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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 426-433
COVID-19 pandemic fatigue among well-educated egyptian population: Cross-sectional study
Gehan Fathy Balata1, Mona Samy Hamed2, Yousef Ahmed ElSherif3, Yara Mohamed Abuelmagd4
1 Department of Pharmaceutics, Faculty of Pharmacy, Zagazig University, Zagazig; Department of Pharmacy Practice, Faculty of Pharmacy, Heliopolis University, Cairo, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Heliopolis University, Cairo, Egypt
4 Department of Pharmacology and Toxicology, Faculty of Pharmacy, Heliopolis University, Cairo, Egypt
Correspondence Address:
Gehan Fathy Balata
Department of Pharmacy Practice, Heliopolis University, Cairo
Egypt
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_126_22
Abstract
Aim: The study explores the emergence of COVID-19 pandemic fatigue among well-educated Egyptians measured in terms of their level of adherence toward COVID-19 protective measures along 20 months since the beginning of the pandemic. Setting and Design: A cross-sectional study was conducted in October 2021, using an online questionnaire for well-educated Egyptians in different governorates. Results: A total of 888 participants completed the questionnaire, their mean age was 39 ± 7.2 years and 60% of them were females. There was a strong association between the presence of either behavioral risk factors or chronic conditions and % of infection. The main sources of COVID-19 information were social media, followed by the Egyptian Ministry of health and population and WHO websites. A pandemic fatigue was observed after nearly 7 to 10 months from the pandemic emergence. The participant's age, previous COVID-19 infection, and occupation status were significant predictors for adherence to COVID-19 protective measures. The participants claimed that difficulty in remaining at home, feeling uncomfortable with face masks, the high cost of protective supplies, absence of governmental enforcement, and forgetfulness are the most perceptive barriers hindering their adherence to COVID-19 protective measures. They suggested some strategies for better adherence and reduced pandemic fatigue that includes: the implementation of governmental enforcement measures, including penalties for nonwearing masks, educational health programs, and availability of free protective supplies at the workplace. Conclusions: Pandemic fatigue was observed after 7 to 10 months from the pandemic emergence even though the high education level of the participants.
Résumé
Objectif: L'étude explore l'émergence de la fatigue liée à la pandémie de COVID-19 chez les Égyptiens bien éduqués, mesurée en termes de niveau de respect des mesures de protection contre la COVID-19 pendant 20 mois depuis le début de la pandémie. Cadre et conception: Une coupe transversal étude a été menée en octobre 2021, à l'aide d'un questionnaire en ligne destiné aux Égyptiens bien éduqués dans différents gouvernorats. Résultats: Un total des 888 participants ont rempli le questionnaire, leur âge moyen était de 39 ± 7,2 ans et 60 % d'entre eux étaient des femmes. Il y avait une forte association entre la présence de facteurs de risque comportementaux ou de maladies chroniques et le % d'infection. Les principales sources de COVID-19 les informations étaient les médias sociaux, suivis des sites Web du ministère égyptien de la santé et de la population et de l'OMS. Une fatigue pandémique a été observée près de 7 à 10 mois après l'émergence de la pandémie. L'âge du participant, sa précédente infection à la COVID-19 et son statut professionnel étaient des prédicteurs significatifs du respect des mesures de protection contre la COVID-19. Les participants ont affirmé que la difficulté à rester à la maison, se sentir mal à l'aise avec les masques faciaux, le coût élevé des fournitures de protection, l'absence d'application gouvernementale et l'oubli sont les barrières les plus perceptibles entravant leur adhésion aux mesures de protection contre la COVID-19. Ils ont suggéré quelques stratégies pour une meilleure adhesion et réduction de la fatigue pandémique qui comprend : la mise en œuvre de mesures d'application gouvernementales, y compris des sanctions pour non-port masques, programmes de santé éducatifs et disponibilité de fournitures de protection gratuites sur le lieu de travail. Conclusions: Une fatigue pandémique a été observée 7 à 10 mois après l'émergence de la pandémie même si le haut niveau d'éducation des participants.
