Social-distancing compliance among pedestrians in Ahvaz, South-West Iran during the Covid-19 pandemic

Gholam Abbas Shirali; Zahra Rahimi; Marzieh Araban; Mohammad Javad Mohammadi; Bahman Cheraghian

doi:10.4103/shb.shb_74_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 4 | Issue : 4 | Page : 131-136

Social-distancing compliance among pedestrians in Ahvaz, South-West Iran during the Covid-19 pandemic

Gholam Abbas Shirali¹, Zahra Rahimi², Marzieh Araban³, Mohammad Javad Mohammadi⁴, Bahman Cheraghian⁵
¹ Department of Occupational Safety and Health Engineering, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
² Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
³ Department of Health Education and Promotion, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
⁴ Department of Environmental Health Engineering, Air Pollution and Respiratory Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
⁵ Department of Biostatistics and Epidemiology, Hearing Research Center, Clinical Sciences Research Institute, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

Date of Submission	20-Jun-2021
Date of Decision	14-Aug-2021
Date of Acceptance	04-Sep-2021
Date of Web Publication	29-Sep-2021

Correspondence Address:
Bahman Cheraghian
Department of Biostatistics and Epidemiology, Hearing Research Center, Clinical Sciences Research Institute, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/shb.shb_74_21

Abstract

Introduction: Social distancing is a public health tool that seeks to reduce opportunities for an infectious agent to spread among individuals. The current study aimed at investigating the social-distancing compliance among pedestrians in Ahvaz city, South-west Iran during the COVID-19 pandemic. Methods: This cross-sectional study was conducted in Ahvaz, South-west Iran, from 2 to August 11, 2020. The data collection was performed based on observation of passers-by in the streets. Chi-square, Fisher's exact test, Chi-square for trend, and logistic regression were used for the data analysis. Results: The overall compliance rate of social distancing was 16.3%. There was a statistically significant difference between age groups and social distancing (P < 0.001), but this relationship was not seen in gender (P = 0.12). The compliance rate of social distancing was significantly higher during morning hours than evening hours (P < 0.001). A significant inverse association was founded between the number of observed group members and the compliance rate of social distancing so that the odds of social distancing compliance among two members groups were 59% higher than the group of 6 and more members (odds ratio = 1.59; 95% confidence interval, 1.47–1.72; P = 0.003). Conclusion: We found that the overall compliance rate of social distancing among the participants was very low and inefficient. This can make disease control difficult and leads the city to a critical situation in terms of coronavirus outbreaks. The findings can help health policymakers and health workers to plan and conduct preventive interventions.

Keywords: Ahvaz, compliance, COVID-19, pedestrians, social distancing

How to cite this article:
Shirali GA, Rahimi Z, Araban M, Mohammadi MJ, Cheraghian B. Social-distancing compliance among pedestrians in Ahvaz, South-West Iran during the Covid-19 pandemic. Asian J Soc Health Behav 2021;4:131-6

How to cite this URL:
Shirali GA, Rahimi Z, Araban M, Mohammadi MJ, Cheraghian B. Social-distancing compliance among pedestrians in Ahvaz, South-West Iran during the Covid-19 pandemic. Asian J Soc Health Behav [serial online] 2021 [cited 2023 Mar 22];4:131-6. Available from: http://www.healthandbehavior.com/text.asp?2021/4/4/131/326958

Introduction

On December 30, 2019, a new unprecedented coronavirus, called SARS-CoV-2, emerged in Wuhan, China. Until now, COVID-19 has sparked a pandemic and is spreading rapidly in many countries.^[1] It has affected all the dimensions of human life and has resulted in economic devastation and social anxiety in the world.^[2],[3]

In the early COVID-19 pandemic, the World Health Organization (WHO) proposed conducting interventions such as social distancing, facemask use, and washing hands to limit transmission. Even now, despite the discovery of vaccines to prevent the COVID-19 disease, due to the lack of adequate vaccines and frequent changes in the strains of this virus, the three strategies proposed by the Center for Disease Control and the WHO should still be considered.

