COVID-19 is rapidly changing: Examining public perceptions and behaviors in response to this evolving pandemic

Abstract

Background
Since the emergence of SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) in late 2019, communities have been required to rapidly adopt community mitigation strategies rarely used before, or only in limited settings. This study aimed to examine the attitudes and beliefs of Australian adults towards the COVID-19 pandemic, and willingness and capacity to engage with these mitigation measures. In addition, we aimed to explore the psychosocial and demographic factors that are associated with adoption of recommended hygiene-related and avoidance-related behaviors.

Methods
A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between the 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariate logistic regression analysis.

Findings
The survey of 1420 respondents found 50% (710) of respondents felt COVID-19 would ‘somewhat’ affect their health if infected and 19% perceived their level of risk as high or very high. 84·9% had performed ≥1 of the three recommended hygiene-related behaviors and 93·4% performed ≥1 of six avoidance-related behaviors over the last one month. Adopting avoidance behaviors was associated with trust in government/authorities (aOR: 6.0, 95% CI 2.6–11·0), higher perceived rating of effectiveness of behaviors (aOR: 4·0, 95% CI: 1·8–8·7), higher levels of perceived ability to adopt social distancing strategies (aOR: 5.0, 95% CI: 1·5–9.3), higher trust in government (aOR: 6.0, 95% CI: 2.6–11.0) and higher level of concern if self-isolated (aOR: 1.8, 95% CI: 1.1–3.0).

Interpretation
In the last two months, members of the public have been inundated with messages about hygiene and social (physical) distancing. However, our results indicate that a continued focus on supporting community understanding of the rationale for these strategies, as well as instilling community confidence in their ability to adopt or sustain the recommendations is needed.

Full text

RESEARCH ARTICLE
COVID-19 is rapidly changing: Examining
public perceptions and behaviors in response
to this evolving pandemic
Holly SealeID
1
*, Anita E. Heywood
1
, Julie Leask
2,3
, Meru SheelID
4
, Susan Thomas
5
, David
N. Durrheim
5
, Katarzyna Bolsewicz
5
, Rajneesh Kaur
2,6
1School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW,
Australia, 2Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia, 3National
Centre for Immunisation Research and Surveillance, Kids Research, Sydney Children’s Hospitals Network,
Westmead, NSW, Australia, 4National Centre for Epidemiology and Population Health, Research School of
Population Health, ANU College of Health and Medicine, The Australian National University, Acton, ACT,
Australia, 5School of Medicine and Public Health, University of Newcastle, Wallsend, NSW, Australia,
6Office of Medical Education, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
*h.seale@unsw.edu.au
Abstract
Background
Since the emergence of SARS-CoV-2, the virus that causes coronavirus disease (COVID-
19) in late 2019, communities have been required to rapidly adopt community mitigation
strategies rarely used before, or only in limited settings. This study aimed to examine the
attitudes and beliefs of Australian adults towards the COVID-19 pandemic, and willingness
and capacity to engage with these mitigation measures. In addition, we aimed to explore the
psychosocial and demographic factors that are associated with adoption of recommended
hygiene-related and avoidance-related behaviors.
Methods
A national cross-sectional online survey of 1420 Australian adults (18 years and older) was
undertaken between the 18 and 24 March 2020. The statistical analysis of the data included
univariate and multivariate logistic regression analysis.
Findings
The survey of 1420 respondents found 50% (710) of respondents felt COVID-19 would
‘somewhat’ affect their health if infected and 19% perceived their level of risk as high or very
high. 849% had performed 1 of the three recommended hygiene-related behaviors and
934% performed 1 of six avoidance-related behaviors over the last one month. Adopting
avoidance behaviors was associated with trust in government/authorities (aOR: 6.0, 95% CI
2.6–110), higher perceived rating of effectiveness of behaviors (aOR: 40, 95% CI: 18–
87), higher levels of perceived ability to adopt social distancing strategies (aOR: 5.0, 95%
CI: 15–9.3), higher trust in government (aOR: 6.0, 95% CI: 2.6–11.0) and higher level of
concern if self-isolated (aOR: 1.8, 95% CI: 1.1–3.0).
