Maintaining Guard: A Mixed Method Study on Adherence to Preventive Behavior in the Wake of COVID Vaccination from Kerala : Dentistry and Medical Research

Secondary Logo

Journal Logo

Original Article

Maintaining Guard

A Mixed Method Study on Adherence to Preventive Behavior in the Wake of COVID Vaccination from Kerala

Alphi, Serena; Anjali, P. H.1; Sebastian, Shaliet Rose1,

Author Information
Dentistry and Medical Research 10(1):p 12-15, Jan–Jun 2022. | DOI: 10.4103/dmr.dmr_32_22
  • Open



The world has been suffering from COVID-19 pandemic since 2019 and it has already had a huge global impact on health, well-being, and economy. Since the introduction of COVID vaccine, there has been a palpable decline in the disease morbidity and mortality. In addition to the vaccine, adherence to preventive measures is of prime importance when it comes to prevention of disease spread. Previous literature shows that vaccination alone is not enough to control the pandemic and emphasizes the importance of multilayered interventions.[1] Every available intervention against COVID 19 has different limitations.[2] Conjoining several layers of interventions could help address the gap between the various layers, thereby enabling effective protection against the disease.[3] A meta-analysis of studies investigating interventions to prevent influenza provided the evidence of benefit from multiple preventive behavior.[4]

A study conducted before the introduction of COVID vaccination in 2021 showed that 88.2%, 99.5%, 94.9%, and 97.4% of the participants adhered to the physical distancing rule, wear a face mask, cover mouth, and nose during coughing/sneezing and wash hands regularly with water and soap, respectively.[5] In a similar study conducted in Western Maharashtra, India in 2021, 95% of the responders reported washing hands immediately with soap after returning from outdoors, 94% always used masks while outdoors, 91% never attended social gatherings, 77% always used hand sanitizer while outside, and 68% of the responders followed all protective measures.[6]

Recent emergence of new variants of the coronavirus and the finding that protection conferred by the vaccine wanes over time further increases the importance of adhering to preventive measures. A study conducted in the UK to assess the changes in compliance following vaccination revealed no clear evidence that vaccinated individuals decreased compliance relative to those who were not yet vaccinated.[7] Another study from Somalia showed a decreasing adherence to COVID-19 preventive measures.[8] There exists a gap regarding the data on adherence to self-care practices after the introduction of the vaccine in India. Hence, this study was undertaken to assess the pattern of preventive behaviors against COVID-19 among vaccinated adults in Central Kerala.


This cross-sectional study was conducted among vaccinated adults aged between 25 and 65 years in Pathanamthitta District, Central Kerala from February to June 2021. The sample size was calculated using the following formula N = (1.96)2PQ/L2 and rounded off to 250 using the prevalence from a similar study.[6] Multistage sampling was used to collect the study data. Out of the 5 taluks in Pathanamthitta district, Thiruvalla was randomly selected using the lottery method. Tiruvalla municipality was randomly selected for the study. Ethical clearance was obtained from the Institutional Ethical Committee. (No-IEC/2021/01/191) A house-to-house visit was made in the selected area, and after establishing a rapport with the family, the nature, purpose, and objectives of the study were explained. A semi-structured questionnaire, derived from a validated questionnaire developed for the assessment of preventive practices against COVID-19 in the general population,[9] was used to elicit information from the study participants after obtaining consent. Compliance to all the 10 questions was taken as positive for adherence to COVID preventive behavior. Since healthcare professionals formed the majority of the population that received the COVID vaccine during the study period, such residential areas were selected. The first house was selected randomly and consecutive houses were surveyed till 250 study participants were surveyed. The study participants were interviewed about their perceived barriers towards maintaining adherence to COVID protocols after vaccination. Out of the collected data, 15 incomplete responses were discarded. The quantitative data collected were analyzed using the software Statistical Package for the Social Sciences version 20. The results have been presented as tables and charts showing frequencies and percentages. The responses on participants' perceptions collected were analyzed using the Inductive approach of Thematic Analysis[10] Data triangulation was done to increase the data validity[1112] and the common themes that emerged from the data were pooled together.


The mean age of study participants was 34 ± 11.7 years. Out of the 235 study participants, 150 (44.7%) were men and 130 (55.3%) were women. 68.5% of study participants (161) were educated up to graduation and above. 129 out of 235 study participants (54.9%) belonged to medical and paramedical professions such as doctor, nurse, and lab technician.

The study showed that 134 out of 235 (57%) were adherent to COVID preventive behavior [Figure 1]. Majority of study participants (66%) reported that they rarely shook hands while greeting people. The preventive practices as reported by the study participants are given in Table 1.