Social distancing includes instructions that individuals maintain social distance when in public, school closures, limitations on gatherings and business operations, and instructions to remain at home.^[4] The rationale for implementing social distancing is that the virus is spread through large droplets and/or airborne transmission through small aerosols.^[5] When an infected person coughs or sneezes or talks near an uninfected person,^[6],[7] if the infected person does not wear a mask, transmission through large droplets usually occurs at a maximum distance of 2 m, but transmission through small aerosols can occur at a distance of 8 m under certain temperature and moisture conditions.^[8],[9]

The COVID-19 outbreak policies have been developed in Iran. However, the lack of a comprehensive approach to governmental management of the disease, inadequate protection equipment and tools, and delay in decisive governance are the biggest policy challenges in dealing with COVID-19.^[10] One of these policies is social distancing, which, despite its importance in preventing the spread of the disease, is difficult to achieve. Due to the lack of scientific documentation and research in the field of social distancing compliance in Ahvaz and limited compliance with COVID 19-related health behaviors in the city,^[11] we designed this study so that the main results will pave the way for health policy-makers in the management and design of appropriate health and educational interventions.

Methods

Study design and setting

This study was a cross-sectional and observational study, conducted from August 2 to 11, 2020, in Ahvaz city, South-west Iran, Ahvaz, the capital of Khuzestan Province, is the seventh most populous city in Iran. There are 1.3 million people in the city with an area of 18650 sq. km. It has a subtropical and hot climate with long summers and short winters. The temperature of this city sometimes exceeds 50°C during summers, and its humidity reaches above 90% on some days.

Sample size and Sampling procedure

To determine the minimum required sample size, we used a sample size formula for estimating a population proportion. We considered α = 0.05 and regarding unknowing of the estimated percent of social-distancing compliance in Ahvaz, to obtain the largest sample size, we used P = 0.5 and according to that, d = 0.05. Furthermore, a design effect equal to 1.7 was selected based on the characteristics of the clusters. The minimum sample size of 652 was estimated for each district. Regarding the eight districts of the city, the final sample size estimated for this study was 5,220 pedestrians. In this study, a total number of 174 thirty-person clusters were assessed from the 93 urban neighborhoods of Ahvaz.

A multistage sampling method was applied to select the participants. At the first stage, every eight urban districts was considered a stratum, and the defined number of clusters were assigned to each neighborhood, proportionally to their size. Each cluster included 30 pedestrians, and the location of the observation stations was determined by a targeted sampling strategy from the busy passages of each neighborhood. A nonprobability convenience sampling method was applied for the last stage in such a way that the nearest pedestrian group to an observer was selected as the first sample, just after the observer's presence at each observation station. Following the completion of recording the data pertaining to the first group, the next closest group to the observer was selected as the next sample, and this procedure continued until the total number of selected persons in each cluster reached 30. The data were collected by eight well-trained observers. The observations were performed during the busy hours of each area from 9.00–13.00 to 17.00–23.00 o'clock.

Inclusion and exclusion criteria

The inclusion criteria for participation in the current study were groups of people consist of at least two persons and also the participants aged above 2 years old. On the other hand, belonging the observed group to a family and also exposure to the observer for such a short time that the researcher could not record the required information were the exclusion criteria for this study.

Measures

Each observation and E-data of pedestrians, including gender, approximate age, number of members of groups were collected, and social or physical distancing in this study were considered as the observance of at least 1.5 m separation between two people for the conduct of public activities as recommended by the WHO.^[12]

Ethical consideration

The Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (AJUMS.REC.1399.396) approved the morality and ethics of the study.

