Summary of Main Findings
One major finding is the strong and consistent association of lower educational level with most of the protective behavior outcomes. Interestingly, while high education seems to be clearly associated with behavior change, we found no educational gradient, i.e., there is no consistent pattern across all eight outcomes indicating a positive linear relationship between education and protective behavior. However, for most protective behaviors such as avoid gatherings, reduce personal contacts and meetings, or increased hand hygiene, our results suggest that lower educated people are less likely to undertake these measures. Contrary, lower education is associated with higher odds for undertaking no protective behavior at all. This is in line with surveys from other countries. A cross-sectional study among adults in the United States found a gradient between health literacy and change of daily routines (15). Accordingly, people with higher health literacy were more likely to change their behavior. A study among adults who were studying at a medical university or completed their medical education showed that both educational attainment and medical education is associated with protective behavior. Higher educated people adopted more preventive measures like wearing masks or using disinfectants (16). Another recent study from Saudi Arabia reported similar results, i.e., higher educated participants were more likely to adopt protective practices (17).
A second major finding is the association between gender and protective behavior. Being female was associated with higher odds of protective behavior for most outcomes. Exceptions were wearing face masks, which was not clearly associated with male or female persons, and adapting the school or work situation, where female respondents were less likely to do so. A higher willingness to change their behavior and to act preventively seems to be more common among women than among men in Germany. This result is also in line with other studies (17).
A third and rather surprising finding is the inconsistent and mostly weak association between individual behavior change and the respondents' age. Against the background that higher age is a known risk factor for a more severe COVID-19-associated illness and death (18, 19), which has also been widely reported in media, we would have assumed that higher age groups show more protective behavior.
Gender and education are important socio-demographic factors related to protective behavior. It is known that there is a socioeconomic gradient, resulting in social and health inequalities related to the COVID-19 outbreak (20, 21). In particular, socioeconomic characteristics like lower income and lower education are associated with an increased risk of COVID-19 related mortality (22, 23), which stresses the necessity to reduce health inequalities (24). Similarly, lower educated people almost have a doubled risk of getting infected with COVID-19 as compared to higher educated people (25). There are three possible explanations for the socioeconomic and educational disparities discussed in the literature. Differential exposure, differential susceptibility, and differential access to health care (26, 27). Differential exposure refers to different living and working conditions. With exception of people working in critical jobs (like health care workers), lower educated people less often have the opportunity for home office and are more likely to have jobs with higher risk exposure (28). Differential susceptibility describes the correlation between higher morbidity and lower income and education. People of lower status groups have disproportionately higher levels of health conditions, that increase the risk of complications from COVID-19 (29). Differential access to health care means that people with lower income and lower education face more barriers in accessing health care provision, are less likely to use preventive services and health services and take more time before seeking help (30–33). Moreover, protective behavior and the perception of health risks varies by socio-demographic factors and socioeconomic status. For instance, people with lower education underestimate the cancer risk due to smoking (34, 35). Thus, differential perception of health risks or differential perception the usefulness of protective behavior would be another explanation for the differences between respondents depending on socio-demographic factors.
In conclusion, adopting or failing to take protective behavior is not only related to sufficient knowledge about COVID-19. People might not have the possibility to change working or living conditions in order to better practice protective behavior. Hence, it is important to either provide sufficient opportunities for home office, or public health measures should aim at making workplace conditions more secure in accordance with distancing or hygiene measures. Another important aspect is the availability and affordability of necessary equipment like face masks or disinfectants. For instance, at the beginning of the pandemic in Germany, the government did not suggest wearing face masks simply for the reason that those masks were not available for the broader public. Furthermore, lower education is often associated with lower health literacy (36), which also affects how people are able to cope with the enormous amount of information on COVID-19 in the media, and how to separate useful and important information from misinformation. A recent study among the German population showed that 56% of the respondents were unsettled by the flood of information, and only 51% believed themselves capable of judging whether information about COVID-19 was trustworthy (37). A lack of knowledge how to properly adopt protective behavior may result in lower educated people being more susceptible to infection risks. As such, improving disease specific knowledge and health literacy and developing strategies for dealing with misinformation is essential.