How do Beliefs Inform and Impact our Pandemic World: An Exploration in Infection, Death and Society – A Blog By Wyatt Reed

For a long (too long) time, we have been in a novel pandemic due to the Severe Acute Respiratory Syndrome Coronavirus 2, SARS-CoV-2, virus. This virus has caused millions of deaths and hundreds of millions of cases around the world, with m any varying responses. This has caused a unique and complex outcome of cases and response.^1,2,3 One way to understand how a disease is spreading and to keep it under control is through testing and monitoring.

There are many vectors to evaluate in this situation, but I want to explore understanding infectious disease through water quality testing and wastewater management. Agricultural runoff and other human manipulations have been an increasing issue in terms of water quality and continuing to negatively impact the environment. Since the Clean Water Act of 1972, water quality has been taken much more seriously. So, routine monitoring and measurement of compounds in water sources has been commonplace. So, it seems like monitoring for infectious disease would be as standard too, right? I mean, in 1854, we made great advancements in our understanding of infectious disease through water when John Snow traced Cholera outbreaks to one well in London.⁴ The CDC took control of testing in 1971, which included infectious disease monitorization.

For our community, the water in question is Lake Monroe, which is filled from mainly 3 forks of Salt Creek. Lake Monroe became the source of water in 1967, and is currently the primary water source for the city of Bloomington, IN. The lake and its surrounding water serve as home to many beautiful creatures, sites for restaurants and whole towns. The watershed is over 440 square miles and includes many smaller creeks that feed into salt creek or the lake directly.⁵

 

With current events like the Flint water crisis and the continual lack of access to sanitary water in developing countries, the paramount importance of water has never been as important to human health and biodiversity.⁶ Monitoring a resource this important is extremely crucial, and extremely timely to explore all possibilities in water and wastewater monitorization due to the ongoing COVID-19 pandemic.

The Issue(s):

Nutrient pollution is when compounds like phosphate and nitrate come into lakes, rivers, and streams in excess. Phosphorous (P) and nitrogen (N) are biochemical precursors to life, along with carbon. P and N help organisms synthesize DNA for cell division, create amino acids the cell needs to live, and create energy for the cell. When excess biochemical precursors like this enter the living environment of the water, algae can start to grow.^6,7

 

Algae is an important organism that eats a lot of carbon dioxide through the process of photosynthesis and produces a lot of oxygen for animals to breathe. However, in excess, these algae can decrease the amount of oxygen and light that water organisms need to survive. Harmful algae have caused many fishes and marine plants to die and has been shown to decrease biodiversity. CITE For us, we most often notice it when it makes out water taste different. Coincidentally, nutrient pollution often comes from agricultural runoff, meaning the reason algae becomes an increasing issue due to food production. So, our food consumption comes at a balancing price to the quality of our consumable water.

 

In addition to the harm that algae can cause, there is also specifically “harmful algae blooms.” As these blooms grow, they produce toxins that can kill fish and humans exacerbating the oxygen depletion effects with toxic additives. They produce cyanotoxin or support cyanobacteria in their microhabitat. In humans, this can cause inflammation, respiratory issues, and interacts with their nervous system to depress it and may be an environmental cause of neurodegenerative diseases like Amyotrophic Lateral Sclerosis.⁹

Nitrogen, phosphorous, mercury, and algae are all measurable through water sampling. The Environmental identifies a safe level of Nitrogen (in the form of NO₃^–) is 10 mg/L, 100ppb in streams and 50ppb in lakes

for Phosphorous (in the form of PO₄^2-). Mercury (in water as Methylmercury MeHg) is considered dangerous at .002mg/L.¹⁰ Algae is a more relative disturbance that does not have a standard “excess level”, but its effects can be seen once that point is reached. Eutrophication is the process of this phosphorous entering the water, and eventually becoming enriched with other chemicals and minerals. As detailed above, eutrophication is the reason that a lot of animal life dies; this enrichment removes oxygen from the water, reducing the ability of fish and other organisms to survive. This imbalance can lead to a reduction of biodiversity in habitats which further emphasizes this imbalance in aquatic systems. Biodiversity can likely create many unintended consequences, but it can affect our population by creating unsafe water, reducing fish populations that people use for sport or food, and reduces organisms for wild animals and birds to feed off .¹¹

