Abstract
Control of the COVID-19 pandemic requires significant changes in people’s health behaviors. We offer this multidisciplinary perspective on the extent of compliance with social distancing recommendations and on coping with these measures around the globe in the first months of the pandemic. We present descriptive data from our survey of 17,650 respondents across 18 countries and territories in June 2020. The majority of respondents worried about contracting the virus. Nearly all engaged in at least some preventive behaviors, particularly handwashing, mask wearing, and avoiding social events. Most reported that it would be difficult to continue these behaviors for more than a few months, and about half reported feeling more anxious since the start of the pandemic. Commonly reported coping behaviors included news consumption, watching television, and sleeping. Our cross-national study highlights areas for developing and implementing health behavior interventions in the global fight to stop the spread of COVID-19.
Perspective
The COVID-19 pandemic has caused major disruptions to health care systems and economies, worldwide. The threat of infection and the measures in place to prevent the spread of the novel coronavirus have also made a significant impact on the health behaviors and coping strategies of individuals around the globe. In the first months of the pandemic, we solely relied on nonpharmaceutical interventions (NPIs) while scientists learned more about the novel coronavirus and biomedical researchers raced to develop effective vaccine and treatment options. The social and behavioral approaches were the most effective measures we had (Ramirez-Valles et al., 2020; Van Bavel et al., 2020) and continue to be important aspects of the multipronged approach to preventing the spread of COVID-19. In fact, research from the United States showed compliance with social distancing early in the pandemic to be effective at reducing how fast COVID-19 spread (Liu et al., 2021). Learning more about the extent to which individuals adopted the recommended health behaviors to prevent COVID-19 infection, their attitudes toward the virus and prevention measures, and how they coped with the pandemic is an important first step in thinking about where to intervene with future public health education initiatives, both for the COVID-19 pandemic and also future pandemics. Our multidisciplinary research team consisting of public health researchers, sociologists, psychologists, public policy researchers, and political scientists established the working group People and Pandemics: Studying International Coping and Compliance (SICC) to promote a better understanding of COVID-19-related attitudes and beliefs, health behaviors, and coping strategies around the world. In this article, we describe our research project and present the descriptive data as a starting point for considering health behaviors and coping during the early summer of 2020, as the pandemic was taking hold across much of Asia, Europe, and North America.
To provide a global perspective, our interdisciplinary team collected cross-national data from 18 countries and territories in five different world regions. All the locations chosen were ones that were experiencing the “first wave” of the pandemic at the time and reflected the expertise of our research team. The online survey was conducted in the first half of June 2020, when much of the world’s population was directed to observe some degree of lockdown and/or follow public health guidelines on social distancing. The survey was created in English, with native speakers translating and back-translating into the major language(s) of each country prior to distribution. In 16 locations, we used online survey panels assembled by Qualtrics, an international market research firm providing survey software and audience panels to academic and corporate clients. These panels were designed to be nationally representative in gender and age. Respondents, all of whom had previously joined the Qualtrics panel for their country on condition of anonymity, were able to opt-in to this specific survey. For Russia and Belarus, we utilized a convenience sample via various web-based channels to reach a diverse sample across the two countries. The University of Michigan’s Human Subject Institutional Review Board (IRB) approved the informed consent, survey instrument, and recruitment strategies (HUM00179291). This perspective is based on results from our initial data analysis, which describes COVID-19-related attitudes, health behaviors, and coping strategies both across our entire sample and at the country/territory level.
A total of 17,650 respondents completed our survey. 1 Among our sample, the average age was 42 years (SD: 15.5), 50.2% were female, and 78% had more than a high school education. These patterns were similar across location with the youngest average age (33 years old) being in Belarus and Vietnam and the oldest being in Germany (50.7) and Sweden (49.5). The Ukrainian sample had the smallest percentage of females (39%), while Russia had the largest (72%).
