The Effect of Working-based Individual Protective Behaviors (WIPB) on COVID-19 Mortality in North-West of Iran: A Case-Control Study
Telma Zahirian Moghadam1, Farhad Pourfarzi2, Chiman Karami3, Shima Rahimpouran1, Hamed Zandian1*, Abdollah Dargahi1*
1. Assistant Prof., Social Determinants of Health Research Center, Ardabil University of Medical Sciences, Ardabil, Iran.
2. Professor, Gastroenterology and Liver Disease Research Center, Ardabil University of Medical Sciences, Ardabil, Iran.
3. Assistant Prof., Dept. of Microbiology, Parasitology and Immunology, Ardabil University of Medical Sciences, Ardabil, Iran.
* Corresponding author: Hamed Zandian, Abdollah Dargahi; E-mail: zandian.hamed899@gmail.com, a.dargahi29@yahoo.com
Abstract
Background: Given the global emergency for COVID-19 infections, only Working-based Individual Protective Behaviors (WIPB) such as health behaviors are emphasized as the most important obstacle in spreading the disease. This study aimed to determine the effect of WIPB on COVID-19 mortality.
Materials and Methods: This case-control study was conducted on 3088 people (case=1955, control=1133) of the northwest of Iran, Ardabil. Data for infected society people as a case group was collected from medical records retrospectively, and for the control group (noninfected) was obtained from the comprehensive health care system. A designed questionnaire was used to identify WIPB in the Ardabil population during the COVID-19 epidemic. Chi-square test and multivariate logistic regression were used in STATA version 16.
Results: The results showed that most patients with COVID-19 in the control group belonged to the Unemployed/Housewives occupational group (27.6%), and the lowest was related to the police officers (2.2%) and transport workers (2.3%). There was a significant difference between groups in terms of sociodemographic factors (p<0.001). Inpatients had used masks, gloves, and disinfectants in the last 14 days by 66.2%, 35.3%, and 44.1%, respectively. There was a significant difference between case and control groups in terms of using a mask (p=0.004), contacting, traveling, and participating in public gatherings (p<0.001).
Conclusions: By increasing WIPBs and teaching how to properly observe such behaviors, including the proper use of masks, disinfectants, and gloves in society, as well as intensifying quarantine by preventing gatherings, the incidence and prevalence of COVID-19 can be reduced.
Keywords: SARS-CoV-2, Health Behaviors, Mortality.
Introduction
Recently, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, with social, economic, and cultural effects, has been declared as a global health emergency by the World Health Organization (WHO) [1, 2]. The number of infected people and the worldwide mortality rate indicate the severity of this viral infection. The COVID-19 infection is a contagious disease with a mortality rate of 3.4%, estimated by the WHO as of March 3, 2020 [3, 4]. Until now (October 2021), COVID-19 has infected 245,007,726 and killed 4,973,772 persons worldwide. In Iran, 5,877,456 and 125,519 persons have been infected and died, respectively, due to the COVID-19 disease [5]. It should be mentioned that Iran is ranked 8th in the world in terms of coronavirus infection (https://www.worldometers.info/coronavirus/). The COVID-19 outbreak will be flat in the new year in Iran if public and social behavior initiatives stick with current patterns or improve [2, 6, 7].
Working-based Individual Protective Behaviours (WIPB) have a significant impact on the patterns of infectious disease transmission, including COVID-19, which threatens the current health system and social organization. They are protective behaviors enacted by people to protect themselves or others from a threat to their health [8, 9]. Until vaccination is fully implemented worldwide, effective social and individual prevention is the only option to neutralize COVID-19. The modeling and interpreting social action processes (e.g., use of mask and social distance), as well as their contextualization with respect to countries' cultural systems, can lead to a stronger national and local reaction to an epidemic [10]. In addition, a retrospective analysis provided evidence of WIPB's key role in preventive actions in the control of acute respiratory syndrome (SARS) in 2003 [11]. WHO Statistical Monitoring reports that prevention and control guidelines lead to a reduction in healthcare-related infections. Various preventive options can be considered as a potential intervention to combat COVID-19 [12]. According to WHO guidelines, infection prevention and control is a practical and evidence-based way to avoid harm to healthy people via preventable infections [13, 14]. Coronavirus-related infections may be transmitted through contact, droplets, and airborne [1, 15]. Given the global emergency for COVID-19 infections, only WIPB remains to limit its prevalence. WIPB is a personal protective behavior and a primary prevention method such as using gloves, masks, and disinfectants, as well as washing hands against Covid 19 disease. The transmission is minimized with proper prevention. The main basis of preventing viral infection is the regular use of soap or sanitizer and personal protective equipment (appropriate mask, eye protection, face) [16]. Also, to control COVID-19 in different countries, especially Iran, various actions have been taken. Closing school, urging people to stay home, reducing the number of close physical interactions among people are some of such actions. Social distancing has simultaneously disrupted the everyday lives of the entire population wherever it has been implemented [17-19]. Such large and sudden disruptions to everyday life are likely to impact human well-being, particularly among people living in dense urban settings with limited public space. For example, elders, who are mainly at risk of suffering from lethal effects of COVID-19, are a risk group by also suffering from anxiety and depression sue to social isolation [20, 21]. All prevention actions utilized for the communicable COVID-19 disease cause loss of usual routine and reduce social and physical contact, which have frequently been reported to cause boredom, frustration, and a sense of isolation from the rest of the world, in turn resulting in distress, depression, stress, low mood, irritability, insomnia, and post-traumatic stress symptoms [22]. This frustration is exacerbated by not being able to take part in usual day-to-day activities, such as shopping for necessities [23], which is associated with harmful health outcomes [18]. In general, essential workers who provide crucial or fundamental public services, including healthcare, social care, sanitary services, and transportation, have continued attending work to carry out their daily duties. These critical worker groups have been exposed to the SARS-CoV-2 virus as a result, which may bring them into close contact with members of the public infected, especially since carriers may be infectious without, or before, exhibiting symptoms.
