Maintaining social distance has been crucial in slowing the spread of novel coronavirus infections (COVID-19), yet some people did not follow early recommendations to limit physical contact with others. Now, a new study by Stanford scholars reveals reasons why people failed to comply.
The researchers, an interdisciplinary team from the Department of Communication and from the Department of Epidemiology, conducted a survey between March 14–23, the period when shelter-in-place orders were first introduced in some parts of the United States.
Their data, reported in a non-peer reviewed, preprint paper released on medRxiv, showed that the most common reasons for noncompliance were work requirements from non-essential businesses, mental and physical health concerns and beliefs that other precautions were enough.
They also found that young people – aged between 18 to 31-years-old – had the lowest compliance rate at 52.4 percent, compared to other age groups.
“As I looked around my own neighborhood in early March, some people were rushing to gather supplies and isolate, while others were going about their normal lives,” recalled study co-author Eleni Linos, MD, DrPH, a dermatologist and epidemiologist at the Stanford School of Medicine. “Our study shows that different people are experiencing this crisis in different ways. Not everyone has the same opportunities.”
Reasons for non-compliance
The researchers collected a total of 20,734 responses to a survey that was posted on social media networks Twitter and Facebook, as well as the neighborhood social networking service NextDoor.
The researchers found that 39.8 percent of respondents reported not complying with social distancing recommendations in the middle of March.
The most common reason for failing to social distance was work requirements for non-essential industries (28.2 percent). One respondent told the researchers, “Work is not canceled, if I don’t go I’ll lose my job.”
Another frequent explanation for not following orders included worries about mental and physical well-being.
Some 20.3 percent said they engaged in social, physical or routine activities to manage unease from sheltering in place, such as “cabin fever.”
As one respondent said, “Staying in my home 24 hours of every day is depressing.” Another emphasized, “I have to get outside now and then for my own sanity.”
Other rationales that people cited for failure to comply with social distancing included the belief that other precautions, such as only hand-washing, were sufficient (18.8 percent).
Some 13.9 percent of people said they wanted to continue everyday activities and 12.7 percent believed that society is overreacting.
Another important factor for some respondents related to child care.
About 4.8 percent of people said they did not comply with social distancing orders because they felt they had to take their children outdoors or to social events for the welfare of both their children and themselves.
As one respondent said, “I have kids and it’s impossible to keep them grounded all the time.”
“Clearly different parts of the population have different kinds of concerns and reasons for not social distancing, and government communication should address those,” said Jeff Hancock, a professor of communication in the School of Humanities and Sciences and a co-author on the paper.
Learning from the words people use
The researchers also analyzed what words participants used in their responses to better understand what respondents were feeling and focused on.
They found that younger people between the ages of 18 to 31 were more likely to use first-person singular words such as “I” and “me,” which, according to the researchers, indicated they were more self-centered than other groups surveyed.
They also found that young people, the group least at risk for COVID-19, displayed more anxiety in their survey answers than other age groups, using words like “anxious,” “disturb” and “nervous,” more frequently than other age demographics.
Meanwhile, the oldest and most at-risk group (65-years-old and up) showed the least anxiety in their responses.
“A key takeaway for me was how resilient the older population seems,” said Hancock.
“They are not as anxious or self-focused as young people. I think this runs counter to the narrative that the old are weak and frail, and instead, they are practiced at social distancing and being comfortable in their home.”
Recommendations
The researchers hope that these survey results can be used by public health officials and other policymakers for targeted messaging campaigns.
“I hope that governments use these findings and recommendations to improve how they communicate public health orders for sheltering-in-place so that we can get as much compliance as possible,” said Hancock.
The researchers lay out specific messaging recommendations to address the key reasons for why people do not comply with social distancing orders.
For example, the researchers suggest that public health messages should be aimed at young people.
“Shelter-at-home is clearly much more difficult for younger people as they are used to more social interactions and life out of the home,” said Hancock.”
