Response-efficacy.

Support for self-imposed isolation due to potential exposure was virtually non-existent, but, in general, participants agreed that someone who has COVID-19, as confirmed by a positive test result, is morally obligated to isolate themselves from others to prevent the spread of the virus. People who questioned the usefulness of quarantine, also questioned the validity of the COVID-19 test, asking what proves that the person has COVID-19. This lack of trust in the COVID-19 test, reflects a broader distrust in the government when it comes to COVID-19 and a sentiment that the matter of quarantine was poorly handled by the government in Côte d’Ivoire. Across numerous FGDs and IDIs, participants recounted that, at the beginning of the pandemic, celebrities (politicians, artists, athletes) and relatives of government officials returned to Côte d’Ivoire from abroad, refused to respect the government-imposed central quarantine and were allowed to quarantine at home. This favoritism undermined the legitimacy of the pandemic in Côte d’Ivoire and contributed to a pervasive fear of quarantine in government facilities. Participants equated quarantine to a “death sentence” or even a “slaughtering house,” and shared the general perception that COVID-19 patients in government facilities were not well cared-for. Fear of forced quarantine paired with fear of stigma also led to a fear of testing and avoidance of hospitals. As one FGD participant said, “If a person suspects they have the disease, because of the eyes of others [stigma] and fear, they will say if I go there, they will retain me and put me in quarantine. So that person starts to treat themselves by taking indigenous remedies” (female, 40–49 years old, FGD, did not know someone who had COVID-19).

Self-efficacy.

Quarantine was viewed as an economically and psychologically difficult sacrifice for the greater good. Participants felt that, in absence of support from the government, quarantine for two-weeks was only feasible for people with economic means. Most Ivoirians, who earn their living day-to-day, neither have the space in their home to quarantine, nor the ability to meet their daily needs for food, water, and rent, during a two-week quarantine. Participants voiced the need for government support for sufferers of COVID-19 and their families, in the form of humane government quarantine facilities and compensation for lost income during quarantine. This government support was largely felt to be completely lacking or misappropriated. Participants also spoke of the psychological toll of quarantine, describing Ivorians as people who value freedom, mobility, and crave social interaction. A health worker said, “Quarantine, in the mentality of most people, is a prison, a deprivation of liberty that is difficult to accept” (male, 50–59 years old, IDI, health provider who did not care for COVID-19 patients). A FGD participant said, “I would say very very difficult. As I said before, every man aspires to move freely. Staying in quarantine is very difficult” (male, 30–39 years old, FGD, did not know someone who had COVID-19). Overall, people who did self-isolate if sick were viewed positively, as sacrificing themselves for others. However, the word “quarantine” was tainted by the negative perceptions of quarantine in government facilities, in contrast to self-isolation at home which wasn’t labeled quarantine by some, and by stigma. Quarantining, either at a government facility or at home, was felt by some to betray a COVID-19 positive status that would leave a permanent mark on the family. Participants expressed an internal, moral pressure to quarantine if a person knows they are sick and an external pressure to quarantine if others know you are sick. Participants who had never met anyone with COVID-19 or who doubted its existence abstained from questions around normative pressure to quarantine, having not experienced contact with the disease first-hand.

Social norms.

In Côte d’Ivoire, isolating a sick person is to stigmatize them and goes against the Ivoirian culture. As one health worker explained, “In Côte d’Ivoire, and in Africa in general, [quarantine] is the measure that is the most difficult for the population to accept…. It isn’t in the culture. If you are sick, you have family around you. Isolating people like that is the measure that will derail the entire system because, in our culture, if you quarantine someone, you stigmatize them” (male, 50–59 years old, IDI, health provider who did not care for COVID-19 patients). Positive deviants among the participants expressed that it is possible to isolate a sick family member at home while respecting all safety measures and still caring for them, not abandoning them. A FGD participant said, “If my family were contaminated, I would follow the measures listed here, but I wouldn’t abandon the person. It isn’t humane” (female, 30–39 years old, FGD, did not know someone who had COVID-19). Another FGD participant said, “If a brother or someone I know is sick, we’ll adopt the barrier measures. He will be quarantined in a room, and we’ll give him the necessary love” (female, 20–29 years old, FGD, did not know someone who had COVID-19).

