COVID-19 related messaging, beliefs, information sources, and mitigation behaviors in Virginia: a cross-sectional survey in the summer of 2020

Analysis strategy

We conducted exploratory analyses by calculating descriptive statistics of survey responses and investigated correlations between information sources, perceptions, beliefs, and risk mitigating behaviors related to the COVID-19 pandemic. Figures presenting these comparisons are used to visualize these comparisons and differences greater than 5% are reported. We also investigated correlates of the fundamental risk mitigating behaviors mask wearing and social/physical distancing in unadjusted and adjusted analyses using logistic regression with robust variance estimates. Statistical significance was taken at the 0.025 level to account for these two primary outcomes using a conservative Bonferroni adjustment and a nominal type I error rate of 0.05. We adjusted for race, political identity, gender, age group, income, reporting national science and health organizations as an information source, believing in alternative messages, and living in southwest Virginia to identify the independent effects of these characteristics on risk mitigation behaviors. These variables were selected a priori as known correlates of COVID-19 beliefs and incidence (Alobuia et al., 2020; Azlan et al., 2020; Barari et al., 2020; Benham et al., 2021; Bonyan et al., 2020; Christensen et al., 2020; McCaffery et al., 2020; McFadden et al., 2020; Sherman et al., 2021; Wolf et al., 2020). Survey responses were excluded only if none of the questions beyond eligibility were answered.

All analyses were conducted using Stata/SE 16.1 and Microsoft Excel. This work was conducted by the Community and Collaborative subgroup of the integrated Translational Health Research Institute of Virginia (iTHRIV), a collaboration between Virginia Tech, University of Virginia, Inova, and Carilion Clinic. This study was approved by the Virginia Tech institutional Review Board (IRB number: 20-353) and the Inova Institutional Review Board (IRB number: U20 05-4056), prior to initiation of study activities at the respective sites.

Respondent characteristics

The survey was open from May 19th to July 19th, 2020. Of the 3,694 individuals who started the survey, 3,678 (99.6%) self-reported as eligible and of these 190 (5%) did not answer any survey questions and were excluded. Of the remaining 3,488 respondents 3,367 (97%) fully completed the survey. Of the 3,488 included in this analysis, 70% completed the survey in May, 21% in June, and 9% in July of 2020. Participants were represented throughout Virginia (Fig. 1), with the largest numbers of respondents residing in Montgomery County (home of Virginia Tech), Loudoun and Fairfax Counties (near Washington DC, home of Inova), and Wise County (home of UVA Wise), reflecting sites where survey recruitment began.

Sociodemographic characteristics are presented in Table 1. Briefly, 78% were women, 3% were Hispanic, 83% were non-Hispanic white, 5% were Black, 3% were Asian, and 87% identified as heterosexual or straight. Six percent were 18–24 years old, 6% were 25-29, 16% were 30-39, 19% were 40-49, 20% were 50-59, 20% were 60-69, and 9% were 70 or older. Most (94%) had completed at least some college or other post-high school education or training. Forty-three percent reported annual household income at least $100,000, 11% between $80,000 and $100,000, 13% between $60,000 and $80,000, 12% between $40,000 and $60,000, and 11% less than $40,000. Forty-six percent of respondents identified as Democrat, 13% as Republican, 22% as independent, and 13% said other or no-preference. Employment status was not mutually exclusive and 58% had full-time employment, 12% had part-time employment, 16% were retired, 5% were students, and 4% were unemployed. Eighteen percent of respondents reported a loss of or reduced employment or income, while 70% reported no change in their employment status as a result of COVID-19.

Trusted information sources

All but 16 respondents (0.5%) answered the question: “Where do you get information that you trust about coronavirus/COVID-19?” Of these (n = 3,472), most reported national science and health organizations (85%) as a trusted source for COVID-19 information and over 50% of respondents reported state/local health departments (75%), healthcare professionals (74%), and online news sources (55%) as a trusted source. Information sources reported by less than half of respondents included family and friends (26%), faith leader (4%), local TV news (34%), national TV news (49%), printed newspapers (20%), radio (20%), social media (22%), local government leaders (46%), and federal government leaders (22%). Only 2% of these respondents reported not following any COVID-19 updates (Fig. 2A).