We often seek to test how our farms affect our water, and how the natural (and manufactured natural) landscapes leech into aquatic systems. The natural world also has a large impact on our experience with infectious disease, but how to we influence that experience? Our farms create runoff that encourages algae; even though the algae flourishes, it kills off much of the aquatic diversity, which throws off natural equilibriums, and can invite infectious diseases to emerge.¹²

Infectious disease can often come into the limelight when humans interact strongly with the natural world we exist in; humans physically interact with viruses, bacteria, and other organisms that they have maybe never experienced before, and this greatly increases the risk of spillover, or a pathogen movement from one host species to a different host species.^12,13 These things can travel through air, water, other organisms, among many things. In terms of our biodiversity, there is a push and pull between biodiversity and infectious disease, and our farming practices play a big role in that. In many areas of the world, we destroy our biodiversity and fertile lands to make room for crops. On one end, this means there is less biodiversity to contribute to genetic mutations that allow for new viruses to be made and given to humans. At the same time, it means that the organisms in that landscape are being concentrated to smaller lands or being pushed into the territory of humans. This increases interactions between other living matter and with humans and may increase the chances of a mutation of a virus to affect          humans drastically, like the COVID-19 pandemic did.¹⁴

Because of COVID-19, this has become increasing topic of conversation not in just water or our forests, but wastewater, or sewage.⁴ Our sewage is a possible source for infectious disease monitoring because it a favorable environment for a pathogen to survive, and feces is a good host for disease. There is infrastructure surrounding water testing, and is well supported, but it is seemingly just now an emerging field because of COVID-19.^15,16 In Indiana, agricultural runoff is one of the larger concerns, since the state is home to many farming communities. I want to explore how communities like this feel about monitoring agricultural runoff and infectious disease, how feasible it is, and what changed would need to be done to increase the frequency in which they test. In addition, since both water quality and infectious disease may have impacts on the environment, I want to explore how the pandemic has manipulates attitudes, beliefs, and perceptions of infectious disease and interactions with the environment.

Upon further investigation, this project morphs from understanding the impact of water on the environment, but to how we understand infectious disease in our natural world in general, to have a more generalizable question. Because of a research grant and experience I was awarded during the synthesis of this project, we decided to follow through with this transition and use the international populations I will have access to as an advantage. I have included the previous work before the transition so that we can all better understand the angle I am coming at this work from, and because research related to agriculture and wastewater would be important future research after my project.

This project is a pilot study and pre-testing of a survey and interview guide to do a larger-scale project related to similar themes in Costa Rica during the summer of 2022. The methodological decisions made throughout this semester will be used to gain information on United States citizens in the following semester, and Costa Rican citizens in the following summer for comparative purposes. Surveys and Interviews were chosen as the main method of data collection for the attitudes because it allows for a larger n to be acquired while also getting targeted qualitative data to give better contexts to the data retrieved. This data will serve as the social side of my research, as I intend to understand the intersection of policy, biology, and society in this novel experience, and use the two countries as a comparison.¹⁷

For qualitative methods, interviewing people is quite time intensive and more subjective than other qualitative methods.¹⁸ However, Interviews do provide contextual information not provided in surveys or quantitative methods.¹⁹ Surveys allow for a flexible medium to get quantitative and qualitative data, but often have many possible variables to consider when creating because it is important to isolate factors to truly evaluate which are impactful. This study intends to use both surveys and interviews to increase participation without losing the contextual data and information an interview can provide over other methods.

Pre-testing of the survey will be with undergraduate students at a large, midwestern US research institution who may or may not have experience in this field. This will help determine any issues with questions.²⁰ In understanding the importance of how people think about pandemics and infectious disease, my main eligibility question was how people believe the COVID-19 pandemic began, this helped tailor my questions to explore belief acquisition and how people understand infectious disease. For example, if all people believe it is a spillover event, then it is not super productive to ask questions about why they think it was created in a lab, or how the lab caused it. If people believed it to be a lab accident, it may be helpful to ask where they think the virus came from before the lab or if it was created in the lab but asking them how they understand spillover is not as imperative to understanding attitudes of infectious diseases.