Statistical analysis

The analyses were carried out with the SPSS software version 22.0 (IBM, Armonk, NY, USA). Statistical significance was declared if the P value was smaller than 0.05. In the descriptive statistics, measures of central tendency, including mean and standard deviation, were used. The estimated prevalence rates were presented with a 95% confidence interval (95% CI). The Chi-square test, Fisher's exact test, and Chi-square test for trend were used to assess the association between two categorical variables. We used an unconditional logistic regression model to control potential confounders. Odds ratios were used to assess the strength of the relationships.

Results

A total number of 5220 pedestrians were assessed in terms of compliance with social distancing. The mean ± SD age of the observed pedestrians equaled 30.7 ± 13.8 years. Among them, 3652 participants (70.3%) were male. The demographic characteristics and frequency of some personal protective measures among the assessed pedestrians are shown in [Table 1].

Table 1: Demographic characteristics and frequency of some personal protective measures among pedestrians in Ahvaz

Click here to view

From 5212 observed pedestrians, 848 people had complied with social distancing. The overall compliance rate of social distancing was 16.3% (95% CI, 15.3–17.3). The observed compliance rates of social distancing by the assessed factors and their confidence intervals (95%) are presented in [Table 2]. The highest rate of the observance of social distancing (19.8%) was observed in the age group of 50–59 years, while the lowest rate (5.5%) was found in the individuals aged below 10 years (P < 0.001).

Table 2: Compliance rate of social distancing in terms of gender, age group, urban district, area, and time

Click here to view

In general, the compliance rate of social distancing in the two age groups of below 10 years and above 70 years was low, whereas social distancing compliance among the other age groups was higher than that in these two groups and almost similar to each other [Figure 1]. In this regard, there was no significant difference between women and men in adhering to social distancing (17.5% vs. 15.7%, P = 0.12).

Figure 1: Comparison of social distancing among different age groups and genders

Click here to view

The pedestrians in the western area of Ahvaz had complied with social distancing significantly more than those in the eastern area (18.6 vs. 14.3%, P < 0.001). The compliance rates of social distancing among pedestrians in the eight districts of Ahvaz were highly different from each other. District two took up the highest compliance rate, while the lowest rate was obtained for district three with the rates of 26.8% and 6%, respectively. The difference in the compliance rates of social distancing was even higher among the neighborhoods, as it ranged between 0.0% and 53.7%. Furthermore, there was an inverse association between social distancing compliance and the number of group members so that as the number of observed group members increased, the compliance rates of social distancing decreased (P < 0.001). The data collection and observations were done from 9:00-23.00 o'clock. The lowest compliance rate of social distancing among pedestrians was seen at 17.00 o'clock (8.5%), while the highest degree of social distancing was observed at 23.00 o'clock (30.8%). In general, the compliance rate of social distancing was significantly higher during the morning hours (19%) than that during the evening hours (15%) (P < 0.001). The compliance rates of social distancing among pedestrians at different day times are presented in [Figure 2].

Figure 2: Compliance rate of social distancing among pedestrians at different hours

Click here to view

The variables that were significant, or close to significant (P < 0.25) in a univariable model, were selected for the multivariable unconditional regression model. Since age, gender, and times could possibly act as confounding factors in this assessment, a logistic regression model was performed to control the effects of these potential confounders. Even after controlling age and gender, a significant association was revealed between different observation times in terms of the compliance rate of social distancing so that the odds of social distancing compliance during morning hours (a.m.) were 29% higher than that in the evening hours (p.m.) (odds ratio [OR] = 1.29; 95% CI, 1.10–1.50; P = 0.002). Furthermore, a significant inverse association was found between the number of observed group members and the compliance rate of social distancing so that the odds of social distancing compliance among 2-members groups was 59% higher than the group of 6 and more members (OR = 1.59; 95% CI, 1.47–1.72; P = 0.003). The details are presented in [Table 3] and [Figure 3].