Response-efficacy.

Most participants understood how physical distancing can limit the spread of the virus; however, successful application of distancing was thwarted by a strong desire for social cohesion. People valued distancing as an alternative to avoiding crowds, as one FGD participant said, “I think that when there are ceremonies and marriages and things that it is useful to maintain distance because there are more than 50 or 100 people, more than 200 people. So I think it is good” (male, 40–49 years old, FGD, did not know someone who had COVID-19). Distancing was not framed in terms of usefulness or uselessness, but rather in the context of social dynamics and mobility that punctuate people’s daily lives. In other words, people considered whether the behavior is “useful” less from a medical perspective and more from the angle of the social proximity in which travel and valued interpersonal interactions take place. Also, this behavior was perceived as non-useful and trivialized for those whose interpretation of the pandemic was influenced by misinformation, as exemplified by a participant who said:

People who insist on the one meter are stupid because in the first place we’ve told you that it doesn’t exist, you’ve never seen it, because us Africans, we like to see to believe, so something that I’ve never seen, that I’ve never even seen, and around me, no one has it, my head isn’t in it, so I can’t worry about one meter. And now you apply it, I already find you bizarre, what are you looking for? Because there is nothing. Corona is for the whites, it’s for the rich, we haven’t had it yet, so it isn’t in our heads to say one meter like that. (male, 20–29 years old, FGD, did not know someone who had COVID-19)

Other participants similarly described the belief that Africans are more resistant to COVID-19, that the virus has a mystical origin, or that COVID-19 is over in Côte d’Ivoire.

Self-efficacy.

Physical distancing confronts the norms that govern social interactions in Côte d’Ivoire. Gestures of familiarity such as greetings, handshakes, and hugs reinforce social bonds. Distancing, by definition, sets one apart from others which goes against the very grain of Ivorian culture. Keeping 1 meter from others was perceived as more feasible among strangers than among friends and family, as one participant described, “People think that they need to keep a distance from people that aren’t from the family, that aren’t from the neighborhood. So, if you go to a supermarket, you know it’s a measure, so you keep your distance. Because you don’t know them, so there it is easy, but in the community, in the neighborhood, in the house, it isn’t easy” (female, 30–39 years, FGD, knew someone who had COVID-19). In some cases, people who insisted on social distancing among familiar others were mocked as overly compliant “puppets” of the government.

In addition, socio-economic factors contributed to an inability to maintain physical distance between individuals. Indeed, housing and travel patterns (overcrowded housing and public transport) limit the feasibility of this behavior. Difficulty in complying with distancing was more marked in spaces with intense and "uncontrolled" interactions such as markets and public transportation, in contrast with other settings such as places of worship, pharmacies, supermarkets, and banks, where distancing was often imposed. The inability to systematically maintain 1 meter from others led some participants to prioritize other behaviors such as handwashing, use of hand sanitizer, or mask wearing to the detriment of respecting physical distancing. On the other hand, some participants felt keeping 1m distance was easier than the other behaviors because it did not require purchasing anything, such as soap, sanitizer, or masks.

Social norms.

Perceived social norms were unfavorable to physical distancing and reflected the government’s failure to model recommended COVID-19 prevention behaviors by holding political rallies and televised funeral rites for a deceased minister. Reported lack of compliance with distancing in health centers further undermined normative support for this behavior. These actions were seen as contradictions by study participants or even as reinforcing misinformation that questioned the existence of the virus.

Response-efficacy.

