Daily census and mortality count are suboptimal representations of the devastation of COVID-19 (1). While living under the darkness of the pandemic, the lives of the millions have changed forever. Even the people who did not have the disease suffered from the threat of contracting COVID-19, financial stress, grief, and depression. India and the USA, two of the largest populous nations, were affected most by the pandemic. However, the confirmed cases and mortality due to the COVID-19 were double in the USA compared with India till the end of 2020 (2). Toward late 2020, COVID-19 cases had steadily declined in India, although the battle continued in the USA (2). While the factors attributing to the different courses are unknown, perceptions and behavior of people toward COVID-19 may hold some answers.

The administrative support, social structures, available healthcare facilities, and family income contrast India and the USA, as reflected by the human development index ranking of 131 and 17, respectively (3). Thus, people of these two countries perhaps experienced COVID-related stress and threat differently. Since COVID-19 was not confined to political and geographic boundaries, population-based research beyond the regional level would help introspect the differences and inform unique strategies based on the diverse necessities.

The healthcare expenditure in the USA is the highest globally, and the USA could afford to maximize COVID-19 testing and upgrade healthcare facilities to match the demand of the pandemic (4). India too conducted millions of COVID-19 testing, and the numbers were only second to the USA (5). However, the Indian healthcare system was overwhelmed during the peak of COVID-19 (5). In contrast, suboptimal healthcare infrastructure was already a stressor in India; severe economic recession, unemployment, home quarantine, and inadequate administrative support had worsened the situation further (6). In this scenario, COVID-related information from authentic sources and awareness could have helped mitigate some apprehensions (7). While websites like CDC (Centers for Disease Control and Prevention) played a major role in spreading awareness in the USA, Indians often relied on social media to learn about COVID-19. In March 2020, social media activities grew by 50 times in India (8). Some of the Indian news channels played a negative role by an upsurge of COVID-19 related information and misinformation, which worsened the preexisting fear and uncertainties about the disease outcome (9, 10).

Preventive measures have been the best way to curb the spread of COVID-19, especially when effective therapy or vaccine was unavailable. Even after the arrival of the COVID-19 vaccine, it is expected to take a considerable amount of time to develop adequate herd immunity (11). The “perceived threat” of an individual has been reported as a major determinant for adherence to the preventive measures, as reported during the 2009 swine flu pandemic, and also during COVID-19 (12, 13). Based on diverse socioeconomic conditions in India and the USA, people in these two countries probably had differences in perceived threats of COVID-19, which has also been considered a determinant of COVID-vaccine acceptance (14, 15).

Several novel therapies for COVID-19 had been promoted worldwide, such as hydroxychloroquine, diethylcarbamazine, azithromycin, and herbal medicine, without any proven benefit (16). Hydroxychloroquine had received major public attention in India and the USA (17, 18). While Indians favored hydroxychloroquine since the Indian Council of Medical Research, the highest medical governing body had approved its use (19), public opinion was deeply divided in the USA during the early days of the pandemic. The public perception of the effectiveness of hydroxychloroquine had never been compared between India and the USA, an interesting question to be asked to the community.

We conducted a survey study with the primary objective of comparing COVID-related perceptions such as stress, knowledge, and preventive behaviors between the Indian participants (IND-P) and the US-based participants (US-P). The secondary objective was to compare perceived threats and attitudes toward COVID-vaccine and hydroxychloroquine between the two groups. We hypothesized that higher COVID-related stress and perceived threat would positively correlate with a better attitude toward preventive recommendations among survey participants. We further hypothesized that the IND-P compared with the US-P would have higher COVID-related stress, perceived threat, and a better attitude to preventive recommendations, including COVID-vaccine and hydroxychloroquine.

The difference in the sociodemographic characteristics between the IND-P and the US-P was one of the features of this internet-based survey. The majority of the IND-P belonged to younger age groups. This trend perhaps reflected the ever-growing popularity of the internet among the tech-savvy younger Indian generation, whereas the older Indian population was probably reluctant to learn new technologies. In contrast, the entire US population had access and was comfortable with online portals, and thus, the US respondents maintained a relatively uniform age-wise distribution compared with the IND-P.

The US-P were predominantly women, and the gender difference followed a similar trend described in prior surveys where women dominated the survey participation (30, 31). A recent global study found that women were three times more likely than men to suffer from serious mental health issues during this pandemic, and amplified COVID-related stress perhaps encouraged higher female participation in the US (27). However, a similar trend was not seen in India, which could be due to male predominance in internet access and usage (32).

This study demonstrated a higher stress level among the IND-P compared with the US-P. In 2020, India had witnessed the worst recession in recent times (33). COVID-related stress was augmented by several factors, including job loss, pay cuts, lack of adequate healthcare facilities, and confinement. Moreover, preexisting poverty, unemployment, and lack of social security altogether resulted in an exponential increase in job-related stresses and insecurities to fulfill basic needs (9). Additionally, a continuous upsurge of information from social media, news channels, and mobile notifications, with an overburdened and inadequate healthcare system, possibly heightened the fear more among the IND-P than the US-P (9).