Targeted interviews for the purpose of study design will take place to here from individuals in varying fields and see how infectious disease, specifically COVID-19 affects their work. These interviews will be professors in health science, wastewater treatment workers, Department of Natural Resources employees, among others. People in health sciences understand the impact different factors have on human health and can provide insight to how infectious disease and COVID have impacted us and impacted out health systems. Hospital systems often do monitorization themselves,

and it would be insightful on their thoughts to see if monitoring through wastewater would be beneficial to these population. Past research has shown repeatedly that physicians who understand their patients’ surroundings and environment create better health outcomes for their patients.²¹ Attitudes surrounding my interview topics may give insight to health outcomes related to these topics. Wastewater treatment employees have the best understanding of the infrastructure of these facilities and can provide insight to the history of testing at these facilities, and what COVID has changed to those procedures. Like agricultural runoff, sewage could be a source of nutrient pollution. I believe their insight on beliefs about nutrient pollution, the impacts of wastewater, and how disease spreads through waste is an important component to understanding the attitudes of those making actionable difference towards this monitoring.¹⁹ Employees of the Department of Natural Resources have a focus on the environment, sustainability, and protection. Monitoring wastewater and water quality directly and indirectly effects wildlife and natural habitats. Since their job is to survey, monitor, and protect our natural world, they may benefit from this monitoring.

The factors of the pandemic that sparked this research was public health responses and how they varied from country to country.²² Though I do not intend to evaluate wastewater specifically, I am curious in how the services and actions we use impact our environment, and how belief on those impacts varies in different groups. To measure this country if living in a different country, and seeing how the country responds to the pandemic influences how people feel about infectious disease, or how severe their beliefs about infectious disease are, I plan to focus my population in university students and researchers in The United States of America and Costa Rica. This is because the two countries have had very different results when it comes to the pandemic.²² I also have both of these populations available to me, and as students and researchers, they are actively providing services, research, and impact on or related to our environment. In the student population, I intend to hear from students who are in biological sciences, and may or may not study ecology, environmental science, or a related topic. This population will most likely be informed on the basics of infectious disease and factors that impact climate and the environment. Research and ecotourism are extremely valuable resources to countries, especially Costa Rica, and understanding how risk, disease, and spread is best mitigated to promote the continuation of tourism, research, and endeavors that promote economic and political advances. For my project, I want these interviews to investigate a few things. Depending on how the believe the COVID-19 pandemic began, I want to understand if they have similar beliefs on other viruses or common communicable diseases. I want to also understand their social situations (i.e. if they are government employees, employees in ecotourism or in industries heavily interacting with the natural world, etc.). If they participate in research, I want to understand how their research has been impacted in the last few years because of infectious disease and what could have been done to mitigate these effects. I am curious if my populations are aware of policies in place that support or inhibit their research and livelihoods. Essentially, I want these interviews to provide the subjective experience and context that I see in the survey data, and I want to explore what ways our human condition and beliefs are affecting everything around us. When exploring the subjectivity of personal experience, and anticipating using it for rational analysis, we must spend a lot of time ensuring what we ask is unambiguous, and genuinely asking the prompt you want. Pre-testing, or putting your first round of questions in practice, is really important for work like this. Since countries responded quite differently, there are different beliefs that are acquired, and issues that researcher did not consider can arise from pre-testing.^1,2,3,17 The first question I chose to pre-test was to inform myself on how people are thinking about the COVID-19 pandemic. I asked, “How do you think the COVID-19 began?” This question was formulated to be a neutral question that informs the following questions of my survey. For example, I gave five option choice with included spillover, lab accidents, lab creations, “other,” or a combination of events. If the participants do not believe the COVID-19 pandemic was a natural spillover event, then it is not beneficial to ask questions about how spillover events occur, what environments encourage spillover events, or why mutations would occur in relation to the environment. Understanding how the timeline of creation of the virus or how that artificial creation was spread would be more imperative.

