Views of South Africans during early lockdown: An HSRC pilot study
South Africa’s strategy to contain COVID-19 relies on the public’s willingness to adhere to the requirements of the lockdown and their understanding of messages around COVID-19 risk factors. The HSRC has been running several surveys to measure the public’s understanding of COVID-19 and their response to some of the pandemic interventions. Prof Priscilla Reddy and Antoinette Oosthuizen report on the results of the pilot study.
Effective communication and community engagement are important aspects of South Africa’s early and continued response to the COVID-19 pandemic. To this end, the World Health Organization (WHO) has provided technical guidance, but it cautioned that the elements of this guidance may differ between countries, depending on their risk levels, capacity and people’s perceptions and needs.
South Africa has a unique history of inequality, which means that its interventions and communication strategies need to target a heterogeneous population with vastly different health, socioeconomic, educational and sociocultural priorities. The country is burdened with other communicable and non-communicable diseases, such as tuberculosis and HIV-related conditions, hypertension, diabetes, obesity and heart conditions, all of which potentially put them at an increased risk of the more severe COVID-19. Social problems, such as substance abuse and high levels of violence both at community and interpersonal levels, especially gender-based violence, contribute to potential instability in some communities, a situation that may put the most vulnerable people, like women and children, at higher risk.
The country’s apartheid legacy of spatial inequality puts many people at risk of infection due to the nature of their crowded living conditions and poor access to services. In many high-density settlements, several people share scanty informal dwellings. To access almost every basic need, such as clean water, sanitation, food and health care, they are exposed to crowded conditions, be it in queues at water points and clinics or on minibus taxis that serve as the main pillar of the public transport system. The areas where they live are often far from employment hubs, contributing to these communities being disproportionally affected by unemployment and poverty.
The authorities need to accurately adapt and target their messaging as the challenges of the pandemic change over time and to avoid message fatigue. This is why all communities’ understanding and responses to COVID-19 need to be monitored early on and throughout the pandemic.
The HSRC pilot study
To support such monitoring, the HSRC ran an online survey in the first week of the lockdown (27 March to 2 April 2020). The data was benchmarked to the distribution of the South African population. A total of 55 823 people participated over the 7-day period for which the survey was operational. After benchmarking, 78% of the sample were black Africans and more than half were in full-time employment. A particularly important aspect of the project was the analysis of responses from 602 participants who reported that they lived in informal dwellings that were categorised as shacks and traditional hut dwellings. The intention was to support an understanding of possible communication and intervention needs in vulnerable communities.
Good knowledge of COVID-19
Generally, the findings showed that South Africans had a good understanding of the cause, incubation, transmission, symptoms and prevention of COVID-19, but there were some knowledge gaps.
Of those living in informal dwellings, 25% thought the disease was caused by a bacterial infection, 8.9% did not know the cause and 8.8% thought it was caused by animals. (Figure 1)
The vast majority of respondents knew that the incubation period for the virus was 2–14 days and that it could be transmitted through contact with an infected person and contaminated surfaces, but those who lived in informal dwellings were less likely (67.4%) to identify the risk of contaminated surfaces than those who lived in formal dwellings (85.8%).
Most people identified the symptoms (cough, fever and shortness of breath), but only half (51.6%) of those in formal and 29.7% of those in informal dwellings were able to identify body pain as a symptom.
These findings present an opportunity to refine and target some COVID-19 messages.
Adopting preventative behaviour
The findings indicated a high uptake of preventative messages, especially regarding handwashing.
Among all residents, 95.2% indicated that they had washed their hands more frequently than usual, 92.9% reported staying home and limiting their social interactions, 89.1% had used hand sanitiser, and 79.1% had covered their coughs and sneezes. Of those living in informal dwellings, 88.2% reported frequent handwashing, 81% reported staying home and socialising less and they were equally likely to report that they were covering their coughs and sneezes. (Figure 2)
A minority of respondents reported self-isolating (less than 40%), possibly in line with the early stage of the pandemic in the country at the time of the survey and the understanding of concepts such as isolation and quarantine to relate to those with symptoms only. The reported wearing of gloves was also low, between 25% (formal) and 30% (informal), possibly due to it having been discouraged in some prevention communication due to feared supply shortages for health and other essential workers on the frontline. The researchers recommended clearer guidance, but in the interim, the government has clarified its recommendations to encourage South Africans to wear cloth masks.
More than two-thirds of respondents reported high trust in government information sources on COVID-19 (see Figure 3). Among those living in informal dwellings, the trust in government information sources (67%) was higher than their trust in radio sources (58%), satellite television sources (54.2%), and even their doctor (43.2%).
The respondents living in informal dwellings also had a stronger belief in the National Government’s ability to manage the COVID-19 outbreak with 56.9% having a positive attitude compared to 47.7% of those living in formal dwellings. More respondents from informal dwellings (55.4%) also felt that the South African health system was capable of managing the COVID-19 outbreak compared to 40% in formal dwellings.
A spatial challenge?
When specifically asked about isolation in the case of someone showing symptoms, more than half (55.4%) of residents in formal dwellings who perceived themselves at high risk of getting COVID-19 indicated that they had a separate space in which to self-isolate or quarantine themselves. Only a fifth (21.1%) of self-perceived high-risk residents in informal dwellings reported that they had such a space. (Figure 4)
This may be related to spatial challenges in such communities, where having a bedroom to oneself is regarded as a luxury by many. This indicates a need for innovative and practical methods of infection prevention to be developed for unique living conditions, ideally in collaboration with communities that understand their own spatial challenges best.
Overall, fewer than a quarter of survey respondents perceived themselves as having a high to very high risk of contracting COVID-19, 36.7% as having a moderate risk and 38.1% as having a low to very low risk. A very high-risk perception was almost twice as high among residents from informal dwellings (19.2%) when compared with those from formal dwellings (10.7%).
Residents were asked what they believed would most likely happen over the following month concerning COVID-19. Among those who perceived themselves as having a high risk of contracting COVID-19, about half — 56% of those living in formal and 49% of those in informal dwellings — believed that the worst was yet to come and things would get worse. This was an indication that the respondents took the danger of COVID-19 seriously. Despite their trust in government interventions, many expect a worsening scenario. This may point to a need for increased mental-health messaging and support services as a crucial component of South Africa’s COVID-19 community-support strategy.
At the time of writing, the HSRC had commenced a second survey to look at how people were affected by the lockdown, asking questions about people’s living conditions, their ability to access food, water and health care, access to alcohol, their ability to earn an income, their interaction with law enforcement officers and their exposure to domestic abuse. The HSRC had also started a survey of health workers. The HSRC had also started a survey of health workers and another with Higher Health, formerly known as HEAIDS, on students’ responses to the crisis.
Authors: Prof Priscilla Reddy, the strategic lead on Health and Wellbeing research in the HSRC’s Human and Social Capabilities division, and Antoinette Oosthuizen, science writer in the HSRC’s Impact Centre