Mots-clés: COVID-19, Égyptiens, fatigue pandémique
Keywords: COVID-19, Egyptians, pandemic fatigue
Introduction 
By March 11, 2020, the WHO announced the outbreak of COVID-19 as a global pandemic.[1] Although all countries are trying to prevent the rapid spread of COVID-19 and its variants, many countries reported an emerged COVID-19 pandemic fatigue.[2],[3],[4],[5] The WHO defined pandemic fatigue as gradual demotivation to follow recommended protective behaviors which is affected by several emotions, experiences, and perceptions as well as the cultural, social, and legislative environment.[6]
The study aimed to investigate the emergence of COVID-19 pandemic fatigue among well-educated Egyptians, explore the barriers hindering their adherence and suggest solutions for sustainable proper health behavior.
Subjects and Methods Participants
The sample was calculated using the OpenEpi, Open Source Epidemiologic Statistics for Public Health, Version 3.01. www.OpenEpi.com, updated 2013/04/06 i program at a 95% confidence interval, 5% margin of error, and design effect equal 2 assuming that the probability of adherence to measures for COVID-19 is 50%. The minimum required sample size was calculated to equal 769 participants. They were approached by convenience sampling using an online questionnaire created as Google Form and the link was shared via E-mail and WhatsApp from 1 to 31 October 2021. Answers to all questionnaire items were obligatory. The target population was adult Egyptians aged 20 and above, who have either bachelor, postgraduate degrees, or university students in different governorates. The selection of only well-educated population was due to their accessibility to the authors.
Study tool
The questionnaire was a modified version of a survey published by the WHO to measure behavioral insights related to COVID-19.[7] The questionnaire was pretested on 30 participants who were not included in the final analysis. The questionnaire was divided into seven sections as follows:
Section 1: Sociodemographic details of the participants (age, gender, governorate, educational level, occupation, financial situation, and chronic illness).
Section 2: COVID-19 personal experience (previous infection, prophylactic treatment, and vaccination).
Section 3: Behavioral risk factors (smoking, physical inactivity, obesity, and unhealthy food).
Section 4: The source of knowledge about COVID-19 protective measures (television and radio, newspaper, Ministry of Health and WHO website, social media, physician, pharmacists in the nearest pharmacy, friends/family, and awareness in the workplace/university).
Section 5: Assess adherence to different protective measures throughout 20 months since the spread of COVID-19 in March 2020 (hygiene preventative measures that include six items, social isolation that includes seven items, and regulations taken by the Egyptian government that includes four items).
Section 6: Causes for the emergence of COVID-19 pandemic fatigue.
Section 7: Suggestions to reduce risk and improve people's motivation.
Ethical approval
This study was approved by the Research Ethics Committee at Heliopolis University, Human Research Division, Cairo, Egypt (HU.REC.H.4-2021).
Statistical analysis
Data were statistically analyzed using Minitab statistical software version 16, Minitab Ltd., Coventry, UK. Numerical variables were expressed as means and standard deviations, and analysis of variance was used for the analysis. Relationships were assessed using the Pearson test.
Results Sample characteristics
Sociodemographic data of the studied participants are displayed in [Table 1]. The study included 888 participants; their mean age was 39 ± 7.2 years. [Figure 1] shows the participants' experience with COVID-19 infection. 59.3% (527) of the participants were not infected with COVID-19, 73.8% (389) of them received the vaccine, and only 37.4% (197) received prophylactic treatment for COVID-19. 20.4% (181) of the participants had a confirmed infection by nasopharyngeal swab; 64.6% (117) of them received the vaccine; and 52.5% (95) received prophylactic treatment for COVID-19. 20.3% (180) had nonconfirmed infection; 61.1% (110) of them received the vaccine; and 40.6% (73) received prophylactic treatment for COVID-19.
[Figure 2] displays the effect of behavioral risk factors present on the % of COVID-19 infection. 39.5% (351) of the participants had no behavioral risk factors, with only 35.9% (126) being infected. 35.1% (312) had one behavioral risk factor, with 45.8% (143) being infected. 16.3% (145) of the participants had two behavioral risk factors, with 44.8% (65) being infected. Only 9.1% (80) of the participants had more than two behavioral risk factors, with an equal percentage (50%) of infected and noninfected participants.