Results:

With this first pre-test question I was able to survey over 150 students at a Midwest research institution. Below are the results from this 1 question survey:

Figure 1: Survey results from Introductory Anatomy Course (n=169)

Figure 2: Survey Results From 400-Level Capstone Course Related to Environmental Sustainability (n=19)

Figure 3: Total Survey Results (n=187)

Discussion:

I chose these populations for a few specific reasons. Initially, I chose to compare the anatomy class with the capstone course because of the large difference in population size. These population also provide a unique parallel to the population I plan to use in the fully-fledged study in the future. I can infer that the anatomy student population has interests related to humans or human health, and this population will have a higher probability of understanding mechanisms of infectious disease, or have interested related to human health, policy, or the COVID-19 pandemic. In contrast, the students in the capstone course have related interests to human health but have an additional lens of understand in the human and environmental impacts of infectious disease. This is particularly interesting because COVID-19 is widely believed to be a naturally created or occurring virus, and these populations help me infer if environmental education plays a factor. 1 in 10 students from the anatomy course believe the virus was an artificial creation in a laboratory setting. The survey of the capstone course only had an n of 19. Due to this, a larger sample of students with similar education perspectives as the capstone course students would be needed for better inference or relationship causality; however, since no students believed it was an artificial creation or ‘other,’ in the capstone course, and 1 in 5 students believed it to be one of those options, there may be a higher correlation between some factors than what it seems on the surface. I would have to spend more time surveying students to better understand possible factors and relationships in the answers.

This initial survey was extremely informative to me and reminded me of the bias researchers can have while doing research. Though I gave options for multiple things in the survey, I did not intent for them to be chosen as frequently as they did. Like I discussed above, this helps me inform the rest of my survey, and I need to have a broader range of questions to encompass more ideas of infectious disease manifestation and the novel COVID-19 pandemic.

A limitation to this pre-test is the more generalizable region. I was talking above about how different regions and countries have responded and understood the pandemic differently. So, this data may only be generalizable to Indiana college students in topical health courses. For example, Costa Rica has been positively internationally recognized in its efforts to fight the pandemic, and the United States has not.^24,25 The United States has also had better access to vaccine resources compared to Costa Rica. Notably, the Costa Rican government had preemptive plants for pandemic preparedness that they utilized early in the pandemic, and the United States heavily disregarded and changed the plans they had in place previously.²⁶

When considering the factors of these unique populations, I have decided to survey students at two large, public, research universities – one in the US and one in Costa Rica. After pre-testing in both areas, a tailored survey will be administered to the ranges of populations specified. I want to have tailored surveys and interviews because populations may have different ideas that I am unaware of. For example, I intend to have my other ‘other’ option in the real survey to have the opportunity to explain what other belief they have, so I can better understand the full scope of ideas I am working with. The goal of the survey is to be able to analyze a larger number of people more understanding broad ideas and perceptions as a group. As stated, surveys tend to lack subjective experiences and provide less context to potential causal factors of these beliefs.^20,22 Because of this, I intend to interview select participants. These interviews, in addition to exploring their beliefs on infectious disease and the environment, will probe the participants for suggesting how their issues could have been mitigated in their research area or homeland. This is to help evaluate the severity of belief and what factors influence belief acquisition. The survey and interview will also ask basic demographic information so that a low-level analysis, like an audit study, a study in which all characteristics of a population match except for the one being tested for discrimination, can be done. This will help infer if factors like location or educational status have higher indications on how severe beliefs on topics of COVID-19, pandemics, infectious disease, and the environment really are. There are factors such as poverty, lifestyle, political affiliation, among many other things that can influence these beliefs, or how people shaped their attitudes and actions during the COVID-19 pandemic.

