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Public perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic: A UK-based focus group study

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Abstract

OBJECTIVE: Explore the perceptions and experiences of the UK public of social distancing and social isolation measures related to the COVID-19 pandemic. DESIGN: Qualitative study comprising five focus groups carried out online during the early stages of the UK's social distancing and isolation measures (5-12 days post lockdown). SETTING: Online video-conferencing PARTICIPANTS: 27 participants, all UK residents aged 18 years and older, representing a range of gender, ethnic, age and occupational backgrounds. RESULTS: The social distancing and isolation associated with COVID-19 policy has had having substantial negative impacts on the mental health and wellbeing of the UK public within a short time of policy implementation. It has disproportionately negatively affected those in low-paid or precarious employment. Practical social and economic losses - the loss of (in-person) social interaction, loss of income and loss of structure and routine - led to psychological and emotional 'losses' - the loss of motivation, loss of meaning, and loss of self-worth. Participants reported high adherence to distancing and isolation guidelines but reported seeing or hearing of non-adherence in others. A central concern for participants was the uncertainty duration of the measures, and their ability to cope longer-term. Some participants felt they would have lingering concerns over social contact while others were eager to return to high levels of social activity. CONCLUSIONS: A rapid response is necessary in terms of public health programming to mitigate the mental health impacts of COVID-19 social distancing and isolation. Initial high levels of support for, and adherence to, social distancing and isolation is likely to wane over time, particularly where end dates are uncertain. Social distancing and isolation 'exit strategies' must account for the fact that, although some individuals will voluntarily or habitually continue to socially distance, others will seek high levels of social engagement as soon as possible.
Public perceptions and experiences of social distancing and social isolation
during the COVID-19 pandemic: A UK-based focus group study.
Simon N Williams1,2 Senior Lecturer in People and Organisation:
s.n.williams@swansea.ac.uk
Christopher J. Armitage3,4, Professor of Health Psychology:
chris.armitage@manchester.ac.uk
Tova Tampe5, Independent Consultant: tova.tampe@gmail.com
Kimberly Dienes3, Lecturer in Psychology: kimberly.dienes@manchester.ac.uk
1 School of Management, Swansea University, Swansea, SA1 8EN
2 Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern
University, Chicago, Illinois, 60611, United States of America
3 Manchester Centre for Health Psychology, University of Manchester, Manchester, M13 9PL
4 Manchester University NHS Foundation Trust, Manchester Academic Health Science
Centre, Manchester, M13 9PL
5 World Health Organisation, 1211 Geneva 27, Switzerland.
Correspondence to: Simon Williams simonwilliams@northwestern.edu
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ABSTRACT
OBJECTIVE: Explore the perceptions and experiences of the UK public of social distancing
and social isolation measures related to the COVID-19 pandemic.
DESIGN: Qualitative study comprising five focus groups carried out online during the early
stages of the UK’s social distancing and isolation measures (5-12 days post lockdown).
SETTING: Online video-conferencing
PARTICIPANTS: 27 participants, all UK residents aged 18 years and older, representing a
range of gender, ethnic, age and occupational backgrounds.
RESULTS: The social distancing and isolation associated with COVID-19 policy has had
having substantial negative impacts on the mental health and wellbeing of the UK public
within a short time of policy implementation. It has disproportionately negatively affected
those in low-paid or precarious employment. Practical social and economic losses - the loss
of (in-person) social interaction, loss of income and loss of structure and routine – led to
psychological and emotional ‘losses’ – the loss of motivation, loss of meaning, and loss of
self-worth. Participants reported high adherence to distancing and isolation guidelines but
reported seeing or hearing of non-adherence in others. A central concern for participants was
the uncertainty duration of the measures, and their ability to cope longer-term. Some
participants felt they would have lingering concerns over social contact while others were
eager to return to high levels of social activity.
CONCLUSIONS: A rapid response is necessary in terms of public health programming to
mitigate the mental health impacts of COVID-19 social distancing and isolation. Initial high
levels of support for, and adherence to, social distancing and isolation is likely to wane over
time, particularly where end dates are uncertain. Social distancing and isolation ‘exit
strategies’ must account for the fact that, although some individuals will voluntarily or
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habitually continue to socially distance, others will seek high levels of social engagement as
soon as possible.
What is already known on this topic
Adherence to non-pharmaceutical interventions during pandemics is lower where
people have low trust in government and where people perceive themselves at
relatively low risk from the disease
There is a need for evidence on public perceptions and experiences of the
psychological and social public experiences of COVID-19 related social distancing
and isolation, and its relation to adherence.
What this study adds
People lack trust in government and perceive themselves at low personal risk,but
closely adhere to social distancing and isolation measures motivated by social
conscience, and are critical of non-adherence in others.
Population-wide social distancing and isolation can have significant negative social
and psychological impacts within a short time of policy implementation.
Key concerns during social distancing and isolation are uncertainty of duration and
ability to cope longer-term.
At the end of pandemic ‘lockdowns’, some individuals will likely voluntarily or
habitually continue to socially distance, while others will likely seek high levels of
social engagement as soon as possible.