The US-P demonstrated a better COVID-related knowledge than the IND-P, which could be related to greater awareness and better access to authentic information in the USA. Although most of the IND-P indicated that television was their preferred source of information, the quality and authenticity of the information provided could greatly vary among the countries. On the contrary, many of the US-P chose official state websites and CDC websites, which offered correct information reflected in their knowledge scores.

The IND-P, compared with the US-P, reported a higher perceived threat, had a better attitude to the preventive guidelines, and were more willing to accept the COVID-19 vaccine or participate in future drug or vaccine trials. The perceived threat has been identified as a key determinant of compliance with preventive guidelines in previous COVID-19 studies (34). We found a similar association between the individual perceived threat and positive attitude toward the preventive guidelines, which further established that observation. Finally, higher faith in hydroxychloroquine among the IND-P could be influenced by the administrative approval in India and desperation to prevent COVID-19 infection.

We conducted this comparative study before the COVID-vaccine was launched in late 2020, and a new wave of pandemics hit the USA around the same time (35, 36). Our study demonstrated that the IND-P were more willing to accept COVID-vaccine compared with the US-P. Interestingly, COVID-vaccine hesitancy was later recognized as the foremost public health challenge in the USA (37), whereas many Indians could not be vaccinated, despite willingness, because of inadequate availability (38). In both countries, new waves of COVID-19 were facilitated due to the relaxation of preventive behaviors. India enjoyed initial success in containing COVID-19, prematurely declared a victory, followed by a preventive behavior collapse in early 2021 (39). Subsequently, India, without adequate immunization coverage, faced the worst global COVID-19 crisis in April 2021 due to the delta variant of SARS-CoV-2 (40). The concern with lack of healthcare facilities, expressed by the IND-P of our survey, was proven justified, as India struggled to provide even basic medical facilities to the staggering numbers of morbid patients with COVID-19 (41), and the death toll was sky-high between April and June 2021 (42). While in the USA, a significant percentage of the population were confident with available healthcare and were reluctant to accept the COVID-19 vaccine. Now they became vulnerable to the delta variant of SARS-CoV-2, as the country is currently facing (August 2021) resurgence of COVID-19 cases due to the delta variant (43).

One of the limitations of this study is generalizability. Considering the diverse and vast population of India and the USA and the moderate sample size of this survey, the results may not represent the general population. Instead, this study report should be considered as a trend and needs to be externally validated with a large sample survey prior to accepting the results as a general trend. Nonetheless, we have made considerable efforts to reach out to people across India and the USA. Since the difference in sociodemographic distribution between the IND-P and the US-P was significant, we adjusted GLM for potential sociodemographic confounders. However, building a prediction model was not the goal of this study. Finally, the study questions were in English, and about 90% of Indians were not comfortable with that language (44). Since the study was conducted during the pre-vaccine period, we could not capture the change in COVID-related perceptions during the post-vaccination period, including vaccine hesitancy in the USA. Moreover, the survey was conducted in 2020 and did not capture the devastating impact of the delta variant in India.

Nonetheless, this study has few strengths. This survey is among few epidemiological studies that compared people's perception of COVID-19 between India and the USA, representing the developing and developed worlds. This study demonstrated an association among preventive behaviors, stress, and perceived threat, and despite lower knowledge, the IND-P had a better attitude toward preventive guidelines than the US-P, which could be related to higher stress. However, it is unknown whether better adherence to preventive guidelines helped India achieve better initial success against COVID-19 than the USA. Finally, enthusiasm to participate in future drug or vaccine trials among the IND-P has conveyed an important message to the regulatory bodies to consider.

The IND-P perceived COVID-19 as a higher threat than the US-P, perhaps due to a lack of faith in the available healthcare system and social security. Driven by stress and perceived risk during the pandemic, IND-P possibly were more inclined to accept the preventive measures, including COVID-vaccine and unproven therapies like hydroxychloroquine, than the US-P. The causal association between the preventive practice and the pandemic course was beyond the scope of this study. A nationwide survey with a larger sample size in the future is necessary to understand whether better compliance to the preventive guidelines had helped India with initial success against COVID-19 compared to the USA, in 2020.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: https://data.mendeley.com/datasets/hp3pdpjgrs/2.

The studies involving human participants were reviewed and approved by Penn State College approved the study of Medicine Institutional Review Board (approval ID: STUDY00015136), and all methods were performed in accordance with the relevant guidelines and regulations. The patients/participants provided their written informed consent to participate in this study.

AS, SP, JD, and PM: conceptualization, writing—review, editing, validation, methodology, and investigation. AS and PM: visualization, data curation, formal analysis, software, and writing. JD and PM: supervision. AS: project administration. PM: funding acquisition and resources. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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