Figure 2: Relationship between behavioural risk factors and percentage of COVID-19 infectionThe effect of the presence of chronic diseases on the % of COVID-19 infection is illustrated in [Figure 3]. 68.1% (605) of the participants had no chronic diseases, with only 37.2% (225) being infected. 24.1% (214) had one chronic disease, with 50.9% (109) being infected. 6.9% (61) of the participants had two chronic diseases, with 49.2% (30) being infected. Only 0.9% (8) of the participants had more than two chronic diseases, with an equal percentage (50%) of infected and noninfected participants. Social media, followed by the Egyptian Ministry of health and population (MOH) and WHO websites, were the most reported sources of COVID-19 information [Figure 4].
Figure 3: Relationship between chronic diseases and percentage of COVID-19 infection
Figure 4: Pareto chart representing the distribution of Sources of information about COVID-19 among the study participants[Table 2] summarizes the results of the adherence level of the studied participants to different COVID-19 protective measures for 20 months. In general, there was an observed pandemic fatigue after nearly 7–10 months from the beginning of the pandemic. However, the adherence level to different protective measures was variable. The adherence to hygiene protective measures, “Covering the nose and mouth while coughing” showed the highest adherence; 31.2% of the participants were committed to the practice for 20 months, while the mean adherence level was 10.4 ± 1.59 months. On the contrary, washing the nose with a salty solution was an uncommon practice where only 2.6% of the participants were adherent for 20 months, and the mean adherence level was 2.06 ± 0.33 months. The findings of adherence to different social isolation measures revealed that “Isolate yourself when feeling sick” showed the highest adherence level; 22.2% of the participants were adherent for 20 months, and the mean adherence level was 8.94 ± 1.16 months. Conversely, “Avoiding meeting more than 5 persons” was the lowest adherent practice; only 6.6% of the participants were adherent for 20 months and the mean adherence level was 5.97 ± 0.54 months. Concerning the adherence to regulations taken by the Egyptian government, “Putting on a face mask” showed the highest adherence level; 24.3% of the participants were adherent for 20 months and the mean adherence level was 10.26 ± 1.2 months. Oppositely, “Measurement of temperature at entrance of malls and workplace” was the lowest adherent practice; 11.6% of the participants were adherent for 20 months, and the mean adherence level was 7.25 ± 1.29 months.
Table 2: Study of the adherence level of the study participants regarding different COVID-19 protective measuresThe effect of different variables of the studied participants on the adherence to different COVID-19 protective measures is demonstrated in [Table 3]. Both the age of the participants and their infection by COVID-19 had very significant effects (P = 0.000) on the level of adherence to different protective measures. Participants with the age range of 40–49 years showed the highest level of adherence (8.96 ± 3.6–9.81 ± 1.42 months), while those of 20–29 and >60 years showed poor adherence levels (6.55 ± 2.2–7.55 ± 1.28 months). Participants who were infected with COVID-19 showed higher adherence levels (8.64 ± 3.2–9 ± 1.32 months) than those who were not exposed to COVID-19 infection (7.39 ± 2.96–7.73 ± 1.72 months). The participants having either governmental or private occupations showed significant (P = 0.007) higher adherence levels than university students or retired people. Other participant variables had nonsignificant (P > 0.05) effects on the level of adherence.
Table 3: Effect of different variables of the studied participants on the adherence to different COVID-19 protective measuresParticipants' perceptions and suggestions
The participant's perceptions toward the barriers hindering their adherence to different protective measures are demonstrated in [Figure 5]. Difficult remaining at home, feeling uncomfortable with face masks, the high cost of the required protective supplies, no governmental enforcement toward adherence, and forgetfulness were the most common perceptive barriers among the participants.
Figure 5: Participants' perceived barriers hindering adherence to COVID-19 different protective measuresThe participant's suggestions for better adherence and less pandemic fatigue include governmental enforcement measures such as penalties for nonwearing masks, educational health programs, availability of free protective supplies at the workplace, and limitation of gatherings and ceremonies.