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OPEN ACCESS
Citation: Seale H, Heywood AE, Leask J, Sheel M,
Thomas S, Durrheim DN, et al. (2020) COVID-19 is
rapidly changing: Examining public perceptions
and behaviors in response to this evolving
pandemic. PLoS ONE 15(6): e0235112. https://doi.
org/10.1371/journal.pone.0235112
Editor: Wen-Jun Tu, Chinese Academy of Medical
Sciences and Peking Union Medical College,
CHINA
Received: April 6, 2020
Accepted: June 2, 2020
Published: June 23, 2020
Copyright: ©2020 Seale et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The data is available
at https://figshare.com/articles/COVID-19_
AustSurvey_xlsx/12298844.
Funding: No funding was received for this specific
study. MS is supported by a fellowship from the
Westpac Scholars Trust.
Competing interests: The authors have read the
journal’s policy and the authors of this paper have
the following competing interests: HS has
previously received funding from drug companies

Interpretation
In the last two months, members of the public have been inundated with messages about
hygiene and social (physical) distancing. However, our results indicate that a continued
focus on supporting community understanding of the rationale for these strategies, as well
as instilling community confidence in their ability to adopt or sustain the recommendations is
needed.
Introduction
In the course of four months, since the first reports about a novel strain of coronavirus, severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging in December 2019 [1,2],
countries around the world have introduced a range of community mitigation strategies with
the aim to lower the trajectory of this pandemic by reducing transmission, and avoid over-
whelming health services. Community mitigation strategies refer to measures that people, and
communities can take to slow the spread of infection during a period when vaccines and/or
medical treatments that are not available [3]. They include the use of personal protective mea-
sures for everyday use (e.g., voluntary home isolation of ill persons, respiratory etiquette, and
hand hygiene); community measures aimed at increasing social distancing (e.g., maintaining a
physical distance of 15–20 meters between people, staying at home and postponing or cancel-
ling gatherings); and environmental measures (e.g., routinely disinfecting surfaces). In some
settings these strategies are voluntary, whereas in others they are now enforced (such as, via
fines and/or jail time).
Governments are implementing strategies at large-scale that have previously been used in
limited ways and for limited time periods i.e. during Ebola, avian influenza outbreaks and
SARS. This means a large proportion of the population do not have prior experience undertak-
ing these strategies. People’s ability to comply with recommendations during emergency situa-
tions is influenced by a range of modifiable and nonmodifiable factors including: (1) what
people perceive their susceptibility to infection to be [4]; (2) whether they perceive the infec-
tion to be serious, if acquired; (3) whether they have the necessary capacity, confidence and
resources to comply with the strategies [5]; and (4) their sociodemographic status [6]. Effective
control of this pandemic requires an understanding of people’s perceptions about their will-
ingness, motivation and ability/capacity to adopt strategies and how this relates to their per-
ceived risk [7]. Perceived costs, perceptions about the benefits of the behaviors and the
perceived impact of an individual’s behavior on another’s health will also influence engage-
ment with these behaviors [8,9].
In Australia, the government has recommended specific behaviors that can be classed as
hygiene-related and avoidance related. To engage in these behaviors, people will weigh up the
perceived costs and benefits related to themselves and others. It is therefore important to
understand community perceptions and behaviors in order to develop effective messages.
Accordingly, we carried out a cross sectional online survey of a large, demographically repre-
sentative sample of the population of Australia in March 2020.
