of confirmed cases of COVID-19 infection are 40 years of age or older³³33 Cheng ZJ, Shan J. 2019 Novel coronavirus: where we are and what we know. Infection 2020; 48:155-163.. Additionally, older adults are considered a factor of concern for contamination with COVID-19, since increasing age is associated with death³⁶36 Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; pii:S0140-6736(20)30566-3.. For study participants aged 80 or over, their belief system favors negligent behavior, as they believe that they have a medium risk of infection, the pandemic level will be lower in Brazil, and that we have greater protection for COVID-19 (Table 2). This group also reported that their quarantine is partially performed because of the flow of people at home, which can be explained due to the generational bond of Brazilian families, where older adults are protected³⁷37 Inouye K, Barham EJ, Pedrazzani ES, Pavarini SCI. Percepções de suporte familiar e qualidade de vida entre idosos segundo a vulnerabilidade Social Psicol Reflex Crit 2010; 23(3):582-592., besides the figure of the caregiver present mainly in the last decade³⁸38 Araújo JS, Vidal GM, Brito FN, Golçalves DCA, Leite DKM, Dutra CDT, Pires CAA. Perfil dos cuidadores e as dificuldades enfrentadas no cuidado ao idoso, em Ananindeua, PA. Rev Bras Geriatr Gerontol 2013; 16(1):149-158.. Therefore, data point to a higher vulnerability of elderly participants in the State of Ceará to infection by COVID-19 due to social and behavioral aspects. The main limitation of this study is that it was carried out in a convenience sample, which restricts the external generalization of the findings.

The level of education can be considered a risk factor for the spread of infectious viral diseases and developing to death²⁵25 Lemos DRQ, Neto RJP, Perdigão ACB, Guedes IF, Araújo FMC, Ferreira GE, Oliveira FR, Cavalcanti LPG. Fatores de risco associados à gravidade e óbitos por influenza durante a Pandemia de Influenza A (H1N1) 2009 em região tropical/semi-árida do Brasil. J Health Biol Sci 2015; 3(2):77-85.^,3939 Lenzi L, Wiens A, Grochocki MH, Pontarolo R. Study of the relationship between socio-demographic characteristics and new influenza A (H1N1). Braz J Infect Dis 2011; 15(5):457-461.. In this paper, participants with elementary education considered that they were at a lower level of risk than participants with a higher level of education and adopted voluntary quarantine less (Table 3). However, what is observed in the research is that the level of education and the severity of the disease may be associated with the individual’s social class, suggesting that habits, living conditions, and knowledge about the disease influence the prognosis²⁵25 Lemos DRQ, Neto RJP, Perdigão ACB, Guedes IF, Araújo FMC, Ferreira GE, Oliveira FR, Cavalcanti LPG. Fatores de risco associados à gravidade e óbitos por influenza durante a Pandemia de Influenza A (H1N1) 2009 em região tropical/semi-árida do Brasil. J Health Biol Sci 2015; 3(2):77-85.^,3939 Lenzi L, Wiens A, Grochocki MH, Pontarolo R. Study of the relationship between socio-demographic characteristics and new influenza A (H1N1). Braz J Infect Dis 2011; 15(5):457-461.. Thus, individuals with lower schooling would be more likely to contract the infection, as they use public transport, live and visit places with a higher number of individuals, and have limited access to medical resources. Among other factors, they would have fewer resources to adopt preventive measures, such as the use of gel alcohol for hand hygiene, and therapeutic measures, such as the use of palliative drugs, predisposing these individuals to death from infection³⁹39 Lenzi L, Wiens A, Grochocki MH, Pontarolo R. Study of the relationship between socio-demographic characteristics and new influenza A (H1N1). Braz J Infect Dis 2011; 15(5):457-461..

The coronavirus arrived in Brazil through people who had traveled abroad, and it started in the big capitals. So when the questionnaire was applied, we expected that those living in the RMF were more likely to have direct contact with someone tested positive for coronavirus compared to those living in the inland region (p = 0.031). This also makes them less reclusive (p < 0.001). Even with a high level of education (85.1% with higher education and postgraduate degrees), people living outside large centers tend to be closer. According to Vargas⁴⁰40 Vargas MA. Moradia e pertencimento: a defesa do Lugar de viver e morar por grupos sociais em processo de vulnerabilização. Cad Metrop 2016; 18(36):535-557., a prevailing inland life outside of large urban centers provides a more significant network of social support, helping to survive, supplying the very absence of the State in its many needs. Such a situation creates bonds, and distance and isolation can become harder. Probably, these links and closest social connections in inland cities strengthen certain beliefs present in Table 4.

Conclusion

We can conclude that the approach of the COVID-19 pandemic in the State of Ceará generated significant differences of beliefs when comparing gender, age, education, and place of residence. The system of local beliefs and behaviors showed that men, less educated people, older adults over 80 years, and those living in inland cities of the State are more vulnerable to infection by the coronavirus.

References

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