More women than men received information they trusted from local government leaders (48% vs. 41%) and more men than women received information they trusted from family/friends (31% vs. 25%), and federal government leaders (26% vs. 20%) (Fig. 2B). Young adults age 18-24 were more likely than those of all older ages combined to receive trusted information from family and friends (39% vs. 25%) and social media (31% vs. 21%) and less likely from printed news (6% vs. 21%), radio (10% vs. 21%), and local government leaders (36% vs. 47%) (Fig. 2C). Slightly less non-Hispanic white and Asian respondents received trusted information from faith leaders (4% and 3%, respectively) than other races including 9% of Black and 10% of multiracial respondents. Non-white respondents were also more likely than white respondents to receive information from local TV news (42% vs. 33%), and social media (27% vs. 21%) (Fig. 2D). White respondents were more likely than non-white respondents to receive information from printed local newspapers (21% vs. 14%), national science and health organizations (87% vs. 82%), or state and local health departments (77% vs. 71%) (Fig. 2D). More Democrats than Republicans received information they trusted from national science and health organizations (93% vs. 72%, respectively), State or local health department (83% vs. 62%), online news (65% vs. 41%), national TV news (55% vs. 43%), local government leaders (54% vs. 46%), printed newspapers (45% vs. 13%) and radio (26% vs. 14%) (Fig. 3A). More Republicans than Democrats received information they trusted from federal government leaders (46% vs. 13%), faith leaders (6% vs. 3%), or did not follow coronavirus/COVID-19 updates (5% vs. 0.3%). Similar proportions by political identity received information from local TV news, family/friends, healthcare-professionals, and social media.

More of those with than without a college degree received information from local printed newspapers (22% vs. 13%), radio (22% vs. 15%), online news (58% vs. 44%), local government leaders (47% vs. 43%), national science and health organizations (89% vs. 74%), and State or local health departments (79% vs. 64%) (Fig. 3B). More of those without than with a college degree received information from local faith leaders (6% vs. 4%), local TV news (38% vs. 33%), and federal government leaders (26% vs. 20%). More higher- than middle- and lower-income individuals received information from local printed newspapers (23%, 18%, 15%), online news (58%, 55%, 51%), local government leaders (49%, 43%, 45%), national science and health organizations (89%, 84%, 83%), and State or local health departments (80%, 77%, 70%) (Fig. 3C). Differences in information sources were also observed across regions indicating some heterogeneity geographically (Fig. 3D). Other differences presented in Figs. 2 and 3 were less than 5%.

Perceptions & beliefs related to COVID-19

Twenty-three percent of respondents reported being “very worried” about catching COVID-19 and 34% were “very worried” about experiencing severe disease or complications if they were to catch COVID-19. Most respondents considered COVID-19 to be very serious (82%) or somewhat serious (13%). Demographic differences greater than 5% among those considered COVID-19 to be very serious were observed between women vs. men (85% vs. 77%), Democrats vs. Republicans vs. others (95% vs. 61% vs. 78%), those 60 or more years old vs. those under 60 years old (91% vs. 81%), LGTBQ+ vs. heterosexual (89% vs. 83%), and higher-income vs. lower-income (86% reporting $100,000 vs. 78% making less than $20,000), and those with vs. without a college degree (86% vs. 75%). Other demographic characteristics were not <5% different in terms of perceived seriousness of COVID-19. Differences by race and ethnicity were also observed with 91% of Asian, 87% of Black and Hispanic, 84% of multiracial and white, non-Hispanic respondents reporting they believed COVID-19 to be very serious.

Among those who answered the question: “Which if any of the following impacted your belief that COVID-19 was serious” (n = 3,371), more than half selected hearing about COVID-19 in other countries (77%) or other states (73%), public-school closings (69%), the governor recommending a stay-at-home order (51%), mandating a stay-at-home order (65%), and declaring a state of emergency (68%), the CDC recommending that everyone wear a face mask in public (67%), restaurant dining rooms shutting down, (58%), and sporting events being canceled or postponed (52%) (Fig. 4A). Less than half selected becoming sick (3%) or knowing someone who became sick (30%), being high-risk or living with some-one who is high-risk for severe disease (40%), starting to work from home (35%), being laid off or losing their job (5%), when stores began limiting purchases of essential items (42%), when religious services were moved online (40%), and when a public figure tested positive (17%). Two percent of those who responded to this question said they did not think COVID-19 is serious, and 11% selected some other reason not listed in the survey.