There was considerable variation in beliefs about whether masks are helpful, neutral, or harmful. Some thought that masks were contaminated with the SARS-CoV2 virus and would infect people. The suspicion about masks intersected with stigma around the origin of the illness, as described by a participant who said that most masks “come from China and the disease started there. The Chinese want to propagate [the disease] here, so one thought is that it is in the masks” (female, 30–39 years old, FGD, knew someone who had COVID). On the other hand, some people did not feel the masks were useful or necessary because they did not believe in COVID-19 at all or that COVID-19 was still in Côte d’Ivoire. A participant said, “they are fed-up. When you say, ‘you have to wear a face mask,’ insults follow: ‘You are pissing people off with your Corona business… there is no Corona here’” (female, age not provided, IDI, recovered from COVID-19). As with other preventive behaviors, this doubt about the existence of the virus undermined compliance with mask wearing. Health workers, on the other hand, valued mask wearing as a way of protecting others. One health worker explained, “If you love your neighbor, it means that you also love yourself. So, you have to wear your mask correctly” (female, 30–39 years old, IDI, health provider who cared for COVID-19 patients). Participants in the general population often framed the need for a mask around whether they were around people close others or strangers. One individual differentiated between the home neighborhood as opposed to the larger city, saying “Here, in the neighborhood, when we don’t go out, we’re just here in our sector, we find that it’s not useful [mask wearing]. But when we want to go out, it is imposed on us” (female, 30–39 years old, FGD, did not know someone who had COVID-19). The only valid time to wear a mask in the neighborhood was if you were diagnosed with COVID-19, a belief that led to harmful assumptions about people who did wear masks. One participant described being afraid of people wearing a mask, saying, “someone who always has their mask on, we fear him, because we think he has the disease” (male, 30–39 years old, FGD, knew someone who had COVID-19). Another participant described being temporarily expelled from her housing situation because wearing a mask exposed her COVID-19-positive status.

Self-efficacy.

Wearing a mask was difficult for community members to respect. According to participants in FGDs as well as health workers, the main issues were comfort and cost. Participants described people objecting that masks “suffocate them. So, some people don’t wear them. Not because they don’t know its importance! But some people say that it makes them tired, so that’s why people have let up [on mask wearing].” (female, 30–39 years old, FGD, knew someone who had COVID-19). Particularly in the heat, masks were considered untenable. As with other barrier measures that had to be purchased, the cost was prohibitive for some participants.

Social norms.

Mask wearing, except in places and spaces where it was required, was considered unacceptable for most people after the initial phase of the pandemic. Wearing a mask was seen as setting oneself apart, as described by a participant who said, “we find him superior to us, because he thinks his Corona, his COVID-19, is so important” (female, 20–29 years old, FGD, knew someone who had COVID-19). COVID-19 survivors were more determined to wear masks; their experience with the illness gave them motivation to overcome unfavorable social norms. One participant who had survived COVID-19 said that, after having COVID-19, he continued to wear a mask even when others did not, saying, “with respect to the barrier measures, I was the first to wear a mask” (male, age not provided, IDI, recovered from COVID-19). Another participant who had recovered from COVID-19 perceived her risk to be higher, saying she was now convinced COVID-19 exists and “in my opinion, the only way to avoid the disease is to wear a mask.” (female, age not provided, IDI, recovered from COVID-19).

People described that wearing masks in public places was acceptable where it was required. Mandates and enforcement appeared to have a favorable impact on mask uptake in crowded settings, as a participant explained, “In my church, there are people who come without a face mask, but it is mandatory, without a face mask, you can’t enter. So, they are obligated to wear it. If it were just up to them, they would enter without a face mask” (female, 20–29 years old, FGD, did not know someone who had COVID-19).

Response-efficacy.

Among participants who felt that COVID-19 was both real and severe, handwashing was valued as a way to protect oneself. Those who questioned the efficacy of handwashing often also questioned the existence of COVID-19 in Côte d’Ivoire and subscribed to a narrative of African invulnerability to the disease:

In the beginning, there was really a scare everywhere. But after that, people in families, in neighborhoods, people don’t pay much attention anymore. Me, for example, at my work there was a time when everyone washed their hands. The buckets of water are still there today, but it is rare that people wash their hands because, by the grace of God, God is with us, when you look at Africa, if it isn’t the white, yellow or other skin, in Africa, really, blacks don’t die like that. Even the second wave that is disfiguring Europe, America, in Africa we don’t hear that.” (male, 50–59 years old, FGD, did not know someone who had COVID-19).

