COVID-19 related misconceptions among older adults in Bangladesh: findings from a cross-sectional study

Introduction

The human population is shrouded in a global health crisis due to the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)¹. As of the 24^th of January 2021, more than 96 million people have been infected, and more than two million people have lost their lives². Furthermore, this unprecedented pandemic has substantially changed the way we live across the globe, with deleterious societal and financial outcomes likely to take many years to return to normal³. The ongoing COVID-19 pandemic has affected each part of the world, leaving no country untouched⁴.

However, certain population groups are more vulnerable than others to the deadliest effects of COVID-19. Mortality rates from the USA show that over 80% of COVID-19-related deaths occur among patients ≥65 years⁵, with similar figures reported globally, demonstrating that older adults are especially vulnerable to complications and death resulting from COVID-19^6,7. The severity of the SARS-CoV-2 infection is influenced by the age of a patient, and disproportionately affects adults over 65 years⁸, meaning that older people are at a higher risk of morbidity and deaths due to COVID-19⁶. Older adults with comorbidities like diabetes, chronic obstructive pulmonary disease, organ receiver/donor, hypertension, heart and kidney diseases are at a significantly higher risk of SARS-COV-2 severe infection and increased case fatality rates⁹.

Bangladesh, in South Asia, reported its first COVID-19 patient on 8^th March 2020¹⁰, when a traveller returned from Italy is believed to have brought the virus into the country¹¹. Since then more than 500,000 infected cases have been reported as of 11^th January 2021, with 7,781 deceased due to COVID-19². This triggered a nationwide response to curb the pandemic that has been in operation since early March 2020¹². However, the absence of travel restrictions and allowance of mass gatherings for religious functions are responsible for the recent growth in COVID-19 cases¹³. Like many other countries, Bangladesh is also experiencing growth in the older population, with more than 3.2 million people, or 7.7% of the total population, aged 60 years or above; a proportion that is projected to increase three-fold to 21.9% by 2050¹⁴. As age is a critical risk factor related to COVID-19, Bangladeshi older adults are disproportionately vulnerable to COVID-19; although nearly 7% of total COVID-19 patients are aged ≥60 years, this group faces a mortality rate of almost 39%¹⁵.

Just as SARS-CoV-2 has spread all over the world, so too has misinformation. Misleading or false information has led to individuals putting themselves and others at risk by believing or acting upon falsehoods, not engaging in protective measures, and self-medicating using toxic medicines. Common misconceptions about the pandemic include: the idea that face masks do not filter SARS-CoV-2, that COVID-19 is like seasonal flu, and that only old older people are affected by the virus¹⁶. Electronic media serves as the dominant platform for circulating fake news and misinformation about the public health crisis¹⁷, creating what the Director-General of the World Health Organisation has called an ‘infodemic’¹⁸. Social stigma is closely associated with believing false information about how SARS-CoV-2 spreads, while gossip quickly circulates rumours and myths¹⁹. Nearly 59% of Bangladeshi have access to the internet, through which they can access rumours and fear about COVID-19²⁰.

Although some recent studies carried out in Bangladesh focused on knowledge, attitude, and fear of COVID-19^12,21, none have focused on COVID-19 misconceptions among older adults. Given the heightened vulnerability of older adults to COVID-19-related morbidity and mortality, understanding what older adults believe is of paramount importance in facilitating effective interventions to educate and protect the older adult population. Therefore, the aim of this study was to explore the misconceptions about the COVID-19 pandemic, and associated predictors, amongst older people in Bangladesh.

Methods

Results

Background characteristics

A total of 1032 older Bangladeshi adults aged 60 years and above participated in the study (Figure 1). Table 1 describes the sociodemographic and lifestyle characteristics of participants, reflecting a higher proportion of participants aged 60–69 years (77.8%), male (65.5%), married (81.4%), illiterate (58.3%), residents of rural areas (73.9%), and living with other family members (92.3%). The most common source of COVID-19 related information was radio/television (83.04%), followed by friends/family/neighbors (71.2%), and a very small number also received information from health workers (9.3%). The majority of participants reported that they were concerned about (71.3%) and overwhelmed by (63.2%) COVID-19. Reduced social interaction during the pandemic was reported by 42% participants and around 59% had pre-existing non-communicable chronic conditions.

Figure 1. Participants enrolment.