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INTRODUCTION
The current coronavirus (COVID-19) pandemic presents the greatest threat to public health in
living memory and promises to be the deadliest pandemic since 1918-19.[1-2] Pandemics are
challenging for clinical and public health agencies and policymakers because of the scientific
and medical uncertainty that accompanies novel viruses like COVID-19.[3-4] Since COVID-
19 is a new virus, pharmaceutical interventions like vaccines are not presently available.
Public health policy is therefore exclusively reliant on non-pharmaceutical interventions
(NPIs). The key NPIs being used in relation to the COVID-19 pandemic in the UK and
globally (in addition to personal hygiene advisories (e.g. emphasising regular and thorough
handwashing)) are social distancing (e.g. prohibiting public gatherings, closing schools and
other non-essential services, and keeping a distance of >2 metres apart from others) and
social isolation (e.g. remaining indoors except for one brief outing for per day for physical
activity or ‘essential supplies’).[5]
Due to the unprecedented scale and severity of the social distancing and social
isolation measures being implemented in response to COVID-19, the social and
psychological impacts on the public are also likely to be unprecedented in scale and severity.
A recent rapid review of the psychological impact of quarantine found that longer quarantine
duration, infection fears, frustration and boredom, inadequate supplies, inadequate
information, financial loss and stigma were among the major stressors.[6] Another
systematic review of the literature on NPIs in relation to pandemic influenza and SARS
found that people actively evaluate NPIs in terms of criteria such as perceived necessity,
efficacy, acceptability and feasibility.[7] Public views on social distancing and social
isolation are ambivalent in some contexts because of their perceived adverse social and
economic impacts and their ability to attract stigma, particularly amongst those required to
self-isolate.[7] Existing research on social distancing and isolation highlights a number of
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challenges for public health policymakers, including a lack of trust in government;[8]
concerns over strains in family resources;[8] gaps and confusions in some areas of pandemic
information communication;[9] and low adherence to voluntary social isolation and relatively
low adherence to non-attendance at public gatherings.[10] Although there is existing research
from past pandemics on its likely effects,[6] and new quantitative research is starting to
emerge,[11] there is no published qualitative evidence on public perceptions and experiences
of the psychological and social public experiences of COVID-19 related social distancing and
social isolation, and its relation to adherence – a gap that the present study addresses.
This study aimed to explore four main questions: (1) What are the social and
psychological impacts of social distancing and isolation experienced by the UK public during
the COVID-19 pandemic? (2) What are people’s views on government communication
around social distancing and isolation? (3) What are people’s current experiences of
adherence in relation to social distancing and isolation? (4) What are people’s views on the
future in regard to COVID-19 social distancing and isolation. This study therefore aims to
contribute to knowledge of adherence to social distancing and isolation policy to provide
insight into how communication with the public on social distancing and isolation may be
shaped and improved in the future.
PARTICIPANTS AND METHODS
Five online focus groups with 27 participants were run between March 28th and April 4th,
2020 (5-12 days after lockdown commenced on the 23rd March 2020). Participants were
adults aged 18 years or over currently residing in the UK. Under normal circumstances,
online focus groups can be a useful way of eliciting public views related to matters of health
and medicine, particularly from diverse and geographically dispersed participants [12-13] but
were necessary due to social isolation policy.
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Purposive sampling was used to provide a diverse range of ages, genders,
race/ethnicities and social backgrounds and to explore the study’s research questions.[14-15]
Potential participants were asked to complete a very brief demographic survey to provide
background information and to facilitate recruitment of a diverse population (Table 1). Due
to social distancing measures, it was necessary for all recruitment to be conducted online.
Researchers used a combination of social media snowball sampling, online community and
volunteer advertising sites and social media advertisements (Facebook ads).
Table 1: Demographic details reported by participants.
Characteristic N (%)
Gender
Female 13 (48)
Male 14 (52)
Age range
18-24 7 (26)
25-34 6 (22)
35-44 8 (30)
45-54 5 (19)
55-64 1 (3)
Ethnicity
White - British 16 (59)
White – any other White background 6 (22)
Asian or Asian British - Pakistani 3 (11)
Mixed – White and Asian 1 (4)
Other 1 (4)
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Occupational Classification
Managers, directors and senior officials 2 (7)
Professional occupations 6 (22)
Associate professional and technical occupations 5 (19)
Administrative and secretarial occupations 1 (4)
Skilled trades occupations 1 (4)
Caring, leisure and other service occupations 1 (4)
Sales and customer service occupations 3 (11)
Elementary occupations 1 (4)
Full-time student 5 (19)
Unclassified/occupation not provided 2 (7)
Note: occupational classifications coded using the Office for National Statistics (ONS) Occupation
Coding Tool.
To ensure that online discussion was manageable, focus groups were kept to between 5-8
participants. Each group met virtually via a web video-conferencing platform (Zoom) for
between 60-90 minutes. Participants joined using both video and audio. All focus groups
were organised and moderated by SW (a medical social scientist). The topic guide for the
focus groups was initially developed using existing literature on public attitudes and
experiences in past pandemics and was tested and refined in a pilot focus group. The main
topics for the focus groups were: general views on social distancing and isolation; health
impacts of social distancing and isolation; views on government COVID-19 advice and
communication; and views on compliance with, and the future impacts of, social distancing
and isolation.