Attitudes and Beliefs Toward COVID-19
Among all respondents, 10% reported having had or suspected they had been infected with COVID-19, and 18% of the respondents reported knowing someone who has been suspected or confirmed to have COVID-19. In some Asian locations, including China, Hong Kong, Taiwan, Thailand, and Vietnam, a higher percentage of respondents reported that they had been sick with COVID-19 than those who reported they had known someone that had the virus. For all other countries, the pattern was the opposite—more people reported knowing someone who had contracted the virus than reported being sick themselves—with the biggest differences seen in Belarus, Russia, and Sweden. On June 1, 2020, there were around 6.5 million confirmed cases of COVID-19 worldwide (European CDC, 2020). Nonetheless, our data show concern around contracting the virus was high. Across our entire sample, 85% were concerned about their personal risk for getting COVID-19. This ranged by country, with 61% in Taiwan to more than 90% in Indonesia, Malaysia, the Philippines, Poland, and Singapore. The overwhelming majority (more than 95% across all countries) were also concerned that their loved ones would contract the virus. More details are shown in Table 1.
Attitudes and Beliefs Toward COVID-19 and Engagement in Health Behaviors to Prevent Transmission (% of Respondents).
Health Behaviors to Prevent COVID-19
A large majority of our respondents reported engagement in behaviors to prevent the transmission of the virus. Around the world, handwashing (92%), mask wearing (83%), and avoiding social events (76%) were the most commonly reported behaviors used to prevent COVID-19. Some respondents also reported avoiding public transit (64%), cooking at home more often (60%), avoiding physical contact when greeting friends and family members (58%), avoiding enclosed spaces outside the home (44%), and not going to work (42%). The top three health behaviors trends held up across countries, except in Canada, Sweden, Thailand, and Turkey. The starkest difference was that only 7% of respondents in Sweden said that they were wearing masks. In Canada, more respondents reported avoiding physical contact when greeting others, cooking at home, and avoiding public transportation than the percentage who reported wearing masks. In Thailand, more respondents reported cooking at home and avoiding enclosed spaces than avoiding social events. In addition, in Turkey, more respondents avoided public transportation than avoided social events. Respondents in the Asian countries and territories reported higher levels of engagement in preventive behaviors, with somewhat lower engagement in these behaviors reported by our European and North American survey respondents. For example, mask wearing was highest in the Philippines, where 97% reported mask wearing, followed by Vietnam and Hong Kong. Mask wearing was below 80% in our samples from Belarus, Canada, Poland, Sweden, and Ukraine. Avoiding social events was lowest in Poland (63%) and China (66%) and highest in the Philippines (92%), Malaysia (85%), and Indonesia (84%). Only 2% of all respondents reported no change in their behavior; in most Asian countries/territories, less than 1% of the samples reported no behavior change. Respondents in Sweden, Ukraine, and Germany were most likely to report no behavior change, although these percentages are notably small. At the time of our survey, 7% of respondents had tested for COVID-19, which may be just as much a reflection about testing availability as individual desire to get tested. More detailed information can be found in Table 1.
Coping During the COVID-19 Pandemic
Our results suggest that the pandemic is taking a toll on the mental well-being of people. Over half of the respondents (52%) reported feeling “more anxious relative to before the pandemic,” with some variation across countries/territories. There were fewer respondents reporting increased anxiety in the western European countries (Germany 22%, Sweden 25%) compared with other parts of the world (approximately 60% in Poland, Thailand, and Turkey). Sustained behavior change to adhere to public health recommendations about social distancing was difficult for many. There was a large range in how long respondents reported being able to continue social distancing: 39% could sustain these practices for more than 6 months if needed, while 22% could sustain them for another 3–6 months and 39% were unwilling to go past another 3 months. In Belarus, Canada, Germany, Malaysia, Philippines, Singapore, Sweden, Thailand, and Turkey, the largest proportion of respondents said that they could sustain their practices for more than 6 months. On the other hand, more than half of the respondents in China, Hong Kong, Taiwan, and Vietnam reported that they were unwilling to keep up the social distancing behaviors for greater than three more months. This may be reflective of the fact that COVID-19 and its associated restrictions had been in Asian countries longer than in other parts of the world at the time of the survey. Although, nearly half of the respondents in Poland, Russia, and Ukraine also reported that it would be difficult to sustain their current level of social distancing for more than 3 months.
Only 16% of the respondents found their current level of social distancing to be very or extremely difficult. However, there was a wide variation across our sample. Less than 5% of respondents in Thailand and Taiwan found it to be difficult, while more than 50% of respondents in Poland said it was difficult. More than 20% of respondents in the Indonesia, the Philippines, and the United States reported that it was difficult or extremely difficult to socially distance.