There are many unanswered questions about the COVID-19 epidemic, from the epidemic situation to the factors that reduce or eliminate the disease, especially regarding the impact of WIPB on the prevention and risk of COVID-19, in people's minds, particularly in high-risk locations where overcrowding is a major concern. Care in using the recommended precautions is especially important for all patients with respiratory diseases [27]. Even if they are not suspected of having COVID-19, they may be carriers; thus, regular use of these preventive and control measures in health behavior is recommended [14]. Therefore, in this study, we examine the effect of WIPB (using masks, disinfectants, gloves) on coronavirus disease (COVID-19) mortality in the northwest of Iran.
Materials and Methods
The present study is a case-control study performed on the data obtained from patients hospitalized due to coronavirus disease and the healthy population of Ardabil province, located in the northwest of Iran with a population of about 1.3 million and a gender composition of 58 % men and 48 % women. Fig 1 presents the map of the northwest of Iran. Data were acquired from a retrospective medical record recorded in the integrated information system of patients with COVID-19 in Ardabil province. The information of all infected patients with COVID-19 registered in the mentioned system was collected from March 21 to September 20, 2020, in the form of a census, which included a total of 1955 files. The information in this study was related to the total coronavirus data (of admitted patients) in hospitals in all cities of Ardabil province. Exclusion criteria for the case group were incorrect or incomplete patient information in the system, patients with reasons for hospitalization other than Covid-19, and patients who stated, at the time of admission, that they did not want their data to be used. The data related to the control group were extracted from the information registered in the comprehensive health care system of the province (SIB system) based on the national code and the random sampling method. Exclusion criteria for the control group were patients with incomplete information in the SIB system, unavailability of the selected person, or people who were unwilling to collaborate on the study (who was replaced with a similar person from the same system). For the case group, 1133 healthy individuals without a history of COVID-19 were selected in the relevant period.
Fig. 1. Area of study (cities of Ardabil province located in northwestern Iran during the SARS-CoV-2 pandemic)
The data collection tool in the present study was a questionnaire to identify the health behaviors of patients and healthy individuals, being designed electronically and used as an information system. The validity of the tool was measured using the content validity method, and its value was equal to 0.84. In addition, in evaluating the reliability of this scale, Cronbach's alpha coefficient was obtained to be 0.79, indicating its good reliability. The dependent variable in the present study was considered to be mortality due to COVID-19. The WIPB of the case and control groups included four sections, i.e., contact and travel history, direct contact with customers or clients, observance of health protocols at work and home, and presence in different circles and places during 14 days. The incubation period for COVID-19 disease, which is the time between exposure to the virus (becoming infected) and symptom onset, is on average 5-6 days, but it can be up to 14 days [28, 29]. For this purpose, a period of 14 days was considered. Demographic variables, including age (<10 to >80 years), gender (male and female), place of residence (provincial capital or affiliated cities), underlying disease states (diabetes, obesity, as well as cardiovascular, lung, and metabolic diseases), smoking (Yes/No), body mass index (from underweight to overweight), and occupational groups (direct contact with customers, Yes/No) were considered and relevant information were collected for all participants. According to the job classification plan (approved by the Islamic consultative assembly in the second socio-economic development plan of Iran and then notified to the organizations by the government), jobs in Iran can be classified into one of the eight groups presented in Table 1 [30]. In this study, we divided participants into eight occupational groups, including unemployed or housewife, educational workers, official employees, medical staff, shopkeepers, farmers/ranchers, police officers, protective service workers, social service workers, and transport workers. Unemployed and housewives were categorized as separate groups.
Table 1. Jobs in Iran classified by governmental organizations
Row |
Description |
1 |
The field of educational, cultural, and artistic affairs (such as teachers and professors) |
2 |
Administrative and financial field (such as bank officers and private insurances officers) |
3 |
Field of social affairs (such as all fields of research in psychology, sociology, political science, etc.) |
4 |
The field of health and treatment (including all professions of medicine, dentistry, paramedical, nursing, etc.) |
5 |
Field of services (including all brokerage, shopkeepers, sales, mechanics, etc.) |
6 |
The field of agriculture and environment (including farming and harvesting jobs, etc.) |
7 |
Technical and engineering field (including all hardware and software jobs in industry and technology, etc.) |
8 |
The field of data processing (including all occupations related to information, etc.) |
Accurate t-test and Chi-square were used to evaluate and compare the case and control groups in terms of demographic and background variables. Also, Fisher tests were used to examine the relationship between two groups of unpaired data in the case of qualitative data availability. A Chi-square test with a significance level of 0.05 was considered to compare the two groups in terms of health behaviors. Multivariate logistic regression was used to investigate the relationship between independent and contextual background with COVID-19 mortality in inpatients.
Results
The frequency of people involved in coronavirus disease in the whole society in Ardabil province is shown in Fig 2. According to the figure, the highest and lowest society infected with coronavirus in the province were related to Ardabil and Kowsar cities, respectively. Also, the percentage of coronavirus infection, mortality, and recovery of people hospitalized were equal to 1.63%, 0.09%, and 1.51%, respectively.