Materials and methods
Cross sectional online survey
We conducted an online survey of Australian residents via a market research company (Qual-
ity Online Research (QOR)) between 18 and 24 March 2020. This sample size provided us
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for investigator driven research and consulting fees
to present at conferences/workshops and develop
resources (bio-CSL/Sequiris, GSK and Sanofi
Pasteur). She has also participated in advisory
board meeting for Sanofi Pasteur. This does not
alter our adherence to PLOS ONE policies on
sharing data and materials. There are no patents,
products in development or marketed products
associated with this research to declare.

with a sample error of ±3%. Proportional quota sampling was used to ensure that respondents
were demographically representative of the general public, with quotas based on age, gender
and state/territory. Respondents were required to be 18 years or older and to speak English.
Respondents earned points for completing the survey.
Ethics statement
Ethics approval for the study was obtained from the University of New South Wales HREAP
G: Health, Medical, Community and Social (HC200190). After reading the participant infor-
mation, consent was implied if the person completed the survey and submitted it via the QOR
website. No personal identifiers were collected.
Survey design
The questions for this survey were adapted from published studies by HS during the 2009
influenza H1N1/A pandemic [10,11]. The study tool is available upon request. Two primary
outcome variables used were hygiene-related and avoidance-related behaviors. (see Table 1).
Ten items were used to assess respondent perceptions about the COVID-19 pandemic, includ-
ing perceived risk level and impact on health (if infected). 8/10 items were phrased as state-
ments, with Likert response options scored as 5 for strongly agree through to 1 for strongly
disagree. Two items measuring participants level of worry about current Covid-19 were used
on a 5 point Likert scale ranging from 1 for strongly disagree to 5 for strongly agree, these were
combined and changed into a dichotomous scale of high and low.
Respondents were asked to rate the perceived level of effectiveness of 13 items in reducing
the risk from COVID-19 on a 5-point scale These items included those promoted by the gov-
ernment and those that were not (mask use when not symptomatic, taking antibiotics). The
Table 1. Adoption of hygiene-related and avoidance-related behaviors.in response to COVID-19.
Hygiene-related behaviors: actions taken over last month due to COVID-
19 (Cronbach’s alpha = 0701)
Number (%) Standardised
loading
Increased the time I spent cleaning or disinfecting things I might touch,
such as door knobs
537/1420
(378)
0.740
Washed my hands with soap and water more often than usual 1088/1420
(766)
0.763
Used alcoholic hand gel or hand sanitizer more than usual 806/1420
(568)
0.807
Avoidance-related behaviors: Actions taken over last month due to
COVID-19 (Cronbach’s alpha = 0797)
Deliberately cancelled or postponed a social event 519/1161
(447)
0.814
Cancelled or delayed travelling overseas 407/811
(502)
0.745
Reduced my use of public transport 448/880
(509)
0.816
Kept away from crowded places generally 889/1332
(667)
0.778
Performed 1 of three recommended behaviors 1205/1420
(849)
Performed 1 of six avoidance behaviors 1326/1420
(934)
Total number of participants lower than overall total of 1420 due to exclusion of participants who ticked ‘not
applicable’ options.
#
587 participants had children of school or childcare going age.
https://doi.org/10.1371/journal.pone.0235112.t001
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strategies were grouped into: (1) hygiene related behaviors (hand washing/sanitizing, cleaning
surfaces) and (2) avoidance-related behaviors (avoiding crowds, public transport, and comply-
ing with quarantine restrictions). Given the relative novelty of social distancing for the Austra-
lian community, we also included a question that assessed the respondent’s ability to adopt 6
different social distancing strategies (working from home, keeping children home from school,
avoiding travelling, avoiding large crowds, quarantine if exposed, and isolation if symptom-
atic) with possible response options scored as 1 for very high and 5 for very low. The last sec-
tion of the survey included six items focused on self-isolation. Respondents were asked to
comment on their willingness to comply, their level of concern regarding the impact on being
placed into self-isolation (at home), their ability to comply, their access to assistance from fam-
ily/friends and issues they have with the strategy. All predictor variables and the items and
scales are described in the supplementary materials.