Figure 1:
Proportion of Adherence to COVID protocol among study participants
Table 1:
Adherence to COVID-19 preventive measures among the study population

Chi-square analysis and binary logistic regression were done to find out the factors associated with nonadherent behavior. Gender and occupation did not reveal an association with nonadherence. Education of the study participants was found to be significantly associated with nonadherent behavior [Table 2].

Table 2:
Factors associated with nonadherent behaviour

Perceived barriers for adherence to preventive measures for COVID-19

A qualitative survey was undertaken to understand the reason for nonadherence to COVID preventive measures. The participant responses have been categorized into themes as follows;

Low level of awareness

Among the 235 study population, few participants opined that they do not believe COVID spreads through shaking hands with others. While a few of them considered maintaining social distancing unnecessary, some of them considered social distancing to be a hindrance to effectively communicating with others. A study participant stated; “I cannot avoid shaking hands as it looks rude not to do so.”

Among the 235 study population, 20% of the people do not clean personal items on reaching home. The reason one of them stated was “Disinfection is needed only if there has been contact with COVID positive patients.”


32.3% of people touches their eyes/nose/mouth without cleaning hands because they don't remember to do so. When enquired about sanitizing hands, a participant said; “I forget to sanitize my hands as I am not used to it.”

Congestion at workplace

The study participants were enquired about the reasons for inability to maintain at least one-meter distance between each other. One of them stated that:

“I cannot maintain social distance while having food with colleagues due to lack of space.”


The study population were asked their opinion on covering nose and mouth while wearing masks. The reasons stated for the same are as follows:

“I cannot cover my nose and mouth while wearing mask because it is difficult to breath.”

“Due to a loose fit, my mask slides down.”


The present study conducted a quantitative and qualitative enquiry into the adherence of the community to COVID preventive behavior in a sample of 235 vaccinated adults in Central Kerala. The study revealed that 57% of study participants continued to practice COVID preventive behaviour. In 2021, a study carried out in Iran showed that 61.9% of the participants frequently washed hands for at least 20 s, which is close to our findings.[13] In our study, approximately 30% of the study population rarely or occasionally attended social gatherings in the past 2 months This is a much lower percentage when compared to a study conducted in Maharashtra which included 1016 adults, out of which 91% refrained from attending social gatherings.[6]

A similar study conducted in Somalia showed a decreasing adherence to COVID-19 preventive measures.[8] This study finding underscores our finding that there is a fall in the adherence to preventive behavior in the community.

A notable finding was that even though 54% of the study participants were health care workers, the adherence to COVID protocols was only 57%. This is low compared to the adherence among healthcare workers in a similar study conducted in Saudi Arabia, in wearing masks, gloves, gowns, and goggles with a percent of 82%, 95%, 85%, and 68%, respectively.[14]

A study conducted in New Delhi showed that 56% of the participants sanitized their hands on all occasions,[9] which was higher than the present study which shows 31.1% for the same. Also, it was found that, 36% of the study population were mostly able to maintain social distancing compared to 62% from a similar study[9] Another study conducted in different states of India with a sample size of 984 reported that 52% practiced social distancing 79% of them ensured wearing masks properly.[15]

The present study revealed that the percentage of study participants correctly wearing masks was 65%. Comparison of the results reveals that there is a lowering adherence to COVID personal precautions. A similar study found that less than 40% of the participants ensured cleaning hands before touching eyes/nose, mouth, and cleaning/sanitizing personal items (purse, mobile phone, etc.) with sanitizer after coming home[15] is comparable to the prevalence of 31% and 16% respectively in the present study. The reason could be that the realization of the benefits of the same has led to a change in behaviour in the community and thereby a social change has been brought about. The present study showed the level of education of study participants to be significantly associated with their level of education. Comparable findings were found from a similar study that the odds of good level of adherences towards COVID-19 preventive measures increase with level of education.

The study participants were interviewed on the determinants of non-adherence to COVID preventive practices. The major perceived barriers that emerged from the study were forgetfulness, lack of space at workplace, misconceptions, and inconvenience. A similar qualitative study revealed that negligence and ignorance among the study participants were the barriers for practice of preventive measures for the COVID-19 pandemic.[16] These findings were similar to the findings of the qualitative survey done in the present study.


Since the healthcare workers were the initial vaccine recipients, the study of adherence to COVID protocol among the vaccinated individuals has led to an over representation of health care workers. The data which was self-reported could have been distorted by social desirability bias.