Discussion At the beginning of the COVID-19 pandemic, the Egyptian Government had taken a series of preventive measures to face the pandemic, including closing all schools, universities, and public areas, reducing the number of employees in nonvital work, night curfew, isolation of infected places, implementation of disinfection program and several awareness campaigns as well as forcing the wearing of face masks. By the end of June 2020, the government has re-opened the country to limit the economic impact of the pandemic, which in turn put the main responsibility of preventing COVID-19 spread to Egyptian individuals by adherence to protective measures.[8],[9] As a result, the authors perceived that it is important to evaluate the problem of COVID-19 pandemic fatigue among the well-educated Egyptian population. The findings illustrated a high vaccination rate among the participants indicating their awareness of the importance of COVID-19 vaccination for combating the infection spread. This was parallel with an Egyptian study conducted by Elsayed et al., 2022, to investigate the acceptance of well-educated populations toward COVID-19 vaccination.[9] Meanwhile, the administration of herbal prophylaxis against the virus had no effect on infection prevention, which agreed with Silveira et al., in 2020, who reported that herbal medicines cannot avoid the virus infection but may improve the general well-being of patients.[10]
There was a strong positive correlation between either the number of behavioral risk factors (Pearson coefficient = 0.899, P < 0.05) or the presence of chronic illness (Pearson coefficient = 0.789, P < 0.05) and the percentage of COVID-19 infection. Wood et al. 2021, reported that behavioral risk factors play a significant role in increasing the number of COVID-19 cases and deaths.[11] In addition, findings of a meta-analysis of seven studies conducted in China reported a significant association between COVID-19 and hypertension, chronic respiratory disease, and cardiovascular disease.[12] Many previous studies lend insights into the effect of either lifestyle behaviors or preexisting medical conditions on the population's immunity and hence, the severity of COVID-19 outcomes.[13],[14] social media and the official Ministry of Health website were the primary sources of health information for the participants at the expense of more traditional media platforms, namely: Newspapers. Similar results were reported in Eygpt by Shehata, 2021[15] and Abd Elhameed Ali et al. in 2021,[8] as well as in Jordan by Olaimat et al. in 2020.[16] A study conducted in Saudi Arabia reported that social media is a convenient source for sharing medical and health-care information and knowledge that can be quickly discovered by patients.[17]
Although the Egyptian MOH used all means of communication in educating the public about the disease and protective measures, including posting different educational videos and brochures on its website, television, mobile messages, and even social media platforms and established a specialized hotline to provide medical counseling services, pandemic fatigue was observed among the well-educated population and the highest adherence level did not exceed 10 months from the beginning of the pandemic. COVID-19 pandemic fatigue was observed in many countries, including Denmark,[18] United Kingdom,[19] and Brazil.[20] A German study explained the decline in adherence levels to COVID-19 protective measures by the negative impact of the pandemic on the economy, occupation, health, and social life as well as the longer pandemic duration that makes people less likely to follow the recommended protective measures.[21] Olsson reported that pandemic fatigue is a real feeling of exhaustion due to COVID-19's negative impact on our lives – from quarantining to lost jobs to the fears of getting sick.[22] Behavioral scientists ascribed the problem of people's demotivation to many reasons that include: people becoming adapted to the existence of the virus and the threat it poses as well as continued restrictions resulting in inconveniences in everyday life.[23]
It was highlighted that the pandemic and its restrictions have led to stress, loneliness, and boredom with consequent loss of motivation and COVID-19 initiatives.[24],[25] In addition, Barakat and Kasemy, in 2020, studied the Egyptian preventive behaviors to COVID-19 over three periods of time through the pandemic and claimed that information or media fatigue resulting in reduced behavioral engagement.[2] Authors of the epidemiological models reported that the declined adherence as a function of time is closely match postpeak dynamics in the number of cases.[26]
High adherence level was observed for covering the nose and mouth while coughing as well as putting on a face mask which was parallel to previous studies conducted in Egypt,[27] China,[28] and Europe.[29] Mandatory mask-wearing had been implemented in Egypt and applied to several public places and public transport. Sim et al. in 2014, reported that facemask-wearing was associated with environmental factors, such as regulations around daily life that influence one's choice to engage in preventive behavior.[30]