We collected data on gender, age, education and employment status, children (including
attendance at childcare/school), country of birth/language spoken at home, whether they iden-
tify as Aboriginal and/or Torres Strait Islander, international travel patterns since 1 January
2020, private healthcare insurance coverage, income protection insurance, the presence of any
chronic illness and self-reported health status (very good, good, moderate, poor, very poor).
Due to the promotion of social distancing and working from home by the Australian Govern-
ment, we also included two items that assessed access to internet and a computer at home.
Analysis. Correlation matrix of all scales was studied. Items of scales with low correlation
with the rest of the items of a scale were excluded. This was followed by Principle Component
analyses using direct Oblimin rotation to determine the number of components to retain and
loading of items for all scales. Cohen alpha was used to check the internal consistency of all
items of the scale (See S1 Table). Univariate associations were tested between primary outcome
measures and demographic factors. Univariate associations between worry and outcome mea-
sures was also assessed using univariate logistic regression. Two separate multivariate logistic
regression models were used to measure the associations of perception factors with each out-
come factor after adjusting for independent variables. Demographic variables with a P<0.25 in
the univariate analysis were used to adjust the models. In Model one hygiene behaviour was
tested as the outcome and was adjusted for gender, country of birth, travelled overseas and
worry variables. Model two tested avoidance behaviour as the outcome and was adjusted for
age, gender, country of birth, employment, current health conditions and worry variables. For
all analyses, P values of less than 0.05 were considered statistically significant. Data were ana-
lyzed using the SPSS software version 26.0 (SPSS Science, Chicago, IL, USA).
Correlation matrix of hygiene related behaviour items demonstrated a moderate correlation
of included three items (rs ranged between 0.34 and 0.405). Overall KMO value of 0.65 was
adequate for exploratory factor analysis. Correlation matrix for the avoidance behaviour scale
revealed that the third and the last items were outliers and were not related to the other items
in the scale (rs = 0. 19 and 0.10 respectively) and were therefore excluded. The correlation of
the remaining items showed moderate correlation (rs ranged between 0.33 and 0.39). Overall
KMO value was 0.66. Standardised loading of items included in these scales is shown in
Table 1.
From the rating of level of effectiveness to reduce risk of COVID, fourth and seventh items
of the scale demonstrated a low correlation (0.04 and 0.14) with other items of the scale and
were therefore excluded. The remaining items of the scale showed moderate to high correla-
tion (rs between 0.49–0.67). Similarly, second item from the rating of ability to adopt social
distancing strategies scale was excluded due to its low correlation with rest of the scale items
(rs = 0.16). The remaining items of the scale showed moderate correlation (rs between 0.34–
0.55). From the variable ‘rating of level of concern if self-isolated’ third item was excluded due
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to low correlation with other items of the scale (rs = 0.15). The rest of the items of the scale
showed moderate correlation (rs between 0.32–0.44). The factor loading of items of these three
scales is shown in S1 Table. Combined items for all variables demonstrated a moderate (Cron-
bach’s α= 0.733) to high (Crohn’s α= 0.877) internal consistency and were therefore retained.
Results
Of the 1420 respondents, 740 (52%), were female, 47 (33%) identified as Aboriginal and/or
Torres Strait Islanders, 830 (585%) had private health insurance, 792 (55.8%) had children
with 211/792 (267%) attended childcare/school. Of the respondents, 37 (%) reported knowing
of a COVID-19 case amongst their family or friends. Television news was the primary source
of information about COVID-19 (n = 724, 51%), followed by government websites
(n = 241,17%) and social media (n = 198, 14%). When asked about the level of trust they had
in the information coming from the Government, 667 (47%) stated high to very high.
Perceptions about susceptibility and severity
Respondents ranked their risk of acquiring COVID-19 as very high (n = 71, 5%); high
(n = 198, 14%), intermediate (n = 497, 35%), low (n = 397, 28%) and very low (n = 156, 11%).