In addition to their subjective belief, we have global data. The globe has done a diligent in reporting coronavirus cases and deaths by country, province, region, state, and cities. I plan to use this data in combination with the survey and interview data to investigate any patterns in the data. For example, people who saw more death in their region may have more extreme views about infectious disease. This allows for an interdisciplinary approach that can investigate biological data such as vaccination rates, cases, death, and when and how policy was implemented to impact infectious disease. I hypothesize that people who were put in tough situations (like forced to do work that required contact with the environment of virus to feed their family) will have a different evaluation of the past two years compared to people who were impacted very little by the pandemic.²⁷

I want to take a step back, this probably seems like a lot of pieces to figure out a small puzzle, right? Well, often pilot studies, or investigatory research, has a lot of factors to implement for the work to be applicable. Another common pathway is to investigate one specific aspect of a research question, and do further research on the topic, depending on time constraints and resources. The bulk of my work will be done in 10 weeks while researching in Costa Rica; however, a lot of prep work will happen before then to do preliminary surveys and pre-test more questions. My work will also be in two countries who speak different languages, and use human subjects as an aspect of this research, and this means that there extra care will have to be taken when the Institutional Review Board (IRB) and the Organization for Tropical Studies (OTS) review the questions I plan to ask in surveys and interviews to ensure I am not violating cultural norms and keeping myself and research participants safe from possibly scrutiny from my research. Though this is a long and tedious process, it helps ensure that the research I do is good, safe, and will have benefits to academic communities or the communities I am studying.

The number of moving pieces in this research is also a limitation. Because of the timeline I have to do this research, the scope of questions much be paired down, or use a smaller number of participants when analyzing. Additionally, questions are not currently able to be pre-tested with Costa Rican citizens; therefore, I am now able to tailor the survey and interview guide as specifically as I could for someone in the United States. In the future, I think this work would be important to introduce in the context of nutrient pollution, agriculture, and wastewater monitoring, as a way to research actionable mechanisms to catch infection earlier. This research can also serve as foundational work to be manipulated for other population to understand their beliefs, and how their governments handled certain topics.

Whether it be wastewater, drinking water, the air, or the hugs we give our friends, disease is everywhere. We encounter bacteria and viruses every day that could potentially be harmful to us or the ones we love. Luckily, we have immune systems that help us out significantly, but there are unique circumstances that can arise that really

take a toll on us. When things like agricultural runoff, wastewater, or even things like deforestation, get out of control, we increase our ability to create a new virus, to create a new pandemic, and to experience similar or worse things than the COVID-19 pandemic brought about. This is why understanding the broad and interdisciplinary factors in this research I believe is a more impactful route than using one aspect of the issue to study. This research has the opportunity to understand how the issues of environmentalism, infectious disease, lifestyle, and disaster policy intersect to create a nuanced and unique experience with infectious disease, more currently the SARS-CoV-2 virus. These surveys and interviews correlated with COVID-19 infection and death data can help us better understand how and why a government makes the decisions they make when mitigating crises. Using other methods of compound and disease monitoring already in use in these areas may inform the feasibility of public health monitoring for infectious disease in similar places. To plan and to understand how to mitigate a response to environmental issues, we need to work together to get the whole picture, and that is how informed policy is made. This pre-testing and informed interviewing will help gain the needed perspective and foundation for work to be done that can mitigate disease risk while also supporting frontline worker, or those working in jobs that increase environmental risks. It takes a team to make a plan, and a good plan attacks an issue from all sides. My goal is to bring in the social aspect that is so important to understanding spread and risk in out globalized world.

Appendix:

 

 

Pre-test Question

How do you think the COVID-19 Pandemic Began?

 

A natural spillover event from bats to humans.

An accident in a laboratory that was studying or in contact with the virus.

An artificial creation of the virus in a laboratory.

A combination of these events.

I do not believe COVID-19 is real.

Other

 

PRELIMINARY DRAFT OF INTERVIEW GUIDE AND SURVEY QUESTIONS (not finalized or tested)

 

Interview Questions HUBI / IRES

 

Do you consent to being a voluntary participant in this interview?

 

Do you consent to this interview being audio and/or video recorded?

 

This interview may ask questions related to your beliefs on vaccinations and other public health topics. Do you understand you are not required to answer these questions if you do not want to?