Table 3: Crude and adjusted odds ratios for effects of time on compliance of social distancing obtained from multiple logistic regression model

Click here to view

Figure 3: Adjusted odds ratios (95% confidence interval) of social distancing compliance according to the number of group members

Click here to view

Discussion

The COVID-19 disease has spread from country to country and quickly become a global crisis. Governments have tried to stop or slow down the outbreak of this emerging disease through various interventions. Due to the lack of effective pharmacologic treatments, close contact among people must be avoided to reduce viral transmission.^[13] Research findings have shown that social distancing, use of masks, and frequent hand-washing can be considered among the main precautions against contracting the infection in the world.^{[14],[15],[16],[17],[18]}

In the current study, the overall compliance rate of social distancing was equal to 16.3%. This rate has been very low and inefficient in controlling the disease; thereby, this city has been oriented to a critical situation (red zone) in terms of coronavirus outbreaks for several months. The ignorance of health protocols, including social distancing, may be due to the low-risk perception of the study community regarding the disease. Therefore, this has made some people overlook health protocols and commute easily in public and crowded environments. In addition, large-scale ceremonies as weddings, mourning, etc., disregard the social distancing; so, the critical situation has worsened. Various studies confirmed the effect of social distance on reducing the number of cases of disease and consequently reducing death.^[19],[20]

The findings of the present study indicated that although social distancing compliance was slightly higher in women than that in men, this difference was not statistically significant. This assumption also holds true for individuals' age and the observance of social distancing. For example, the compliance rate of social distancing in two age groups (i.e. under 10 and above 70 years) was low, whereas the social distancing compliance among the other age groups was higher than the two aforementioned age groups but almost identical to each other.

This study demonstrated the compliance rates of social distancing among various urban districts are different. The differences in the compliance rates of social distancing were even higher among the neighborhoods so that it ranged from 0.0% to 53.7%. These differences can be associated with cultural diversity, literacy level, income level, health knowledge, and so on.

We showed the lowest compliance rate of social distancing was seen at 17.00 (8.5%) o'clock, while the highest rate was observed at 23.00 (30.8%) o'clock. As mentioned earlier, Ahvaz is located in a subtropical region with hot and humid conditions. The temperature sometimes exceeds 50°C during summers, and the humidity on some days reaches above 90%. For this reason, during the hot hours of the day, streets are less crowded, while the passages become crowded, and the compliance rate of social distancing is reduced in the afternoon when the temperature drops slightly.

We observed that there was an inverse relationship between the number of group members and the social distance rate. This is possible because there are people who gather in larger groups who pay less attention to the regulations of health during the corona pandemic.

The strengths of the study

This investigation had some major strengths. The use of the observation method in this study led to the collection of more authentic data in comparison with the employment of questionnaires and self-reporting methods. Furthermore, the large sample size of the study guaranteed sufficient statistical power and precise estimation of the rates in such a way that the calculated confidence intervals are mostly narrow.

Limitations

Also, our study had some limitations. First, applying the observational method for data collection led to ignorance of some important factors like socioeconomic status. It is noteworthy that socioeconomic status can be possibly a reason for lack of social distancing. Besides, the observers in this study have not been able to ask the exact age of the subjects, and thereby, approximate ages were recorded instead. Therefore, a non-differential misclassification might have occurred in the age grouping. The point to be considered in the study of social distance is whether it is a religious and belief factor that can act as a confounder to examine the distance between the opposite sex, and we could not examine this issue in our study. The other limitation of the study was its cross-sectional design.

Conclusion

Social distancing is the main tool used to control COVID-19 and reducing contacts that could potentially transmit infection. In this study, we used an observational method to estimate the social distancing rate in pedestrians. We found that the compliance rate of social distancing was very low. This has occasioned a rapid spread of this disease and a dramatic increase in the number of infected cases. In our study, an inverse relationship was between the number of observed group members and the compliance rates of social distancing. We demonstrated a statistically significant association between different hours of the day and social distancing.

Acknowledgment

Hereby we would like to appreciate the attempts made by all the observers who helped us conduct this project. Moreover, the authors appreciate AJUMS for the financial support.