Table 1. Sociodemographic and lifestyle characteristics of the respondents (N=1032).

Characteristics	n	%
Administrative division
Barishal	149	14.4
Chottogram	137	13.3
Dhaka	210	20.4
Mymensingh	63	6.1
Khulna	158	15.3
Rajshahi	103	10.0
Rangpur	144	14.0
Sylhet	68	6.6
Age (years)
60 – 69	803	77.8
70–79	174	16.9
>= 80	55	5.3
Sex
Male	676	65.5
Female	356	34.5
Marital status
Married	840	81.4
Widow/Widower	192	18.6
Family size
≤4	318	30.8
>4	714	69.2
Family monthly income in Bangladeshi taka
<5,000	145	14.1
5,000–10,000	331	32.1
>10,000	556	53.9
Residence
Urban	269	26.1
Rural	763	73.9
Current occupation
Employed	419	40.6
Unemployed or retired	613	59.4
Literacy
Illiterate	602	58.3
literate	430	41.7
Living arrangement
Living with other family members	953	92.3
Living alone	79	7.7
*Source of COVID-19 related information
Radio/Television	857	83.04
Health workers	96	9.3
Friends/family/neighbours	735	71.2
Walking distance to the nearest health centre
<30 min	508	49.2
≥30 min	524	50.8
Feeling concerned about COVID-19
Hardly	299	28.97
Sometimes/often	733	71.03
Feeling overwhelmed by COVID-19
Hardly	370	36.38
Sometimes/often	647	63.62
Presence of any non-communicable chronic conditions
No	424	41.09
Yes	608	58.91
Communication with others during the COVID-19
Same as previous	598	57.95
Less than previous	434	42.05
Family members not responsive to their needs during COVID-19
No	687	66.57
Yes	345	33.43
Feeling himself at highest risk of COVID-19
No	603	58.43
Yes	429	41.57

*Multiple responses

Factors associated with misconceptions

The final model, based on the lowest AIC, retained the variables shown in Table 3. Hence, the model is adjusted for all the variables in Table 3. The q-q plot of the residuals of the model (Figure 2) shows that the data is normally distributed, while VIF values of less than 10 for each variable (Table 4) reflects the absence of multicollinearity. Average misconception scores were higher among participants who were living alone (β: 0.94, 95% CI: 0.43 to 1.45); who were literate (β: 0.43, 95% CI: 0.18 to 0.68); whose family members were not responsive to their needs during COVID-19 (β: 0.99, 95% CI: 0.71 to 1.28); who received COVID-19 related information from radio/TV (β: 0.89, 95% CI: 0.55 to 1.21); and who received COVID-19 related information from health workers (β: 0.60, 95% CI: 0.25 to 0.94). On the other hand, the misconception scores were lower among participants who were aged 70–79 years (β: -0.57, 95% CI: -0.87 to -0.26); who had pre-existing non-communicable chronic conditions (β: -0.43, 95% CI: -0.70 to -0.15); who were overwhelmed by the pandemic (β: -0.40, 95% CI: -0.69 to -0.10); and who felt themselves at highest risk of COVID-19 (β: -0.41, 95% CI: -0.68 to -0.14).

Table 3. Factors associated with misconceptions among the participants.

Characteristics	β	P	95% CI
Age (years)
60 – 69	Ref
70–79	-0.57	<0.001	-0.87, -0.26
>= 80	-0.21	0.507	-0.85, 0.42
Family size
≤4	Ref
>4	0.21	0.141	-0.07, 0.49
Family monthly income in Bangladeshi taka
<5000	Ref
5000–10000	-0.03	0.900	-0.50, 0.44
>10000	-0.46	0.054	-0.93, -0.01
Living arrangement
Living with other family members	Ref
Living alone	0.94	<0.001	0.43, 1.45
Literacy
Illiterate	Ref
Literate	0.43	0.001	0.18, 0.68
Feeling overwhelmed by COVID-19
No	Ref
Yes	-0.40	0.008	-0.69, -0.10
Feeling himself at highest risk of COVID-19
No	Ref
Yes	-0.41	0.003	-0.68, -0.14
Family members not responsive to their needs during COVID-19
No	Ref
Yes	0.99	<0.001	0.71, 1.28
Presence of non-communicable chronic condition
No	Ref
Yes	-0.43	0.002	-0.70, -0.15
Received COVID-19 related information from Radio/TV
No	Ref
Yes	0.89	<0.001	0.55, 1.21
Received COVID-19 related information from health worker
No	Ref
Yes	0.60	0.001	0.25, 0.94

Figure 2. Normality q-q plot.