Other participants felt that handwashing was the only behavior worth continuing in light of waning risk perception, as described by one individual who lost a family member to COVID-19, “I don’t care. It is finished. I don’t care… what will happen, will happen. I’m careful to a certain extent, I wash my hands, but I’m no longer like I was before, at the beginning, when we barricaded our noses, we didn’t visit, we didn’t touch people. Listen, I go where I want” (male, age not provided, IDI, lost a family member to COVID-19). This fatalism regarding infection was common among people who felt both low risk perception as well as low self-efficacy to maintain the prevention behaviors.

Self-efficacy.

The installation of handwashing stations at the entrances to communities, businesses, and homes temporarily boosted self-efficacy and favorable perceived social norms at the beginning of the pandemic. However, self-efficacy eroded over the course of the pandemic as people felt unable to maintain the initial systematic handwashing over the long term and began to feel impervious to the disease, as described by a participant, “At the beginning, we washed our hands a lot. Every time we went out, we washed our hands. In every courtyard, even, some people even put buckets and things, but as we went along, we started to tend to live a little bit with the disease” (male, 20–29 years old, FGD, knew someone who had COVID-19). As the pandemic progressed, fear waned as did compliance with the prevention behaviors.

Social norms.

Handwashing benefitted from prior normative support, as a practice that predates COVID-19 and has long been promoted to fight infections. In that regard, handwashing escaped the stigma attached to other prevention behaviors that emerged specifically in response to COVID-19. Promotion in schools and through various disease-based programming has led to general acceptability of handwashing as a preventative practice. However, the acceptability of handwashing is often limited to specific times or rituals (like before meals). A health worker explained that the inappropriate timing of handwashing can be perceived as insulting: “very few people will wash their hands. Imagine that you shake my hand and that you immediately go and wash your hands. What impression would I have of the fact that after shaking my hand, you go and wash them? That’s not accepted in our culture” (male, 50–59 years old, IDI, health provider who did not care for COVID-19 patients). Across groups with respect to public places, participants characterized the existence of handwashing stations as a form of pressure as well as being asked to wash hands before entering a places like supermarkets. At the household level, participants who knew someone who had had COVID-19 appeared to feel and exert more pressure within families to wash hands regularly.

Response-efficacy.

Participants generally expressed the belief that using hand sanitizer not only prevents COVID-19 but is also effective against other diseases that can be transmitted by dirty hands. However, some participants from the general population, especially those who did not know someone who had had COVID-19 and/or who did not believe in the disease, did not believe that hand sanitizer was useful in preventing COVID-19.

Self-efficacy.

Frequent use of hand sanitizer was perceived by study participants to be the easiest COVID-19 prevention behavior to adopt and maintain over time. They opted for hand sanitizer as a way of foregoing other, more challenging, behaviors to adopt, as described by a participant who said, “One of my friends was telling me that when he wears the mask, it suffocates him. So everywhere he goes he takes hand sanitizer. Every time he touches something, he puts a little in his hands” (male, 20–29 years old, FGD, knew someone who had COVID-19). Given that cost (and stock outs at the beginning of the pandemic) were the primary barriers to frequent use of hand sanitizer, some participants advocated for making hand sanitizer available to the population free of charge. Hand sanitizer is relatively low cost, quick and fun to use, portable, discrete, and therefore inoffensive, and easy to share making it a prevention behavior that contributes to social cohesion and is culturally acceptable. A health worker described this link between self-efficacy and social cohesion, saying, “If you have your little hand sanitizer, that hand sanitizer, it can be shared, you see? You can share it, so it is easy for them to have” (female, 20–29 years old, IDI, health provider who cared for COVID-19 patients).

Social norms.