The researchers also recommended that messages to younger audiences address the negative consequences arising from their noncompliance, and also emphasize how individual actions affect community-wide health outcomes.
Meanwhile, Linos and Hancock have updated and extended their survey and are encouraging more people to participate.
“We hope more people of all backgrounds will take the survey so everyone’s voice can be heard,” said Linos. “One way people can help is to participate in research.”
The findings reported here were part of a larger study published Apr. 7 in the Journal of the American Medical Association that looked at public concerns in the US of the coronavirus pandemic.
Identifying the Human Threat – Israel experience
Who are the potential threats?
Refusers: The obvious threats are the outright refusers.9 From a psychological perspective, these are people who are either oppositional in their attitude or in denial regarding the effects of their refusal.
While both are intentionally violating guidelines, the former do so understanding that they are creating risk for others while the latter deny it, at times adopting an “it won’t happen to me” attitude.
Deniers: Closely related to outright refusers are the “deniers” whose personality and social identity is central to their daily functioning. People who are friendly, outgoing, and interact actively in their social sphere will suffer the most by being “distanced” from their routine.
Their adjustment may require more time and may be accompanied by attempts to minimize the seriousness of the need to distance or to challenge it by erroneously claiming the need to continue life as normal in the face of a threat.
While Israelis are defiant in the face of external threats, the COVID-19 threat differs in that the virus is not influenced by such behavior.
Whereas “standing up to the enemy” is a positive Israeli trait, applying it to an invisible and indifferent enemy that is unimpressed by these efforts is futile and even harmful to others. Nevertheless, the psychological makeup and social personality of some people represent a challenge to a system attempting to enforce discipline.
The Young: Data from outbreak areas shows that the most severely affected victims of the virus are above 60 years of age.10 Thus, the younger you are, the less likely you are to experience any serious symptoms.
As such, the virus represents less of a physical threat to younger people. While all adults cognitively understand their personal responsibility in following government instructions, younger adults, especially teenagers and pre-teens, may not. As one review of low adherence in adolescents noted, “… they may remain self-centered and feel invulnerable to consequences – negative things happen only to others.”11
Special efforts may be required for older people to understand that exposure to their own grandchildren and adult children can potentially cause them physical harm.
Viewing the under-21 population as a threat may not be easy. With schools closed and social venues limited, this population will be difficult to control, especially since they realize that the danger the virus poses to themselves is minimal.
While parents have greater control over younger children, those children who already have social independence, namely those in middle and especially high school, may not be easily persuaded to restrict their social contacts as they pursue autonomy.12
Cultural, Religious, Tribal factors: Cultural considerations pose an additional challenge. Unlike individual personalities, group dynamics can create patterns of behavior that are reinforced by peer pressure and imbedded in collective behavior.13
Religious behavior, in particular, can pose a problem if there is a perceived conflict between a specific practice and the need to isolate and distance.14
While official and responsible religious leaders have publicly and strongly urged complete compliance,15 we can expect and have seen certain sectors and outliers within the community to having difficulty breaking from traditional practice and routine.16
Thus, reports of Israeli citizens in an Arab town refusing to self-isolate17 should be seen as a signal of another potential area where regulating compliance may be compromised.
Understanding the Threat
Providing reliable, accurate, and dependable information is a major element in ensuring compliance with COVID-19 guidelines. When the public trusts the source, compliance will be greater.18 Frequent reminders in the media and repetition of key points (handwashing, 2-meter rule, etc.) will improve compliance.
One “Catch-22” situation is that, in an effort to reduce anxiety, the media presents interviews with individuals in isolation, some of whom have been formally identified and diagnosed with COVID-19.19 While this can help in allaying many fears, it also can reduce compliance by minimizing the fear factor. Finding the balance between creating heightened awareness and avoiding undue anxiety needs to be considered carefully.
Measures to Take
Democratic societies such as Israel require extra effort to ensure compliance with behavior such as social distancing that is essentially voluntary. While most of society will likely comply and some will be particularly cautious, especially for identifiable and limited periods of time, the “refusers” will continue to present a problem.