Survey respondents reported engaging in a range of coping behaviors, including increased news consumption (58%), watching videos or TV (54%), sleeping (39%), connecting with friends and family (32%), eating due to stress or boredom (30%), exercising (22%), and using alcohol or other drugs (13%). Increased news consumption was commonly reported, except in Belarus, Russia, and Ukraine where less than 40% reported this as a coping behavior. Watching TV or videos was not very common in Belarus (29%) or Sweden (7%). Vietnam had the largest proportion of respondents who exercised to cope (40%). More than half (57%) of the respondents in Turkey reported eating due to stress or boredom as a coping behavior. Reported alcohol and drug use as a coping behavior was highest in the United States (20%) and the Philippines (19%). More details are shown in Table 2.
Coping With COVID-19 Pandemic (% of Respondents).
Conclusion
Our multidisciplinary research project, SICC, aimed to identify what health behaviors people across the world were engaging in to prevent the virus, how they coped during the pandemic, and how long they would be able to sustain these efforts. The COVID-19 pandemic continues to affect much of the world’s population and, while there is hope in the effectiveness of vaccination campaigns, we still rely on NPIs to prevent significant morbidity and mortality. Health behaviors for prevention are key to stopping the rapid transmission of the virus, but place significant burden and stress on individuals. As our study findings highlight, the vast majority of our respondents engaged in at least some these behaviors. It was encouraging to find nearly all respondents (98%) had engaged in some type of behavior change to prevent the spread of COVID-19. Behaviors thought to be the most preventive for COVID-19 at the time—mask wearing and social distancing—were employed at high levels in most countries. Our findings indicate that many people across the world worried about the virus for not only their own health, but also fear for the health of their loved ones. Health education activities to promote COVID-19 prevention should not exacerbate the fear and anxiety that is already prevalent due to the pandemic (Stolow et al., 2020).
The “pandemic fatigue” is becoming more and more of a problem (Meichtry et al., 2020). A significant number of respondents said that it was difficult for them to sustain these behaviors for more than 3 months. The mental health effects of the COVID-19 prevention measures will also be important to address in both the short and the long term. Managing the ongoing COVID-19 pandemic requires massive public health campaigns to reduce spread of the virus based largely around social and behavior changes—including physical distancing, handwashing, and wearing a mask. The success of these measures is dependent on individual compliance that often depends on the perception of risk to an individual as well as the burden on an individual and on society.
Our study highlights the importance of comparative multicountry studies in understanding COVID-19 compliance. We noted more engagement in the key health prevention behaviors in Asian countries while some countries in Europe and North America had less compliance. It is also important to remember that compliance is not simply a function of individual agency. Some behaviors are also influenced by social and structural determinants of health. For example, avoiding public transportation may not be possible for those who are required to travel to work. Government responses, including both public health and social policies, are also important to consider when studying the health behaviors of individuals during the pandemic. Moreover, mask wearing and restrictions to promote social distancing have became highly politicized in many contexts around the world in the past couple of years (Allcott et al., 2020; Bruine de Bruin et al., 2020; Chan et al., 2020; Sabat et al., 2020).
The descriptive data we present here are meant to serve as a starting point to learning more about the health behaviors and coping methods that individuals across countries engage in during the COVID-19 pandemic. Future studies may want to consider collecting longitudinal waves of data to track behavioral changes throughout a pandemic. They provide a foundation for seeing what patterns there are across various countries/regions. Our data warrant further analysis to better understand what factors are correlated with engagement in preventive health behaviors and coping behaviors across several cultural, social, economic, and political contexts. Ideas for further analysis include examining how trust and confidence in global and local governing institutions and health officials correlates with engagement in preventive health behaviors, how media consumption is associated with attitudes toward COVID-19 and engagement in health behaviors, and differences in both preventive and coping behaviors based on sociodemographic characteristics. The ongoing analyses of the SICC data will serve both as a guide for ongoing COVID-19 mitigation efforts as the pandemic continues, important lessons from the beginning of the pandemic, and as information in future pandemics.
Footnotes
Author Note
Ekaterina Aleksandrova and Peter Meylakhs is now affiliated to International Centre for Health Economics, Management and Policy, National Research University Higher School of Economics, St. Petersburg, Russia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded by Center for Southeast Asian Studies, Department of Psychology, Ford School of Public Policy, Lieberthal-Rogel Center for Chinese Studies, the MCubed Program, School of Public Health, Weiser Center for Emerging Democracies, and Weiser Center for Europe & Eurasia at the University of Michigan, Ann Arbor, MI, United States.