Frequent use of hand sanitizer as a social norm ebbed and flowed with risk perception related to highly mediatized public health threats. Participants recounted that hand sanitizer was made available in most public places during the Ebola crisis in 2014 and then disappeared when the perceived threat of Ebola was gone, and a similar pattern was emerging with COVID-19. The availability of hand sanitizer and reminders to use it before entering public places (banks, pharmacies, hospitals, places of worship, etc.) generated a positive social norm around the frequent use of hand sanitizer and boosted self-efficacy by overcoming barriers related to access.

Response-efficacy.

Most study participants were skeptical of the response-efficacy of limiting gatherings to 50 people. Participants questioned the scientific basis for the 50-person threshold and felt that limiting gatherings to 50 people would not guarantee protection against COVID-19. Changing guidance about the number of people who could safely gather and large public events undermined trust in the efficacy of this recommendation, as described by an individual who said, “at first it was 50 people but now they’re saying it’s 200 people. You see, I think that even here, I think that the State itself thinks that it is not important” (male, 20–29 years old, FGD, knew someone who had COVID-19).

Self-efficacy.

Self-efficacy related to avoiding large gatherings or limiting gatherings to fewer than 50 people was low, given socioeconomic and cultural constraints. Participants expressed being unable to avoid crowded places like markets and public transportation. Institutions such as administrative offices, banks, pharmacies and places of worship were able to impose restrictions on the number of people, but individuals expressed being unable to ban family members and friends from events they would have otherwise attended.

Social norms.

Social norms favor large gatherings for the celebration of important life events as opportunities to express social solidarity, strengthen social ties and show hospitality. Participants described others who tried to limit the size of social gatherings as “mean,” “selfish,” “cheap,” and “antisocial.” One participant described it as “not easy at all because the men, the people in the community are called to live together, every day, they have to share their problems, their worries, their emotions together. Forcing them to respect the fifty people, the fifty people in a gathering, I think that it is impossible, it is difficult” (male, 30–39 years old, FGD, knew someone who had COVID-19).

Response-efficacy.

Participants understood why limiting movement would limit the spread of the virus, but the term “non-essential” created confusion because most travel was deemed essential for economic or sociocultural reasons. Participants described maintaining certain behaviors while allowing themselves to travel, “they don’t find it useful, they say to themselves that they can travel, they can move around, there is no problem. What people have retained in this story of Coronavirus, what they have retained to fight disease is masks, hand sanitizer. As for traveling, I don’t think it is important, he moves about. If he’s in a car and he wears a mask that is enough” (male, 30–39 years old, FGD, knew someone who had COVID-19). This tendency to observe certain prevention behaviors and not others was common and often influenced by economic realities.

Self-efficacy.

Participants felt they could postpone certain travel, yet family obligations were particularly difficult to avoid, as described by a health worker who said, “maybe for 1 month you can limit [travel]. Beyond that, there are difficulties, for example, there’s a funeral, the guys have to go to the village” (male, 50–59 years old, IDI, health provider who did not care for COVID-19 patients). The ease or difficulty of complying with this behavior also depends on social status and type of work. Many participants expressed that it would be easy for well-to-do families (with stored resources to meet their needs for a longer period of time) to limit their travel, and more difficult for those who are less well off or are living hand-to-mouth. Receiving material assistance and food supply facilitated adopting this behavior, whereas misinformation–particularly skepticism that COVID-19 exists–undermined compliance. As limited travel disrupts social habits that involve mobility, contact and interaction with others, participants expressed considerable skepticism that the behavior could be maintained long term.

Social norms.

Participants felt that members of the general population did not limit travel and pointed to a lack of modeling on the part of public figures. Within communities, there was little or no pressure from peers to limit non-essential travel, both due to a general disbelief in COVID-19 and a shared understanding that socioeconomic priorities came before observing ambiguous government restrictions. People who encouraged others to limit travel were perceived as "wimpy," "lazy," "overzealous," or "rich”. Notably, those who felt the behavior was important tended to have some personal exposure to COVID-19 through their family or social networks.