Classifying the refusers’ behavior as a risk and treating them as a genuine threat is a national priority. Criminalizing violations of mandatory guidelines (such as self-isolation) can lead to civil suits, fines, and disciplinary action by relevant authorities.
Social pressure can also serve as a psychological means to reduce the frequency of noncompliance with social distancing. When peers make known their displeasure and disapproval of not following guidelines, noncompliance is likely to fall. As the COVID-19 threat becomes more difficult to control, many of the guidelines are likely to move from suggestions to mandatory actions. The gradual but steady move closing more and more public venues and limiting more and more public gatherings is evidence of this.20
Notwithstanding available punishments, building desired behavior ultimately requires individuals to voluntarily comply.
This will take place when people sense that the benefit attained by compliance outweighs the benefit of refusal.21
Where individuals see the short-term benefit of refusal as more rewarding than the long-term benefit of compliance, negative consequences may help in some cases, but will not in many others.
Since the cadre of those who intentionally or unintentionally put the public at risk cannot be eliminated solely through education and social pressure, law enforcement and government authorities may have to intervene.
These interventions may need to consider measures that would ordinarily not be accepted or legal, something mentioned as likely in Israel.22
While understandably not popular with those that value the protection of civil liberties,23 we nevertheless need to accept that the probability of behavioral management of the public will not be totally successful.
Thus, the suspension of these protections in times of national emergency may prove to be central in reducing mortality and morbidity of the population as well as in limiting the economic consequences of a protracted battle with an unseen enemy hiding in a friendly population.
Notes
1 https://www.foreignaffairs.com/articles/2020-03-03/pandemic-disease-threat-national-security
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/
3 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext
4 Ibid.
5 https://www.apa.org/practice/programs/dmhi/research-information/social-distancing
6 https://dailyvoice.com/new-jersey/hackensack/news/postponed-bergen-county-shutdown-starts-saturday/785095/
7 https://www.ft.com/content/dc35ec0c-662f-11ea-a3c9-1fe6fedcca75
8 https://www.jpost.com//Breaking-News/Israelis-with-coronavirus-Health-Ministry-reports-304-patients-621258
9 https://www.timesofisrael.com/video-shows-man-in-tel-aviv-being-arrested-for-violating-quarantine/?fbclid=IwAR0fpc9FT8QZmC7E02d6K0zbCxWHmJOsbT3CryLnAtAxNxaEA1ohkyoHsJM
10 https://www.cdc.gov/media/releases/2020/t0309-covid-19-update.html
11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528818/
12 https://www.ncbi.nlm.nih.gov/pubmed/14987214
13 https://www.researchgate.net/publication/320852716_Social_Influence_and_Intercultural_Differences
14 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486343
15 https://www.jpost.com/judaism/Halachic-handbook-for-the-coronavirus-pandemic-620597
16 https://judaism.walla.co.il/item/3346701
17 https://www.haaretz.com/israel-news/.premium-in-arab-israeli-town-100-returnees-from-overseas-flout-quarantine-1.8670062
18 https://www.neliti.com/publications/229036/public-trust-and-regulatory-compliance
19 https://www.youtube.com/watch?v=65_0jFWR-u0
20 https://www.timesofisrael.com/israel-set-for-drastic-restrictions-on-workplaces-gatherings-no-lockdown-yet/
21 https://pr.princeton.edu/news/04/q4/1014-brain.htm
22 https://www.jpost.com/HEALTH-SCIENCE/WATCH-LIVE-Netanyahu-addresses-Israels-plans-amid-coronavirus-panic-620971
23 https://twitter.com/MeravMichaeli/status/1239077260843458560
More information: Ryan C Moore et al. Experience with Social Distancing Early in the COVID-19 Pandemic in the United States: Implications for Public Health Messaging, (2020). DOI: 10.1101/2020.04.08.20057067