Among those who answered the question: “Which if any of the following impacted your belief that COVID-19 was serious,” women were more likely than men to state someone they knew became sick (31% vs. 26%), being or living with someone high-risk (42% vs. 32%), public schools closing (71% vs. 63%), the governor declaring a state of emergency (70% vs. 63%), the CDC recommending face masks (69% vs. 63%), hearing about it in other countries (78% vs. 75%) and states (74% vs. 69%), stores limiting purchases (43% vs. 38%), religious services gong online (41% vs. 35%), and the governor recommending a stay at home order (52% vs. 47%) and mandating stay at home order (68% vs 57%) (Fig. 4B). Young adults were more likely than all other age-groups combined to select restaurant dining rooms (66% vs. 57%), being furloughed (laid off) or losing their job (16% vs. 4%), stores limiting purchases, (52% vs. 42%), and a public figure testing positive (26% vs. 17%) and less likely to select hearing about COVID-19 in other countries (72% vs. 78%), the governor recommending a stay-at-home order (41% vs. 52%), though this is not true for when the governor mandated the stay-at-home order (68% vs 66%) compared to other age groups (Fig. 4C). Non-white respondents were more likely than white respondents to select personally becoming sick (6% vs. 2%) or someone they knew becoming sick (45% vs. 28%), stores limiting purchases (52% vs. 41%), religious services moving online (47% vs. 39%), and a public figure testing positive (23% vs. 17%) (Fig. 5A). Democrats were more likely than Republicans to select knowing someone who was sick (32% vs. 24%), public schools closing (74% vs. 62%), restaurants closing (61% vs. 53%), the governor declaring a state of emergency (80% vs. 45%), starting to work from home (40% vs. 29%), the CDC recommending face masks (76% vs. 53%), hearing about COVID-19 in other countries (86% vs. 59%) and states (81% vs. 58%), stores limiting purchases (46% vs. 38%), sporting events being canceled or postponed (56% vs. 48%) and a public figure testing positive (20% vs. 13%) (Fig. 5B). More Republicans than Democrats selected religious services moving online (45% vs. 37%). More of those with than without a college degree reported their belief was impacted by the governor declaring a state of emergency (70% vs. 63%), beginning to work from home (38% vs. 24%), the CDC recommending face masks (69% vs. 63%), hearing about COVID-19 in other countries (81% vs. 65%) or states (75% vs. 65%), and sporting events being cancelled (53% vs. 49%) (Fig. 5C). More of those without than with a college degree reported their belief was impacted by becoming sick (5% vs. 3%), being or living with someone who is high-risk (47% vs. 39%), being furloughed (laid off) from work (9% vs. 4%), stores limiting purchases (46% vs. 41%) and religious services moving online (46% vs. 38%).

Fewer higher-income (>$100,000) than middle-income ($60,000–$99,999) and lower-income (<$60,0000) reported their belief was impacted by being or living with someone who is high-risk (37%, 41%, 44%), being furloughed (laid off) from work or losing their job (4%, 5%, 9%), stores limiting purchases of essential items (37%, 46%, 48%), religious gatherings being moved online (36%, 42%, 41%), a celebrity getting testing positive for COVID-19 (16%, 16%, 22%), and/or the governor recommending a stay at home order (49%, 55%, 52%). More higher- than middle- and lower-income reported beginning to work from home (39%, 35%, 32%), and hearing about COVID-19 in other countries (80%, 77%, 75%) (Fig. 6A). Differences in what impacted the beliefs that COVID-19 was serious were also observed across regions (Fig. 6B) for becoming sick, knowing someone who became sick, being or living with someone at high risk, beginning to work from home, and sporting events being cancelled or postponed.

Evidence based and alternative messages related to COVID-19

Over 80% of respondents reported that one or more of the following evidence-based messages impacted their beliefs and/or behaviors: “the coronavirus is highly contagious;” “stay home stay safe;” “stay home, save lives, slow the spread;” “practice social distancing;” “don’t touch your face;” and “wash your hands for at least 20 seconds” (Fig. 7). Of note for focused analyses on alternative messages, 12% percent of respondents reported believing in one or more of the following: COVID-19 “was developed as a bioweapon” (6%), “was developed to lower social security payments to seniors” (1%), “is a sign of the apocalypse/end times” (3%), “is a hoax” (1%), “can be treated with natural remedies” (3%), “was developed for population control” (3%), and/or “was developed to increase sales of cleaning supplies” (4%).

Correlations between alternative messages, demographics, and information sources

The same proportion (12%) of men and women (Fig. 8A), more young adults vs. older ages combined (22% vs. 12%), with the lowest among those 70 years old and greater (5%) (Fig. 8B), less of those who identified as non-Hispanic white (10%) compared to other races/ethnicities including 37% of Black, 22% of multiracial, 21% of Hispanic, and 15% of Asian (Fig. 8C), more Republicans (24%) than Democrats (7%) and others (15%) (Fig. 8D) believed in one of more alternative messages. The percent of those who believed in one of more alternative messages decreased with increasing education (29% of high-school degree or less to 6% of those with a doctoral degree) (Fig. 8E), and with increasing income level (9%, 13%, 17%) (Fig. 8F). More of those in Central Virginia than other regions (20% vs. <14%) (Fig. 8G) believed in one or more alternative messages.