The mean adherence level to different practices concerning social isolation did not exceed 9 months which may be attributed to the economic burden that performing these behaviors affects the individual and society.[4] Another possible explanation is the power of habits and the friendly personality of the Egyptians, as social gatherings and festivals are deeply ingrained in their culture.[9] Mendoza-Jiménez et al., in 2021, reported that noncompliance with social isolation measures depends on the adherence to the other persons' tolerance of such behavior and is hence affected by environmental factors.[31]
Petherick et al. studied the emergence of pandemic fatigue to COVID-19 protective measures among the populations of 14 countries and reported that wearing masks exhibited the highest adherence level while physical distancing showed a decline in adherence over time.[20]
Predictors of the emergence of pandemic fatigue in this study were age, occupation, and previous COVID-19 infection, which were in line with previous literature.[18],[19],[32] It was surprising that university students showed a poor level of adherence despite their high internet using skills and hence their ability to search for information about COVID-19-related health behaviors. A previous study reported although college students showed a high level of eHealth literacy due to COVID-19 information they got online, it is difficult to change behavioral practice in a short-term period.[33] Bawazir et al. claimed that older people had better knowledge and adherence toward COVID-19 due to their worry about the liability to developing a serious disease.[34] Participants with reported COVID-19 infection demonstrated a higher adherence level than those who were not infected. Similarly, Van den Broucke 2021 and Bruine de Bruin and Bennett 2020, stated that infection status may be an important determinant of people's adherence to distancing rules and other preventive measures.[35],[36] The Health Belief Model[37] and the Protection Motivation Theory[38] state that risk assessments influence people's tendency to act reliably.
Despite participants with chronic illness or those who showed some behavioral risk factors being more vulnerable to COVID-19 infection, they experienced earlier pandemic fatigue. Similarly, Mendoza-Jiménez et al. 2021, found no association between people's engagement in behavioral risk factors and adherence, which was explained on the basis that involvement in unhealthy behaviors could lower motivation for positive lifestyle changes.[31] Meanwhile, this was contradictory to The Health Belief Model; the higher adherence to the protective measures is associated with a higher self-perceived risk of COVID-19 infection.[37]
According to the complex nature of human behavior, pandemic fatigue is not the only factor responsible for the observed decline in adherence to the recommended protective behaviors. The perceived barriers reported by the study participants toward adherence to COVID-19 preventive measures were parallel to previous studies reporting that feeling uncomfortable with different preventive measures, lack of resources, lack of governmental push, and forgetfulness are among the most severe barriers to the prevention of COVID-19.[39],[40]
The study participants highlighted the necessity of teaching health literacy and health promotion measures for mitigating the adverse effects of any future pandemics. A previous study reported that individuals with a high level of health literacy are more likely to adopt positive behaviors in their response to any pandemic.[41] Improve the awareness of highly vulnerable people to COVID-19, including those of older age, retired, or having chronic illness. Local authorities should ensure protective measures are enforced in workplaces with regular monitoring. Moreover, financial, social, cultural, and emotional support offered by the government is needed to make recommended behaviors easy and inexpensive. This can involve the provision of fast and cheap Internet connections, free masks and hand sanitizers, and accessible handwashing areas. In addition, reducing the harms associated with negative behaviors through the implementation of smart, time-limited, and risk-based measures rather than broad and extended restrictions such as new formatting of cultural events.[42]
Limitations of the study
The study was conducted with only well-educated populations. Thus, participants with different levels of education might indicate different perceptions and practices. The study design was cross-sectional one, so it might be difficult to ascertain the cause-effect relationship between the study variables. The study tool is an online questionnaire, so the sample is representative of only people who have access to the Internet and social media.
Conclusions Our findings emphasize the emergence of pandemic fatigue among the participants after 7–10 months since the beginning of the pandemic. The study highlights that the improvement in the population adherence level and compacting barriers that accelerate the emergence of pandemic fatigue can be accomplished by modeling health awareness and health behavior together with governmental support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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