Table 4. Multicollinearity diagnosis result.

Variable	VIF	1/VIF
Age
•    70–79	1.27	0.784382
•    >= 80	1.10	0.912809
Family size	3.57	0.279977
Family income (BDT)
•    5,000–10,000	3.66	0.273001
•    >10,000	5.92	0.168917
Literacy	1.83	0.545536
Living arrangement	1.29	0.777372
Feeling overwhelmed by COVID-19	3.14	0.318233
Feeling himself at highest risk of COVID-19	2.01	0.497822
Family members not responsive to their needs during COVID-19	1.69	0.590717
Having any pre-existing non-communicable chronic conditions	2.83	0.353822
Received COVID-19 related information from Radio/TV	6.78	0.147428
Received COVID-19 related information from health worker	1.40	0.711858

Discussion

The present study assessed the prevalent misconceptions about the spread, treatment and prevention of COVID-19 and its associated factors among older adults in Bangladesh. To the best of our knowledge this is the first study to document misconceptions about the COVID-19 pandemic among the older population of Bangladesh at the community level. Overall, we found that some misconceptions related to COVID-19 spread, treatment and prevention remain persistent to varying degrees among the participants. Evidence from similar epidemics (such as Middle East respiratory syndrome (MERS) and Swine flu (H1N1)^23,24) show that misconceptions, myths and rumours always exist in the general population during and following an outbreak, and this is also true for the COVID-19 pandemic^22,25.

In the present study, the most notable misconception was the mandatory use of PPE for everyone to go outside (80.1%). The importance of PPE in preventing the spread of infection is indisputable, but PPE is particularly important for health professionals who come in close contact with COVID-19 patients²⁶. Over-emphasis of PPE as a mode of prevention of COVID-19 and widespread reporting in print media regarding the shortage of PPE in health services might have created the notion that one should wear PPE when outside to protect themselves from COVID-19¹¹.

Many participants in the present study believed that all returnee migrants carry COVID-19. This can possibly be attributed to the increase in number of COVID-19 cases in Bangladesh after the arrival of Bangladeshi citizens returning from abroad during this pandemic²⁷. Also, many countries including Bangladesh have taken measures to restrict international travel and quarantine travellers upon arrival, which might have shaped the perception among the older adults that all returnee migrants carry COVID-19²⁸. While the percentage was relatively low, some participants also reported about the belief that COVID-19 spreads through mosquito bites. This may be because many of the symptoms of COVID-19, such as fever and body ache, are like that of dengue, Chikungunya virus and malaria, which are spread through mosquito bites²⁹. The myth of transmitting the virus through mosquito is also prevailing in neighboring countries (e.g. India) and other parts of the world³⁰.

One of five participants also believed that COVID-19 was spread through testing for it. According to the Centers of Disease Control, one of the key steps for successful COVID-19 management is early test, trace (contact tracing) and quarantine of the cases³¹. This misconception is therefore of serious concern, as it may reduce the willingness of people to undergo testing, and eventually lead to community spread of the virus. This misconception may relate to uncertainty regarding accuracy of the test (due to false positives), false rumors on COVID-19 spread, poor health literacy of older adults, and reports of COVID-19 test scams (e.g. selling COVID-19 positive or negative results without actual laboratory analysis)^32,33.

Some of the participants also believed that COVID-19 is transmitted only to non-religious, less religious and people who practice socially undesirable activities, which is important to consider. Evidence from several countries suggests that religious stigma and orthodoxies resulted in mismanagement of COVID-19. For example, in India, cow dung or urine has been used as a treatment to cure COVID-19, in Latin America and Spain religious leaders have claimed vaccine development as the work of devil stating that it would involve cell lines from aborted fetuses³⁴. Earlier, religious misinformation from Muslim clerics stating that the polio vaccine contains pork have reduced the success of vaccination in Pakistan³⁵. Therefore, it is important to dissect these existing prevailing religious myths regarding the spread of COVID-19 among older population of Bangladesh and make sure that these myths are addressed by appropriate/accurate information dissemination and risk communication.