Those who believed in an alternative message were more likely than those who did not to receive trusted information from family and friends (32% vs. 26%), a faith leader (8% vs. 3%), local TV news (38% vs. 33%), social media (29% vs 21%), federal government leaders (33% vs. 20%), or report not following COVID-19 updates (Fig. 8H). Those who did not believe any alternative messages were more likely than those who did to receive trusted information from a healthcare professional (74% vs. 69%), local newspapers (21% vs. 13%), radio (21% vs. 15%), online news (57% vs, 45%), local government leaders (48% vs. 38%), national science and health organizations (88% vs. 67%), and state or local health departments (78% vs. 59%).

Risk mitigation behavior changes

Ninety-eight percent of respondents completed the questions about changes in behaviors and 98% of those reported changing their behavior in some way in response to the pandemic (Fig. 9). More than half of respondents reported one or more of the following behavior changes: practicing social/physical distancing (95%), wearing a mask when in public (90%), washing hands more often (90%), shopping for groceries and other essentials less often (86%), washing hands for 20 s (86%), being more careful not to touch their face in public (82%) and/or with unwashed hands (80%), using hand sanitizer more often (79%), avoiding public spaces (73%), cleaning frequently touched surfaces (68%), stocking up on supplies (62%), and started working from home (52%).

Wearing a mask in public was reported by more women than men (92% vs. 84%) (Fig. 10A), and the proportion of respondents who reported wearing a mask increased by age from 80% of those 18–24 years old to 95% of those 70 years and older (Fig. 10B). Non-Hispanic White respondents were less likely to report mask wearing (90%) compared to Hispanic (95%), Asian (95%), and Black (94%) respondents (Fig. 10C). Additionally, more Democrats than Republicans and others (97%, 77%, and 87%, respectively) (Fig. 10D) reported wearing a mask, and mask use increased with greater education from 76% of those with a high-school education or less to 94% of those with a doctoral degree (Fig. 10E), and more higher- than middle- and lower-income (92%, 89%, 87%) (Fig. 10F). Those in Southwest Virginia reported less mask wearers (86%) than other regions (91%–95%) (Fig. 10G). Distancing was more common than masking in all groups but showed similar demographic trends as wearing a mask.

More of those who reported wearing vs. not wearing a mask reporting national health and science organizations (89% vs. 58%), state or local health departments (78% vs. 51%), health care professional (75% vs 64%), online news (57% vs. 38%), local government leaders (49% vs. 24%), local TV news (35% vs. 26%), local newspapers (21% vs. 6%), and radio (21% vs. 13%) as a trusted source of information (Fig. 11A). A smaller proportion of those who reported wearing vs. not wearing a mask reported the federal government as a trusted source (21% vs. 28%) or not following COVID-19 information (1% vs. 12%). Similar trends were observed for distancing (Fig. 11B).

In adjusted logistic analyses, we found that the odds of reporting not wearing a mask in public was greater than their comparative groups for those living in Southwest Virginia vs. all other regions combined (odds ratio [OR] = 1.95; 95% CI = 1.48, 2.58; p-value < 0.001), men vs. women (OR = 1.85; 95% CI = 1.36, 2.51; p-value < 0.001), young adults vs. other age-groups combined (OR = 2.42; 95% CI = 1.54, 3.81, p-value < 0.001), and those with household income under $100,000 vs. those with income at least $100,000 (OR = 1.41; 95% CI = 1.06, 1.89; p-value = 0.020) (Table 2). The odds of reporting not wearing a mask in public was greater for those identifying as a Republican vs. Democrat (OR =5.42; 95% CI = 3.63, 8.09; p-value < 0.001), those who did not vs. did report national science and health organization(s) as a trusted information source (OR = 3.16; 95% CI = 2.21, 4.51; p-value < 0.001), those who believed one or more alternative messages vs. not believing in any (OR = 2.09; 95% CI = 1.48, 2.94; p-value < 0.001). Non-Hispanic Whites were less likely to report wearing a mask vs. other races combined in unadjusted analysis (OR = 1.63; 95% CI = 1.09, 2.46; p-value = 0.018), but not in unadjusted analyses (OR = 1.68; 95% CI = 1.04, 2.71; p-value =0.035). Not having a college degree was associated with not wearing a mask in unadjusted analyses (OR = 1.98; 95% CI = 1.54, 2.55; p-value < 0.001), but not in adjusted analyses (OR = 0.98; 95% CI = 0.71, 1.35; p-value = 0.897). All other associations were statistically significant (p < 0.025) in both adjusted and unadjusted analyses. Odds ratios for distancing showed similar associations as for masking, but at a smaller magnitude. Region, gender, race/ethnicity, education, and income were not statistically significant in adjusted analyses for distancing.