Financial support and sponsorship

The Vice-Chancellor for Research of Ahvaz Jundishapur University of Medical Sciences financially supported this study.

Conflicts of interest

There are no conflicts of interest.

References

1.	Zhu H, Wei L, Niu P. The novel coronavirus outbreak in Wuhan, China. Glob Health Res Policy 2020;5:1-3.
2.	Olivera-La Rosa A, Chuquichambi EG, Ingram GP. Keep your (social) distance: Pathogen concerns and social perception in the time of COVID-19. Pers Individ Dif 2020;166:110200.
3.	Sun C, Zhai Z. The efficacy of social distance and ventilation effectiveness in preventing COVID-19 transmission. Sustain Cities Soc 2020;62:102390.
4.	Mohler G, Bertozzi AL, Carter J, Short MB, Sledge D, Tita GE, et al. Impact of social distancing during COVID-19 pandemic on crime in Los Angeles and Indianapolis. J Crim Justice 2020;68:101692.
5.	Zhang R, Li Y, Zhang AL, Wang Y, Molina MJ. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proc Natl Acad Sci U S A 2020;117:14857-63.
6.	Leung NH, Chu DK, Shiu EY, Chan KH, McDevitt JJ, Hau BJ, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med 2020;26:676-80.
7.	Stadnytskyi V, Bax CE, Bax A, Anfinrud P. The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission. Proc Natl Acad Sci U S A 2020;117:11875-7.
8.	Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: Potential implications for reducing transmission of COVID-19. JAMA 2020;323:1837-8.
9.	Wilson N, Corbett S, Tovey E. Airborne transmission of covid-19. BMJ 2020;370:m3206.
10.	Raoofi A, Takian A, Akbari Sari A, Olyaeemanesh A, Haghighi H, Aarabi M. COVID-19 pandemic and comparative health policy learning in Iran. Arch Iran Med 2020;23:220-34.
11.	Rahimi Z, Shirali GA, Araban M, Mohammadi MJ, Cheraghian B. Mask use among pedestrians during the COVID-19 pandemic in Southwest Iran: An observational study on 10,440 people. BMC Public Health 2021;21:133.
12.	Seto W, Conly J, Pessoa-Silva C, Malik M, Eremin S. Infection prevention and control measures for acute respiratory infections in healthcare settings: an update. East Mediterr Health J 2013;19 (supp 1):S39-47.
13.	Araban M, Karimy M, Mesri M, Rouhani M, Armoon B, Koohestani HR, et al. The COVID-19 pandemic: Public knowledge, attitudes and practices in a central of Iran. J Educ Community Health 2021;8:35-40.
14.	Hsiao TC, Chuang HC, Griffith SM, Chen SJ, Young LH. COVID-19: An aerosol's point of view from expiration to transmission to viral-mechanism. Aerosol Air Qual Res 2020;20:905-10.
15.	Peng X, Xu X, Li Y, Cheng L, Zhou X, Ren B. Transmission routes of 2019-nCoV and controls in dental practice. Int J Oral Sci 2020;12:1-6.
16.	Shereen MA, Khan S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91-8.
17.	Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis 2020;26:1628.
18.	Keshava SN, Gupta A, Pant R, Sutphin PD, Kalva S. Practice of interventional radiology during the COVID-19 pandemic. J Clin Interv Radiol 2020;4:01-2.
19.	Haug N, Geyrhofer L, Londei A, Dervic E, Desvars-Larrive A, Loreto V, et al. Ranking the effectiveness of worldwide COVID-19 government interventions. Nat Hum Behav 2020;4:1-10.
20.	Meo SA, Al-Khlaiwi T, Usmani AM, Meo AS, Klonoff DC, Hoang TD. Biological and epidemiological trends in the prevalence and mortality due to outbreaks of novel coronavirus COVID-19. J King Saud Univ Sci 2020;32:2495-9.