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Analysis
Data collection and analysis followed an iterative process, whereby emergent themes from
early focus groups were used to add to or refine questions and prompts during subsequent
focus groups. All focus groups were recorded and transcribed for coding. SW and KD
analysed the transcripts and developed and applied the thematic coding framework. Themes
were discussed and developed with CJA and TT during virtual research group meetings. To
help analysis we looked to validate “sensitive moments” between groups that indicated
difficult but important issues.[16] Negative case analysis was used to seek for information
that did not fit emergent themes, and where this occurred, themes were modified
accordingly.[17]. Following a grounded theory approach, data were organised into primary
and more focused codes that provided insight into identified themes.[14,18] Data collection
and analysis continued until saturation occurred (that is, until no new significant themes
emerged).[18] Data were analysed in NVivo (version 11.4.3, QRS).
RESULTS
Analysis revealed four broad themes: (1) the negative social and psychological impacts of
social distancing and isolation during the COVID-19; (2) criticisms of government
communication around social distancing and isolation; (3) current adherence and non-
adherence of self and others; and (4) Uncertainty, social-reintegration and the future. Within
each broad theme were a number of substantive sub-themes that are discussed below,
supplemented by indicative quotes in Boxes 1-4.
The social and psychological impacts of COVID-19 social distancing and isolation
All participants felt that the social distancing and isolation polices had had significant social
and psychological impacts on their lives and the central theme was loss (Box 1). This
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experience of loss, which one participant likened to a process of “grieving” (Participant 25,
male, age 58, London), consisted of three practical social and economic losses: loss of (in-
person) social interaction, loss of income, and loss of structure and routine. These in turn led
to three psychological and emotional “losses”: loss of motivation, loss of meaning, and loss
of self-worth.
First, participants spoke of a loss of social interaction. The suddenness and
extensiveness of the lack of face-to-face contact had, even after only one week of lockdown,
already “taken its toll on mental health” (Participant 2, Male, age 31, Manchester), leaving
participants feeling “alienated” (Participant 6, male, age 20, London). A number talked about
feeling depressed or anxious as a result of social distancing or isolation, an experience some
likened to “a prison” (Participant 8, female, age 40, London). Second, a number of
participants discussed how a loss of income, either through permanent loss of a job, or
through temporary loss (via lost clients or customers or being furloughed), had left them
feeling “quite depressed” (Participant 8, female, age 40, London). Third, participants
expressed of a loss of structure and routine. The inability to go to work, or for some the
significant re-structuring of work patterns, including balancing home working with home
schooling, meant that participants felt “overwhelmed” (Participant 9, female, age 34,
London).
Participants discussed how impacts like losing their job or not being able to go to
work, and not being able to socialise with friends, meant they experienced a general loss of
meaning in life. One participant already felt in need of professional mental health support,
less than two weeks into isolation. Participants also spoke of a loss of motivation to perform
basic everyday tasks, such as personal hygiene and grooming or exercising. For some, this
lack of motivation had left them feeling “sluggish” (Participant 5, male, age 26, London).
Finally, participants expressed feeling a loss of self-worth. These emotional and
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psychological losses were particularly acute for those living in more urban, densely populated
cities like London or Birmingham. They were also especially evident amongst those in low-
paid or precarious occupations, who had either lost their job or income or were now relying
on parental, familial or state financial support as a result of the pandemic.
Box 1:
The social and psychological impacts of COVID
-
19 social distancing and
isolation
Loss of social interaction
“I’ve been working at home for the past week and a bit and it’s taken its toll … because you think
social contact is such an important part of everyday life and now it’s like you walk down the street
and people are almost too scared to walk too close. It’s so alien.” (Participant 6, male, age 20,
London)
“It’s all over the news, it’s all over your phone, it’s all over the TV, it’s basically everywhere you
turn you are hearing about it. All of a sudden, we can’t do these things we used to do, like going to
the shops and restaurants, and we just have to stay in, and I think people feel claustrophobic in both
a physical and an emotional sense.” (Participant 5, male, age 26, London)
Loss of structure and routine
“I feel really lazy at home. I feel sluggish. I feel out of my routine. I feel much less active, both
mentally and physically. You know, not taking the trip to work every day. My working from
home schedule is neither here nor there. Mentally I am not as sharp, I feel like I am taking lots of
naps in the day.” (Participant 5, male, age 26, London)
“I’m literally planning day-to-day as things go along. … I’m not used to having the kids every
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single day because they are usually at school. It’s difficult to work around them, I can’t do
anything with them, because I can’t go out. I feel so scared and don’t want to risk it.” (Participant
9, Female, age 34, London)
Loss of meaning
“All this talk about social distancing and things is so depressing, terrible, I mean I have even been
contemplating on contacting The Samaritans just to be able to try to get through all this.”
