Health Perceptions and Adopted Lifestyle Behaviors During the COVID-19 Pandemic: Cross-National Survey
Authors: Manjunath Nandi Krishnamurthy , Majumdar Vijaya , Rozzi Antonietta , Huiru Wang , Mishra Avinash , Kimura Keishin , Nagarathna Raghuram , Nagendra Hongasandra Ramarao 
Published: April 2021

Background
Social isolation measures are requisites to control viral spread during the COVID-19 pandemic. However, if these measures are implemented for a long period of time, they can result in adverse modification of people’s health perceptions and lifestyle behaviors.

Objective
The aim of this cross-national survey was to address the lack of adequate real-time data on the public response to changes in lifestyle behavior during the crisis of the COVID-19 pandemic.

Methods
A cross-national web-based survey was administered using Google Forms during the month of April 2020. The settings were China, Japan, Italy, and India. There were two primary outcomes: (1) response to the health scale, defined as perceived health status, a combined score of health-related survey items; and (2) adoption of healthy lifestyle choices, defined as the engagement of the respondent in any two of three healthy lifestyle choices (healthy eating habits, engagement in physical activity or exercise, and reduced substance use). Statistical associations were assessed with linear and logistic regression analyses.

Results
We received 3371 responses; 1342 were from India (39.8%), 983 from China (29.2%), 669 from Italy (19.8%), and 377 (11.2%) from Japan. A differential countrywise response was observed toward perceived health status; the highest scores were obtained for Indian respondents (9.43, SD 2.43), and the lowest were obtained for Japanese respondents (6.81, SD 3.44). Similarly, countrywise differences in the magnitude of the influence of perceptions on health status were observed; perception of interpersonal relationships was most pronounced in the comparatively old Italian and Japanese respondents (β=.68 and .60, respectively), and the fear response was most pronounced in Chinese respondents (β=.71). Overall, 78.4% of the respondents adopted at least two healthy lifestyle choices amid the COVID-19 pandemic. Unlike health status, the influence of perception of interpersonal relationships on the adoption of lifestyle choices was not unanimous, and it was absent in the Italian respondents (odds ratio 1.93, 95% CI 0.65-5.79). The influence of perceived health status was a significant predictor of lifestyle change across all the countries, most prominently by approximately 6-fold in China and Italy.

Conclusions
The overall consistent positive influence of increased interpersonal relationships on health perceptions and adopted lifestyle behaviors during the pandemic is the key real-time finding of the survey. Favorable behavioral changes should be bolstered through regular virtual interpersonal interactions, particularly in countries with an overall middle-aged or older population. Further, controlling the fear response of the public through counseling could also help improve health perceptions and lifestyle behavior. However, the observed human behavior needs to be viewed within the purview of cultural disparities, self-perceptions, demographic variances, and the influence of countrywise phase variations of the pandemic. The observations derived from a short lockdown period are preliminary, and real insight could only be obtained from a longer follow-up.