The remaining 100 respondents reported not knowing what their risk was. When it came to
perceived impact on their health, 710 (50%) reported that COVID-19 would ‘somewhat’ affect
it, while the remaining respondents reported it as: extremely (n = 170, 12%), seriously
(n = 326, 23%), not at all (n = 85, 6%) or don’t know (n = 113, 8%). Fifty percent reported
changing their personal perception of risk after reading or hearing information in the media
or on social media.
Perceived effectiveness of social mitigation strategies and ability to adopt
Fig 1 shows the perceptions towards the degree of effectiveness of measures to reduce personal
risk from COVID-19. Self-quarantine of anyone who has travelled into Australia from overseas
was considered to have high to very high effectiveness (n = 1171, 825%), followed by avoiding
people who have travelled overseas (n = 1155, 814%). Whereas, only 525 (37%) thought that
shutting the restaurants/bars after 6pm would have a high/very high effect and 696 (49%) stated
that wearing a mask (when not symptomatic) would be effective. Taking antibiotics was consid-
ered to have low to very low effectiveness by most (n = 908, 64%). Beyond perceived effectiveness,
respondents were asked to comment on their ability (self-efficacy) to carry out social distancing
strategies, 596 (42%) respondents rated their ability to work from home as high/very high.
Practice of recommended measures/behavior
The most common hygiene-related behavior adopted was washing hands with soap and water
(n = 1087, 766%), whereas keeping away from crowded places generally was the most com-
mon avoidance behavior (n = 947, 667%). Overall, 1205 (849%) respondents reported
undertaking 1 of three hygiene-related behaviors and 1326 (934%) performed 1 of six
avoidance-related behaviors (Table 1).
Table 2 shows association between demographic characteristics and reported behaviors dur-
ing COVID-19 pandemic. Five hundred and five (363%) respondents considered the hygiene-
related and avoidance-related behaviors as ‘the right thing to do’ as their main motivation to
comply. Close to 80% of respondents (n = 1127) who reported being worried about COVID-19
(high-very high) were found to have higher engagement with hygiene-related behaviors (OR
4.2, 95% CI: 3.1–58) and avoidance-related behaviors (OR 4.0, 95% CI: 26–6.2).
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Controlling for demographic and worry variables, there was a higher association between
performance of hygiene-related behaviors and trust in government/authorities (aOR: 27, 95%
CI 14–5.1), perceived high severity if infected (aOR: 14, 95% CI 12–3.0), higher levels of
belief in the effectiveness of behaviors (aOR 32, 95% CI: 1.4–7.2), higher ability to adopt social
distancing strategies (aOR: 3.6,95% CI 16–7.0), higher levels of concern if self-isolated (aOR:
24 95% CI: 11–40) and intermediate to higher level of risk perception (aOR: 1.6, 95% CI:
11–20, aOR: 2.0, 95% CI: 12–3.5) led to performance of recommended behaviors. Reporting
the use of avoidance behaviors was more likely in respondents who: trusted government/
authorities (aOR: 6.0, 95% CI 2.6–110), rated effectiveness of behaviors higher (aOR: 4.0, 95%
CI: 1.3–12.7), and indicated a higher ability to adopt social distancing strategies (aOR: 5.0, 95%
CI 15–13.6), perceived high severity if infected (aOR: 1.8, 95% CI: 1.1–3.0) (Table 3).
Six questions focused on self-isolation as a strategy. The majority (n = 1349, 95%) agreed
that they could self-isolate if necessary and that they had a family member or friend who could
assist them in the event of isolation (n = 1178, 83%). However, respondents did have concerns
(high/very high) about not being able to access shops for food/supplies (n = 681, 48%) and not
being able to access a primary care provider (n = 553, 39%). Amongst those who felt they
could not manage self-isolation at home (n = 122, 8%), the main concerns were centered
around carers responsibilities for children, elderly parents and disabled family members.