 

Participant:

 

Age:

 

Sex/Gender:

 

Profession:

 

Degree Level:

 

This interview is being conducted to better understand how the citizens of Costa Rica understand COVID-19 and its impact. I want to understand your attitudes, beliefs, and perceptions of infectious disease and COVID-19.

 

How would you define infectious disease?

 

Do you think infectious diseases are dangerous?

Should their spread be reduced?

How so?

 

 

Do you agree that COVID-19 is a world-wide pandemic caused by the infectious pathogen SARS- CoV 2?

 

How did you first hear about COVID-19?

 

Do you believe the COVID-19 pandemic was started because of a lab accident, a spillover event from bat to human, or something else?

 

What changes were made in response to the pandemic where you live?

 

Are you happy with how where you live responded?

Why or why not? What could have been done?

 

F/U Do you think that changes will have a lasting impact? If so, what

 

This pandemic has brought forth many different viewpoints about infectious disease, how countries handle disease, and how disease has impacted them in different ways. I want to explore relations with COVID-19 and the environment; however, before I move on to that. I recognize COVID-19 has been different for everyone.

 

Has COVID-19 impacted you negatively?

How so?

How could have this negative impact been lessened or removed?

 

Has COVID-19 impacted you positively?

How so?

(If applicable, do you hope this continues post-pandemic era?)

 

Was the impact of infectious disease on the environment something you considered?

 

Do you think it has an impact?

 

Questions for Researchers:

 

Where are you from?

 

If you can disclose, generally, what research do you do at this station?

 

 

Does your research require you to work directly with any of the following or specimens of the following:

 

Humans

 

Captive and/or Wild Primates

 

Non-Human Animals

 

What interactions do you have with these animals?

 

In your own opinion, before the pandemic, have you ever thought you were putting these groups at risk with your research?

 

Were you required to return to your home country due to the SARS CoV-2 pandemic?

If you did leave, when were you able to return?

 

Was your research halted due to the SARS CoV-2 pandemic?

References:

 

1. Fishbein, M. (1966). The relationships between beliefs, attitudes, and behavior. Cognitive consistency, motivational antecedents, and behavioral consequents, 199-223.

 

2. Bowman, L., Kwok, K. O., Redd, R., Yi, Y., Ward, H., Wei, W. I., Atchison, C., & Wong, S. Y.-S. (2021). Comparing Public Perceptions and Preventive Behaviors During the Early Phase of the COVID-19 Pandemic in Hong Kong and the United Kingdom: Cross-sectional Survey Study. Journal of Medical Internet Research, 23(3), e23231–e23231. PubMed. https://doi.org/10.2196/23231

 

3. de Vries, M., Claassen, L., te Wierik, M., van den Hof, S., Brabers, A., de Jong, J. D….Timen, A. (2021). Dynamic Public Perceptions of the Coronavirus Disease Crisis, the Netherlands, 2020. Emerging Infectious Diseases, 27(4), 1098-1109. https://doi.org/10.3201/eid2704.203328.

 

4. Tulchinsky T. H. (2018). John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now. Case Studies in Public Health, 77–99. https://doi.org/10.1016/B978-0-12-804571-8.00017-2.

 

5. Friend of Lake Monroe. (2016). About Lake Monroe. Friends of Lake Monroe. Retrieved from https://friendsoflakemonroe.org/about/

 

6. Ariel, Eric L. Salas, Sakthi Kumaran Subburayalu. Implications of climate change on nutrient pollution: a look into the nitrogen and phosphorus loadings in the Great Miami and Little Miami watersheds in Ohio[J]. AIMS Environmental Science, 2019, 6(3): 186-221.

 

7. Environmental Protection Agency. (n.d.). Nutrient Pollution. EPA. Retrieved from https://www.epa.gov/nutrientpollution.

 

8. Anderson, D. M., Cembella, A. D., & Hallegraeff, G. M. (2012). Progress in understanding harmful algal blooms: Paradigm shifts and new technologies for research, monitoring, and Management. Annual review of marine science. Retrieved October 1, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373096/.