(Participant 10, male, age 44, London)
“Being locked in a room trying to find something meaningful to do during the day, and I think it’s
had a severe impact … I hope something changes within a few weeks, so I am able to go out and
live a fulfilling life” (Participant 1, male, age 30, Birmingham)
Loss of motivation
“Physically it has had a toll on people. All day you are stuck at home. You eat, you sleep, you
work, its gonna have an effect on the body, there is no real drive or motivation.” (Participant 6,
male, age 20, London)
“We are feeling very down and demotivated, very low very depressed to some extent… it’s become
more stressful to get by and function on a daily basis.” (Participant 1, male, age 30, Birmingham)
Loss of self-worth
“Your self-worth goes down a bit, because you can’t socialise with people and make yourself feel
good about yourself.” (Participant 2, male, age 31, Manchester)
“The company I work for has closed down and I have had to apply for welfare assistance … and
I’ve had to go and live with my parents now, and they have had to support me financially. … it’s
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been difficult, the whole mental health, the ability to function and get by, and being constantly
locked in.” (Participant 1, male, age 30, Birmingham)
Criticisms of government communication around social distancing and isolation
Most participants felt that guidance on social distancing and isolation had been generally
unclear, although some described how it had “become clearer” over the course of the
pandemic (Participant 7, male, age 20, Glasgow) (Box 2). Many participants exhibited a lack
of trust either in government, who were seen to be “politicising” the pandemic (Participant
22, male, age 51, North-West England), or in the media, who they felt were providing
confusing information or “mixed messages” (Participant 1, male, age 30, Birmingham).
Participants felt that despite being locked at home, the constant media and social media
attention on COVID-19 made them feel “claustrophobic in both a physical and an emotional
sense” (Participant 5, male, age 26, London), and that “seeing others in a heightened state of
anxiety makes it harder to suppress that in yourself” (Participant 21, female, age 46, North
West England).
Another common criticism was over the ambiguity of terms such as ‘essential’ and
‘emergency’ supplies and services. This ambiguity, participants argued, meant that advice
was either hard to follow or implement, or that “loopholes” could be exploited (Participant
19, female, age 21, South Wales) (see section below on compliance, non-compliance and the
future).
Box 2
:
Mixed or unclear messages
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“After reading several news publications and channels, there has been much campaign around
social distancing, and with isolation you normally associate it when you have got the virus yourself,
but I think over the past week there have been several mixed messages over social distancing.”
(Participant 1, male, age 30, Birmingham)
“I’m trying to pick my way through what is happening, a lot of politicians are politicising it
[COVID-19] and when you read the internet, it is very difficult to know what is real, true or valid,
even if you read a broad church of views, facts and figures, it is still very difficult to make sense of
it all (Participant 22, male, age 51, North-West England).
Ambiguous definitions
“Now everyone has been told that they have to stay in their houses, and people are thinking well
‘this can be classed as essential, and this can be classed as essential, whereas although we have
been told a list of things we can do, people are finding loopholes and finding ways to get round
them” (Participant 19, female, age 21, South Wales)
“I have seen loads of people outside, and I wonder how people will enforce that [penalty fines for
not social distancing], I’m wondering how can someone prove they are going for an ‘emergency
reason’?” (Participant 2, male, age 31, Manchester)
Current adherence and non-adherence of self and others
All participants reported being highly adherent to government instructions on social
distancing (Box 3). Participants described how, despite the perceived lack of clarity
discussed above, they had been social distancing and isolating as far as possible. Participants
also displayed a high degree of social consciousness, with many acknowledging that despite
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not perceiving themselves as being at high risk, they were doing it to “save lives” and protect
those most vulnerable to the disease.
Despite reporting their own high degree of adherence, many participants suggested
that they had seen instances of non-adherence in others. Observations of non-adherence were
associated with three main factors. First, non-adherence was seen to be due to a lack of
social conscience. Participants were generally critical of what they perceived to be a
minority of “inconsiderate” (Participant 27, female, age 46, London) or “arrogant”
(Participant 17, male, age 22, South Wales) individuals who were not observing instructions
related, for example, to public gatherings and not keeping a distance of >2 metres apart from
others when out for daily walks or runs. Second, non-adherence was seen to be due to a lack
of understanding. For example, participants argued that people who were not observing
social distancing lacked knowledge over how they could help spread the disease even if they
themselves were not exhibiting symptoms. Third, non-adherence was seen to be due to a lack
of enforcement. Many participants were critical that police were choosing to enforce social
distancing restrictions or were not able to (due for example to the ambiguity of terms such as
“essential” as discussed in the previous section). Others discussed how, despite their best
efforts, supermarkets appeared to struggle to implement social distancing.
Box 3: Current adherence and non-adherence of self and others
High levels of support for, and adherence to social distancing and isolation
“Staying at home is actually helping to save lives” (Participant 20, female, age 21, South Wales)
“We have been in lockdown for 14 days, and because of my 87-year-old grandmother who has
health problems, it [going out] is just not worth it.” (Participant 17, male, age 22, South Wales)
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Non-adherence due to lack of social conscience
“I’m worried that people are going to take advantage of the nice weather and ruin it for people …
Its insane because they have shut the park, but you get some inconsiderate people like a group of
lads playing football or people taking over the paths.” (Participant 27, female, age 46, London)
“The canal path we walk along is not 2 metres wide, but you can just about get around it if you go
on the verge and they go on the verge, and most people do but not everybody does … I don’t say
anything because … with all the publicity that’s out, if you are still choosing to do that, then me
telling you not to do it is not going to make a difference, it’s frustrating” (Participant 26, female,
Manchester)
Non-adherence due to lack of understanding
The vast majority of people are taking it seriously and suffering to a certain extent, but there is a
minority who don’t necessarily understand it applies to them also. I know of people who have
gone to parks or gone for a picnic, because they think ‘well we don’t know anyone who has any
symptoms, and we’ve not got anything, so we can go about it in the same way’.” (Participant 19,
female, age 21, South Wales).