Strengths and future directions

The study was conducted as house-to-house survey as against the telephonic and online surveys which were the common methods of collecting the data during the COVID pandemic. This study provides a framework for further studies. Understanding the adherence to preventive health measures will help the program evaluators to identify the existing gaps and initiate training and capacity building activities to decrease the transmission of COVID-19 epidemic now and other unknown pandemics in the future.


The study reconnoitred a fall in adherence to COVID preventive protocols. Regular monitoring of compliance to adherence at the workplace, providing adequate facilities necessary to maintain adherence, conducting awareness sessions to remove misconceptions could help maintain the level of adherence necessary to combat the COVID-19 pandemic till or beyond the desired level of vaccination coverage is attained.

Ethical clearance

The study was approved by the institutional Ethics Committee of Believers Church medical College Hospital (IEC/2021/01/191).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1. Bartsch SM, O'Shea KJ, Chin KL, Strych U, Ferguson MC, Bottazzi ME, et al Maintaining face mask use before and after achieving different COVID-19 vaccination coverage levels: A modelling study Lancet Public Health. 2022;7:e356–65
2. Iezadi S, Gholipour K, Azami-Aghdash S, Ghiasi A, Rezapour A, Pourasghari H, et al Effectiveness of non-pharmaceutical public health interventions against COVID-19: A systematic review and meta-analysis PLoS One. 2021;16:e0260371.
3. Ren X, Weisel CP, Georgopoulos PG. Modeling effects of spatial heterogeneities and layered exposure interventions on the spread of COVID-19 across New Jersey Int J Environ Res Public Health. 2021;18:11950.
4. Wong VW, Cowling BJ, Aiello AE. Hand hygiene and risk of influenza virus infections in the community: A systematic review and meta-analysis Epidemiol Infect. 2014;142:922–32
5. Abeya SG, Barkesa SB, Sadi CG, Gemeda DD, Muleta FY, Tolera AF, et al Adherence to COVID-19 preventive measures and associated factors in Oromia Regional state of Ethiopia PLoS One. 2021;16:e0257373.
6. Shewale SP, Sane SS, Ujagare DD, Patel R, Roy S, Juvekar S, et al Social factors associated with adherence to preventive behaviors related to COVID-19 among rural and semi-urban communities in Western Maharashtra, India Front Public Health. 2021;9:722621.
7. Wright L, Steptoe A, Mak HW, Fancourt D. Do people reduce compliance with COVID-19 guidelines following vaccination? A longitudinal analysis of matched UK adults J Epidemiol Community Health. 2022;76:109–15
8. Ahmed MA, Colebunders R, Gele AA, Farah AA, Osman S, Guled IA, et al COVID-19 vaccine acceptability and adherence to preventive measures in Somalia: Results of an online survey Vaccines (Basel). 2021;9:543.
9. Agarwal A, Ranjan P, Rohilla P, Saikaustubh Y, Sahu A, Dwivedi SN, et al Development and validation of a questionnaire to assess preventive practices against COVID-19 pandemic in the general population Prev Med Rep. 2021;22:101339.
10. Braun Virginia, Clarke Victoria. Using thematic analysis in psychology Qualitative Research in Psychology. 2006;3:77–101
11. Boyatzis R. Transforming Qualitative Information: Thematic Analysis and Code Development 1998 Thousand Oaks, CA Sage
12. Dapkus MA. A thematic analysis of the experience of time J Pers Soc Psychol. 1985;49:408–19
13. Firouzbakht M, Omidvar S, Firouzbakht S, Asadi-Amoli A. COVID-19 preventive behaviors and influencing factors in the Iranian population; a web-based survey BMC Public Health. 2021;21:143.
14. Albeladi FI, Alluli MM, Daghriri KA, Almalki YH, Wafi MY, Otaif FA, et al Level of adherence to COVID-19 preventive measures among health care workers in Saudi Arabia Cureus. 2021;13:e15969.
15. Chakrawarty A, Ranjan P, Thrinath A, Aggarwal E, Isaac JA, Berry P, et al Assessment of preventive practices followed by general public during COVID-19 pandemic – A cross-sectional survey from India Cureus. 2020;12:e11274.
16. Mersha A, Shibiru S, Girma M, Ayele G, Bante A, Kassa M, et al Perceived barriers to the practice of preventive measures for COVID-19 pandemic among health professionals in public health facilities of the Gamo Zone, Southern Ethiopia: A phenomenological study BMC Public Health. 2021;21:199.

Adherence; COVID 19; Kerala; preventive practices

© 2022 Dentistry and Medical Research | Published by Wolters Kluwer – Medknow