The present research supports recent studies that also documented misconceptions regarding prevention of COVID through good nutrition and drinking water^30,36. Although the benefits of hydration, balanced diet and specific nutrients such as vitamin C and D in COVID-19 management is proven, to date there is no evidence that a specific nutrient or food can prevent COVID-19 infection^37,38. Many participants also believed that smoking does not increase the risk of COVID-19, although emerging evidence suggests that smokers are more likely to develop severe COVID-19 symptoms and outcomes as compared to non-smokers^39,40. This misconception may be attributed to poor health literacy⁴¹ and lack of updated information of COVID-19 among older adults in Bangladesh¹².

In our study we found that half of the participants believe that doctors can cure COVID-19. This is also in line with the findings that around 14% of respondents had the misconception that antibiotics can treat COVID-19. The notion that doctors can cure every disease including COVID-19, and antibiotics can treat every disease is not surprising in developing countries. Recent evidence also suggests that there is unnecessary use of antibiotics as a treatment of COVID-19 in many places⁴². A study on hospitalized patients in New York, USA revealed that 71% of COVID-19 patients received antibiotics, while only 4% had bacterial co-infection⁴³. Studies carried out in Australia³⁶ and Iran⁴⁴ also revealed a higher proportion of people inaccurately using antibiotics to treat COVID-19.

The present study also identified some correlates of misconceptions among the participants. It was found that the participants who were overwhelmed by COVID-19 and felt themselves at highest risk of COVID-19 had lower misconception scores, implying that anxiety, worry, and caution might have contributed in a positive way to drive them to acquire more accurate information, or made them more aware of the existing misconceptions⁴⁵. Likewise, misconception scores were significantly lower among those who had pre-existing non-communicable chronic conditions. In general, complications and case fatality risk of COVID have been reported higher in people who had other chronic disease or co-morbid conditions^46,47. There have been reports of increased hospitalization rate and death in elderly populations with pre-existing conditions around the globe^48–50 and have been aired through various news agencies. This might have encouraged older adults with non-communicable chronic conditions to gather accurate information regarding COVID transmission, spread and treatment.

We also observed that living alone, and family members’ non-responsiveness to their needs during the pandemic, increases the misconceptions among older populations. This is important to consider because older people often rely on other family members not only for their medical care but also as trusted source of information⁵¹. We also observed that misconception scores were significantly lower among older adults aged 70–79 years compared to those aged 60–69 years. This suggests that relatively older adults are more open to receiving accurate information related to COVID-19, which is also supported by the findings of recent research⁵². Participants aged 70–79 years may have been open to receiving accurate information regarding COVID-19 due to awareness that COVID-19 related morbidities and mortality increases with age⁵². Therefore, accurate COVID-19 messaging should prioritize the older age groups. The present study found that literacy was not associated with more accurate knowledge, with a BBC report suggesting that literate people may be more prone to misinformation related to COVID-19 because of an overload of information, sharing before thinking, and override of reactions⁵³.

Surprisingly we haven’t observed reduced misconceptions scores in groups who received information from radio/TV compared to those who didn’t receive any information. This is a big concern from the public health perspective since it denotes that there is a mistrust in the content of information provided by the media. There is also evidence that COVID-19 myths and misconceptions can spread through the media^54,55, which could explain distrust of the media as a source of accurate information. Also, misconceptions were higher among the participants who received information from health workers. There could be two possible reasons for this. Firstly, health workers may not be adequately trained on the issues related to COVID-19. Secondly, the participants may not trust the information provided by health workers even when it is accurate. Thus, health care workers need to be properly trained on accurate COVID-19 related information and on effective delivery to the community.

Conclusion

Certain misconceptions are held by many older people residing in Bangladesh regarding the spread, prevention, and treatment of COVID-19, which increases the likelihood of disease transmission and mismanagement of COVID-19 in this vulnerable group. These findings can provide insight into and support public health training and awareness activities in this population. Government and other agencies should co-ordinate education activities with consideration of the prevalent misconceptions, and focus on addressing the varied misconceptions, using appropriate channels, media, and message delivery systems, and applying evidence-based risk communication methods. A holistic health literacy intervention program should be included as part of infodemic management activities to address these misconceptions at individual, household, community, and health care levels.

Data availability