Non-adherence due to lack of enforcement
“They say that you are not allowed to go out for non-emergency reasons, which I don’t think a lot
of people are observing. People are just going out whenever they want. Those guidelines are in
place by Boris [Johnson; UK Prime Minister] but no-one is really enforcing that. You see police
on the street, but they are not really doing anything.” (Participant 2, male, age 31, Manchester)
“The supermarket they are not implementing, what’s the point in having the two-metre thing
outside when you can’t do that inside. … I went to the supermarket and people respect it outside,
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but as soon as you go inside there is [sic] people, they don’t care, they just come right up to you
and try to reach over you.” (Participant 8, female, age 40, London).
Uncertainty, social-reintegration and the future
According to participants, “the biggest problem we’ve got is we don’t know when it’s going
to end” and the sense of “powerlessness” this had fostered (Participant 25, male, age 58,).
Despite their high level of current adherence, participants acknowledged there was a limit as
to how long they and others could adhere, at least without experiencing more severe social
and psychological suffering. Some participants felt that they would rather be told a specific
time frame, even if it was far in the future. Others feared that whilst they and others could
“get through” this initial phase of lockdown, going “in and out” of periods of lockdown (a
scenario some knew was possible due to the potential for COVID-19 to re-emerge in a
second wave) meant that “people will really struggle mentally” (Participant 19, female, age
21, South Wales). Some felt as though they could only take things “day-by-day” because
anticipating social distancing and isolation over a period of time was “too overwhelming”
(Participant 22, male, age 51, North-West England).
Looking to the future, participants were divided as to how they felt they, and others,
would act when social distancing and isolation measures were either relaxed or removed.
Some felt that they and others would “go back to living my life completely as normal”
(Participant 24, male, Manchester) as soon as possible. These participants spoke of “being
desperate to go out and go to restaurants or travel a lot” (Participant 5, male, age 26, London)
and generally not taking a graded approach to social reintegration. They argued that if they
were “told its ok” to socially reintegrate, then this was enough for them to “not feel too
anxious about going out with friends in the future” (Participant 24, male, age 40, North-West
England). Others felt that it would take them a longer to return to pre-pandemic social
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behaviours, and for example felt that they would continue to have “anxiety around health”
(Participant 23, female, age 38, North-West England), would be “cautious” about a
“transition period where I stay in a bit more” (Participant 2, male, age 31, Manchester) and
that people in general might remain “socially distant” from one another (Participant 8,
female, age 40, London).
Others argued that how they would act would likely depend on the circumstances
under which social distancing and isolation measures were being relaxed or removed.
Specifically, this was tied to their perception of whether COVID-19 still posed a risk to them
or to society in general. They argued that, if a vaccine was available, then they would be
happy to return to their pre-pandemic activity.
Box 4:
Uncertainty, social
-
reintegration and the future
The challenge of future uncertainty
“I would rather they [the government] said tonight, ‘you’re gonna be stuck in your houses until
September, than say, we will review in three weeks, and then say, we will review in three week,
and keep doing that, I’d rather they set a date way in advance in the future because then you can
get your head around it” (Participant 17, male, age 22, South Wales)
“I’ve heard on the grapevine and online sources that we are in this lockdown for a few weeks or so,
and then after 12 weeks or so we kind of get released and because we are not all immune
necessarily it all comes back in a wave and then we have this constant thing of being locked down
and then coming out and going back in again, … and so I think it will go downhill, that’s when
people will struggle mentally because they’ve had that taste of freedom, and you don’t know how
long it’s all going to finish.” (Participant 19, female, age 21, South Wales)
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Perceptions of future behaviour
“I’m literally thinking day-by-day, because if one was to consider three months of this, and we are
only two weeks in, it’s just too much, it’s too overwhelming” (Participant 22, male, age 51, North-
West England)
“People are not going to stay like this for another 6 months. It’s for a good reason I know, but it’s
like a prison, we know what people are suffering mentally and emotionally, we don’t know what
people are going through behind their door … When all this comes to an end we don’t know how
life is going to be. Is everybody going to be socially distant? It’s scary.” (Participant 8, female,
age 40, London)
Alternative accounts and positive perceptions resulting from social distancing and
isolation
Although the findings discussed above represent the most common views exhibited by
participants, negative case analysis did reveal some alternative accounts. For example, some
participants argued that social distancing and isolation “hadn’t been hard” (Participant 17,
male, age 22, South Wales). However, these participants were all university students, and
acknowledged that part of the reason it hadn’t been as difficult for them was there had been
no loss of income and, less loss of routine for them.