 

9. Torbick, N., Ziniti, B., Stommel, E., Linder, E., Andrew, A., Caller, T., Haney, J., Bradley, W., Henegan, P. L., & Shi, X. (2018, January). Assessing cyanobacterial harmful algal blooms as risk factors for amyotrophic lateral sclerosis. Neurotoxicity research. Retrieved October 1, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5727154/.

 

 

10. Environmental Protection Agency. (n.d.). Toxic and Priority Pollutants Under Clean Water Act. EPA. Retrieved September 15, 2021, from https://www.epa.gov/eg/toxic-and-priority-pollutants-under-clean-water-act.

 

11. Environmental Protection Agency. (n.d.). Fresh Surface Water. EPA. Retrieved September 15, 2021, from https://www.epa.gov/report-environment/fresh-surface-water.

 

12. Quammen, D. (2012). Chapter 1. In Spillover (pp. 23). story, W.W. Norton and Company.

 

13. Tatem, A. J., Rogers, D. J., & Hay, S. I. (2006). Global transport networks and infectious disease spread. Advances in parasitology, 62, 293–343. https://doi.org/10.1016/S0065-308X(05)62009-X

 

14. Wasserman, M. (2021). Primate Ecology: Lecture 4. Retrieved from HUBI B-400 Canvas site.

 

15. Bandala, E. R., Kruger, B. R., Cesarino, I., Leao, A. L., Wijesiri, B., & Goonetilleke, A. (2021). Impacts of COVID-19 pandemic on the wastewater pathway into surface water: A review. Science of the Total Environment, 145586.

 

16. Jones, D. L., Baluja, M. Q., Graham, D. W., Corbishley, A., McDonald, J. E., Malham, S. K., Hillary, L. S., Connor, T. R., Gaze, W. H., Moura, I. B., Wilcox, M. H., & Farkas, K. (2020). Shedding of SARS-CoV-2 in feces and urine and its potential role in person-to-person transmission and the environment-based spread of COVID-19. The Science of the total environment, 749, 141364. https://doi.org/10.1016/j.scitotenv.2020.141364

 

17. Geldsetzer, P. (2020). Knowledge and Perceptions of COVID-19 Among the General Public in the United States and the United Kingdom: A Cross-sectional Online Survey. Annals of Internal Medicine, 173(2), 157–160. https://doi.org/10.7326/M20-0912

 

18. Nunkoosing K. The Problems With Interviews. Qualitative Health Research. 2005;15(5):698-706. doi:10.1177/1049732304273903

 

19. Sarah Knox & Alan W. Burkard (2009) Qualitative research interviews, Psychotherapy Research, 19:4-5, 566-575, DOI: 1080/10503300802702105

 

20. Collins, D. Pretesting survey instruments: An overview of cognitive methods. Qual Life Res 12, 229–238 (2003). https://doi.org/10.1023/A:1023254226592

 

21. Betancourt, J. R., & Green, A. R. (2010). Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Academic Medicine, 85(4), 583-585.

 

22. Secor, A. (2010). Social surveys, interviews, and focus groups. Research methods in geography, 3, 194-205.

 

23. Fishbein, M. (1966). The relationships between beliefs, attitudes, and behavior. Cognitive consistency, motivational antecedents, and behavioral consequents, 199-223.

 

24. United Nations. (2020). 5 reasons Costa Rica is winning plaudits for fighting covid-19: A UN resident coordinator blog | | UN news. United Nations. from https://news.un.org/en/story/2020/05/1064412.

 

25. Altman D. Understanding the US failure on coronavirus—an essay by Drew AltmanBMJ 2020; 370 :m3417 doi:10.1136/bmj.m3417

 

26. Centers for Disease Control and Prevention. (2017, June 15). National pandemic strategy. Centers for Disease Control and Prevention. Retrieved December 13, 2021, from https://www.cdc.gov/flu/pandemic-resources/national-strategy/index.html.

 

27. Sørensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H. (2012). Health literacy and public health: a systematic review and integration of definitions and models. BMC public health, 12(1), 1-13.