Discussion
Our results suggest that a large proportion of respondents have adopted one or more of either
the hygiene-related and/or avoidance-related behaviors that had been recommended by the
Australian Government. Considering the intense media coverage and government
Fig 1. Rating of level of effectiveness of strategies to control Covid-19 outbreak.
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information, it is not surprising that there was a gravitation towards actual (or willingness for)
adoption of hygiene strategies including hand washing/sanitizing. While anxiety levels were
moderate, concerns were raised about accessing food and medical supplies if placed into self-
Table 2. Association between demographic characteristics and adoption of preventive/avoidance strategies during COVID-19 pandemic.
Variable No (%) of
participants
No (%) using hygiene
behaviors
Odds ratio (95%
CI)
No (%) using avoidance
behavior
Odds ratio (95%
CI)
Sex
Women 740 (521) 646 (873) 15 (11–21) 707 (955) 0.7(0.5–1)
Men 678 (477) 559 (824) Ref 618 (912) Ref
Other
#
2 (01) 0 (0) - 1 (50) -
Age group
18–49 803 (565) 685 (853) Ref 739 (92) Ref
50 617 (435) 520 (843) 09 (07–12) 587 (951) 10 (0.7–1.6)
Aboriginal and/or Torres
Strait Islander
Yes 47 (33) 40 (851) 1.0 (05–2.2) 42 (894) 0.8 (03–2.1)
No 1373 (967) 1165 (849) Ref 1284 (935) Ref
Country of birth
Australia 1096 (772) 919 (839) Ref 1011 (922) Ref
Other 324 (228) 286 (883) 07 (05–10) 315 (972) 3.1 (17–60)
Working status
Not working 591 (416) 497 (841) 12 (09–16) 567 (959) 0.7 (0.5–1.2)
Working full/part time 829 (584) 708 (854) Ref 759 (916) Ref
Educational attainment 30 (21)
None 131 27 (90) Ref 28 (933) Ref
School certificate (year 10) (92)235 108 (924) 05 (02–19) 119 (908) 07 (02–2.7)
Leaving certificate (year 12) (165) 197 (838) 06 (02–21) 219 (932) 12 (03–43)
Trade/apprenticeship/cert 483 (34) 405 (839) 06 (02–2.0) 449 (93) 09 (03–31)
Bachelor’s degree 379 (267) 328 (865) 08 (02–27) 359(947) 2.0 (06–6.7)
Masters or higher 162 (114) 140 (864) 08 (02–27) 152(938) 2.6 (07–9.4)
Children in household
Attending childcare/school 212 (149) 184 (866) 1.2 (08–19) 195 (92) 1.4 (08–2.5)
Not attending childcare/school or no
children
1208 (851) 1021 (845) Ref 1131(936) Ref
Travelled overseas in 2020 222 (156) 201 (905) 1.9(12–3.1)206 (928) 2.3 (1.4–3.9
No 1198 (844) 1004(838) Ref 1120 (935) Ref
Have private health 830 (585) 712(85.8) 1.2(09–17) 1. (93) 1.2 (08–19)
Insurance
No 590 (415) 493(836) Ref 554 (939) Ref
Health rating
Very good/good 1009 (711) 861 (8)69 Ref 945 (937) Ref
Moderate 294 (207) 241 (82) 06 (04–1.1) 271 (922) 11 (05–27)
Poor/very poor 117 (82) 95 (81.2) 07 (0.5–1.0) 110 (94) 08 (05–13)
Chronic health condition
Present 363 (256) 317 (873) 1.5(07–3.3) 345 (95) 12 (04–3.2)