A small number of participants argued that they were able to draw positives from the
social distancing and isolation due to COVID-19. For example, some described how
household quarantine had meant they could have “more time with their children” (Participant
14, male, age 38, North-West England) or had brought family units together (Participant 22,
male, age 51, North-West England). However, those participants who explicitly discussed
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the positives to be drawn from social distancing and isolation were all from higher socio-
economic backgrounds, and tended to live in more rural or less densely populated areas of the
UK.
DISCUSSION
Our findings suggest that a large proportion of the UK public may be suffering from feelings
of depression, anxiety, and loss as a result of COVID-19 social distancing and isolation.
Some already feel in need of professional mental health support. The social and
psychological impacts identified through this study centred around the various losses that
people are experiencing. Practical social and economic losses - the loss of (in-person) social
interaction, loss of income and loss of structure and routine – led to psychological and
emotional losses – the loss of motivation, loss of meaning, and loss of self-worth. Findings
also suggest that participants generally found information on social distancing to be
ambiguous. However, there were differing views as to whether the government was at fault
(insufficiently clear communication) or that the terms themselves are ambiguous and a small
minority of the UK public were taking advantage of the ambiguity. It was recognized that
this ambiguity may have been designed to permit greater social freedom than the more
extreme social distancing and isolation measures implemented in other countries.
Additionally, there was universally high adherence to social distancing and isolation
guidelines reported across the study sample, yet most participants had observed or heard of
non-adherence in others. Participants were highly critical of such instances of non-
adherence, citing lack of social conscience, lack of understanding and lack of enforcement as
likely causes. Perhaps the greatest concern for participants was the uncertainty they faced
over the duration of the social distancing and isolation measures, as well as their ability to
cope longer-term. There was also uncertainty as to how they and others would act, with some
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fearful of lingering inhibitions and anxiety over social contact and health, and others eager to
return to normal levels of social activity.
Relevance to existing literature
Our findings on COVID-19 social distancing and isolation support some of the findings from
existing systematic reviews on previous pandemics related to influenza and SARS.[6-7] For
instance, we found that frustration or anxiety over loss of social interaction or loss of income,
inadequate or ambiguous information, and fears over the duration of social distancing and
isolation measures were all major themes.[6-8]. However, contrary to previous research
which suggests that adherence with pandemic NPIs is lower in instances where people have
low trust in government and where people perceive themselves at relatively low risk from the
disease,[7] our participants were highly adherent to social distancing and isolation measures,
despite many lacking trust in government and perceiving themselves at low risk. In fact,
stigma was more likely to be attributed to those who were failing to socially distance and
isolate. Of course, as noted above the scale and severity of the pandemic and subsequent
measures are unprecedented. As such, although there is existing research on its likely
effects,[6] and although quantitative research is starting to emerge,[11] there is to, our
knowledge, no published qualitative evidence on public perceptions and experiences of the
psychological and social public experiences of COVID-19 related social distancing and
isolation, and its relation to adherence – a gap this study addresses.
Limitations
One limitation of this study is that it is not possible to rule out that the high degree of
adherence and social conscience that participants expressed was not at least partly affected by
social desirability bias, which can often be encountered in focus group studies.[19] However,
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conducting focus groups online has been found to reduce social desirability bias (although it
is worth noting that this is more so where asynchronous or text-only communication is used,
and not video-conferencing as in our study).[12,20]
Another limitation of this study is that it did not recruit participants who are deemed
at particularly high risk from COVID-19-related complications, for example, individuals
aged 70 and over and those living with certain chronic health conditions.[21] Because these
individuals are likely to have been significantly affected by social distancing and isolation
policy (being required to self-isolate for 12 weeks), their views will be important. It is also
worth noting that our recruitment material did encourage those at high risk to apply, though
we received no applications from those over-70. This may be partly due to the fact that those
over-70 are a hard-to-reach group online, because they are significantly less likely to use
social media or be heavy internet users,[22] which, due to the lack of online social support
and interaction, might mean they are at particularly high risk of some of the negative social
and psychological impacts discussed in this paper. Future research will explore at-risk
groups’ experiences in depth. Future papers will also explore further the similarities and
differences in views and experiences in the perceptions of experiences of participants living
in different parts of the UK (e.g. London compared to less densely populated areas), a theme
only briefly discussed here due to limitations of scope.
Implications for policy and practice
This study suggests that the social distancing and isolation associated with COVID-19 policy
is having substantial negative impacts on the mental health and wellbeing of the UK public
within a short time of policy implementation. The prevalence of COVID-19-related
depression and anxiety, and the extent to which it will last beyond the removal or relaxation
of social distancing and isolation policies remains to be seen. Our ongoing research will
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explore these social and psychological impacts longitudinally. Policymakers and the public
health community must discuss measures to respond to the likely wave of mental ill-health
which is expected to follow, and which is tentatively suggested by our early qualitative
evidence. The theme of loss and addressing public concerns around physical and emotional
losses (e.g. meaning and self-worth), may inform current and future therapeutic interventions.
Loss of meaning and self-worth may be due in part to loss of control, and increasing a sense
of control for the public should be considered in future policy, intervention, and
programming.[23] Additionally, findings suggest that a rapid response is necessary in terms
of public health programming to mitigate these mental health impacts. Waiting until
restrictions and isolation measures are relaxed or removed to provide support services could
potentially have devastating impacts. Government and the public health authorities should
look at ways of extending mental health outreach services, especially remotely.[24] Timely
attention is needed for those who are predisposed to depression and anxiety, those who may
be suicidal, and those experiencing significant social, economic and personal loss.
Our study also suggests that although the COVID-19 pandemic has had significant
ramifications for many UK residents from diverse backgrounds, it has disproportionately
negatively affected those in low-paid or precarious employment. Future research and policy
should therefore seek to develop measures that specifically seek to remediate the social,
economic and psychological harms related to COVID-19 as experienced by those from
disadvantaged backgrounds. Looking ahead to later stages in the current pandemic, or to the
development of pandemic preparedness programmes for the future, a couple of lessons can be
distilled, which warrant urgent attention. Firstly, initial high levels of support for, and
adherence to, social distancing and isolation measures are likely to wane over time,
particularly where end dates are and remain uncertain. Secondly, in planning the ‘exit
strategy’ for the UK lockdown, and its possible impact on future resurgences of COVID-19
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infection, policymakers and public health authorities need to account for the fact that,
although some individuals will voluntarily or habitually continue to socially distance (graded
social reintegration) others will seek immediately to re-integrate fully beyond what they are
permitted to.
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DECLARATIONS
Competing interest statement: All authors have completed the Unified Competing Interest
form (available on request from the corresponding author) and declare: Armitage is supported
by NIHR Manchester Biomedical Research Centre and NIHR Greater Manchester Patient
Safety Translational Research Centre. Tampe is an independent consultant and currently
consults for the World Health Organization. The authors have no other relationships or
activities that could appear to have influenced the submitted work.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the
manuscript is an honest, accurate, and transparent account of the study being reported; that no
important aspects of the study have been omitted; and that any discrepancies from the study
as planned (and, if relevant, registered) have been explained.
Authors’ contributions: All authors contributed to the planning of the study. The analysis
was conducted by SW and KD. The initial draft of the article was written by SW. All authors
revised the manuscript and approved the final version for publication. SW is the guarantor of
the article.
Funding statement: This research was supported by the Manchester Centre for Health
Psychology based at the University of Manchester (£2000). Armitage’s contribution was
additionally supported by the NIHR Manchester Biomedical Research Centre and the NIHR
Greater Manchester Patient Safety Translational Research Centre. The funders played no role
in the conduct of the study.
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author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the(which was not peer-reviewed) The copyright holder for this preprint .https://doi.org/10.1101/2020.04.10.20061267doi: medRxiv preprint
Data sharing statement: Ethical restrictions related to participant confidentiality prohibit the
authors from making the data set publicly available. During the consent process, participants
were explicitly guaranteed that the data would only be seen my members of the study team.
For any discussions about the data set please contact the corresponding author, Simon
Williams (s.n.william@swansea.ac.uk).
Ethics statement: Ethical approval was received by Swansea University’s Research Ethics
Committee.
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author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the(which was not peer-reviewed) The copyright holder for this preprint .https://doi.org/10.1101/2020.04.10.20061267doi: medRxiv preprint
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The global impact of COVID-19 has been profound, and the public health threat it represents is the most serious seen in a respiratory virus since the 1918 H1N1 influenza pandemic. Here we present the results of epidemiological modelling which has informed policymaking in the UK and other countries in recent weeks. In the absence of a COVID-19 vaccine, we assess the potential role of a number of public health measures-so-called non-pharmaceutical interventions (NPIs)-aimed at reducing contact rates in the population and thereby reducing transmission of the virus. In the results presented here, we apply a previously published microsimulation model to two countries: the UK (Great Britain specifically) and the US. We conclude that the effectiveness of any one intervention in isolation is likely to be limited, requiring multiple interventions to be combined to have a substantial impact on transmission. Two fundamental strategies are possible: (a) mitigation, which focuses on slowing but not necessarily stopping epidemic spread-reducing peak healthcare demand while protecting those most at risk of severe disease from infection, and (b) suppression, which aims to reverse epidemic growth, reducing case numbers to low levels and maintaining that situation indefinitely. Each policy has major challenges. We find that that optimal mitigation policies (combining home isolation of suspect cases, home quarantine of those living in the same household as suspect cases, and social distancing of the elderly and others at most risk of severe disease) might reduce peak healthcare demand by 2/3 and deaths by half. However, the resulting mitigated epidemic would still likely result in hundreds of thousands of deaths and health systems (most notably intensive care units) being overwhelmed many times over. For countries able to achieve it, this leaves suppression as the preferred policy option. We show that in the UK and US context, suppression will minimally require a combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members. This may need to be supplemented by school and university closures, though it should be recognised that such closures may have negative impacts on health systems due to increased absenteeism. The major challenge of suppression is that this type of intensive intervention package-or something equivalently effective at reducing transmission-will need to be maintained until a vaccine becomes available (potentially 18 months or more)-given that we predict that transmission will quickly rebound if interventions are relaxed. We show that intermittent social distancing-triggered by trends in disease surveillance-may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound. Last, while experience in China and now South Korea show that suppression is possible in the short term, it remains to be seen whether it is possible long-term, and whether the social and economic costs of the interventions adopted thus far can be reduced.
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Background As for all individuals, the Internet is important in the everyday life of older adults. Research on older adults’ use of the Internet has merely focused on users versus nonusers and consequences of Internet use and nonuse. Older adults are a heterogeneous group, which may implicate that their use of the Internet is diverse as well. Older adults can use the Internet for different activities, and this usage can be of influence on benefits the Internet can have for them. Objective The aim of this paper was to describe the diversity or heterogeneity in the activities for which older adults use the Internet and determine whether diversity is related to social or health-related variables. Methods We used data of a national representative Internet panel in the Netherlands. Panel members aged 65 years and older and who have access to and use the Internet were selected (N=1418). We conducted a latent class analysis based on the Internet activities that panel members reported to spend time on. Second, we described the identified clusters with descriptive statistics and compared the clusters using analysis of variance (ANOVA) and chi-square tests. Results Four clusters were distinguished. Cluster 1 was labeled as the “practical users” (36.88%, n=523). These respondents mainly used the Internet for practical and financial purposes such as searching for information, comparing products, and banking. Respondents in Cluster 2, the “minimizers” (32.23%, n=457), reported lowest frequency on most Internet activities, are older (mean age 73 years), and spent the smallest time on the Internet. Cluster 3 was labeled as the “maximizers” (17.77%, n=252); these respondents used the Internet for various activities, spent most time on the Internet, and were relatively younger (mean age below 70 years). Respondents in Cluster 4, the “social users,” mainly used the Internet for social and leisure-related activities such as gaming and social network sites. The identified clusters significantly differed in age (P<.001, ω²=0.07), time spent on the Internet (P<.001, ω²=0.12), and frequency of downloading apps (P<.001, ω²=0.14), with medium to large effect sizes. Social and health-related variables were significantly different between the clusters, except social and emotional loneliness. However, effect sizes were small. The minimizers scored significantly lower on psychological well-being, instrumental activities of daily living (iADL), and experienced health compared with the practical users and maximizers. Conclusions Older adults are a diverse group in terms of their activities on the Internet. This underlines the importance to look beyond use versus nonuse when studying older adults’ Internet use. The clusters we have identified in this study can help tailor the development and deployment of eHealth intervention to specific segments of the older population.
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Background Non-pharmaceutical public health interventions may provide simple, low-cost, effective ways of minimising the transmission and impact of acute respiratory infections in pandemic and non-pandemic contexts. Understanding what influences the uptake of non-pharmaceutical interventions such as hand and respiratory hygiene, mask wearing and social distancing could help to inform the development of effective public health advice messages. The aim of this synthesis was to explore public perceptions of non-pharmaceutical interventions that aim to reduce the transmission of acute respiratory infections. Methods Five online databases (MEDLINE, PsycINFO, CINAHL, EMBASE and Web of Science) were systematically searched. Reference lists of articles were also examined. We selected papers that used a qualitative research design to explore perceptions and beliefs about non-pharmaceutical interventions to reduce transmission of acute respiratory infections. We excluded papers that only explored how health professionals or children viewed non-pharmaceutical respiratory infection control. Three authors performed data extraction and assessment of study quality. Thematic analysis and components of meta-ethnography were adopted to synthesise findings. Results Seventeen articles from 16 studies in 9 countries were identified and reviewed. Seven key themes were identified: perceived benefits of non-pharmaceutical interventions, perceived disadvantages of non-pharmaceutical interventions, personal and cultural beliefs about infection transmission, diagnostic uncertainty in emerging respiratory infections, perceived vulnerability to infection, anxiety about emerging respiratory infections and communications about emerging respiratory infections. The synthesis showed that some aspects of non-pharmaceutical respiratory infection control (particularly hand and respiratory hygiene) were viewed as familiar and socially responsible actions to take. There was ambivalence about adopting isolation and personal distancing behaviours in some contexts due to their perceived adverse impact and potential to attract social stigma. Common perceived barriers included beliefs about infection transmission, personal vulnerability to respiratory infection and concerns about self-diagnosis in emerging respiratory infections. Conclusions People actively evaluate non-pharmaceutical interventions in terms of their perceived necessity, efficacy, acceptability, and feasibility. To enhance uptake, it will be necessary to address key barriers, such as beliefs about infection transmission, rejection of personal risk of infection and concern about the potential costs and stigma associated with some interventions.
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The December, 2019 coronavirus disease outbreak has seen many countries ask people who have potentially come into contact with the infection to isolate themselves at home or in a dedicated quarantine facility. Decisions on how to apply quarantine should be based on the best available evidence. We did a Review of the psychological impact of quarantine using three electronic databases. Of 3166 papers found, 24 are included in this Review. Most reviewed studies reported negative psychological effects including post-traumatic stress symptoms, confusion, and anger. Stressors included longer quarantine duration, infection fears, frustration, boredom, inadequate supplies, inadequate information, financial loss, and stigma. Some researchers have suggested long-lasting effects. In situations where quarantine is deemed necessary, officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. Appeals to altruism by reminding the public about the benefits of quarantine to wider society can be favourable.
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