None 1057 (744) 888 (84) Ref 981(928) Ref
P<005
# Not included in OR calculations.
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isolation. Given the limited community behavioral COVID-19 studies published, we have
compared our findings to two ongoing community surveys. Firstly, results from an online poll
of 14,000 respondents from 14 countries (conducted at the same time point as our study),
reported that their respondents in 8/14 countries expressed a belief that social distancing mea-
sures such as travel bans, and self-isolation would not prevent the spread of the virus, including
participants from Australia (52%) [12]. Secondly, a German survey (conducted a week earlier
then our study) identified that respondents had high levels of knowledge, but adoption of
important protection behaviors was very low, and risk perceptions were especially low among
the elderly [13]. Lastly, a survey from Malaysia reported that a high proportion of respondents
were already adopting precautions such as avoiding crowds (83.4%) and practicing proper
hand hygiene (87.8%) at the time of their study in late March. However, the wearing of face
masks was less common (51.2%) [14].
Amongst our participants, perceived susceptibility to COVID-19 was at an intermediate
level. This aligns with results found in a similar study conducted in the UK, which reported
that just under half of their cohort (n = 2,108) were likely to acquire COVID-19, while 56% felt
that it would have a moderate impact (i.e. would require them to self-care and rest in bed)
[15]. In addition, a separate survey of Australian residents also found that two thirds of respon-
dents were at least moderately worried about a widespread COVID-19 outbreak in Australia
Table 3. Logistic regression models testing association between perception variables and adoption of hygiene/avoidance strategies during COVID-19 outbreak.
Association with carrying or 1 preventive
behavior
Association with carrying out 1 avoidance
behavior
Variables No. (%) OR (95% CI) Adjusted OR (95% CI) OR (95% CI) Adjusted OR (95% CI)
Trust in government/authorities
High 1315/1401 (939) 4.2 (26–67)27 (14–5.1)5.8 (3.2–10.7)60 (2.6–11.0)
Low 86/1401 (6.1) Ref Ref Ref Ref
Perceived Severity
High 1219/1400 (858) 26 (18–37)14 (11–23)20 (12–33)15 (07–3.2)
Low 181/1400 (12.7) Ref Ref Ref Ref
Rating of level of effectiveness of behaviors~
High 1150 (81) 8.8 (5.0–15.5)32 (1.4–7.2)14.3 (6.0–24.3)40 (1.88.7)
Low 270 (19) Ref Ref Ref Ref
Ability to adopt social distancing strategies
High 740/1293 (52.1) 5.7 (3.2–10.4)3.6 (1.6–7.0)15.7 (8.6258)5.0 (1.5–9.3)
Low 553/1293 (38.9) Ref Ref Ref Ref
Level of concern if self-isolated
€
High 274/1359 (193) 1.4 (11–2.0)24 (11–40)15 (08–29 18 (1.1–30)
Low 1085/1359 (76.4) Ref Ref Ref Ref
Level of Risk
Very low/low 553/1320 (419) Ref Ref Ref Ref
Intermediate 496 /1320 (376) 20 (14–28)16 (11–20)15 (1.0–24) 1.1 (06–17)
Very high/high 271/1320 (205) 31 (19–49)20 (12–35)3.0 (17–5.4) 17 (08–3.4)
Impact on health
No/somewhat 806/1304 (618) Ref Ref Ref Ref
Serious/Extreme 498/1304 (382) 16 (12–23)10 (06–15) 3.2 (2.0–5.2)16 (09–2.9)
P<0.05, Two logistic regression models: Model one: Hygiene related behaviour as the outcome, model adjusted for gender, country of birth, travelled overseas, private
health insurance, rating of current health and worry, variables with P<0.25 in the univariate analysis. Model two: avoidance behaviours as the outcome, model adjusted
for gender, country of birth, employment, ATSI status, travelled overseas, children attending childcare/school or not, and worry, variables with P<0.25.
https://doi.org/10.1371/journal.pone.0235112.t003
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in early March [16]. Risk perceptions were also found to be moderate (median 5 out of 10)
based on an online poll of US residents undertaken in early February [17]. There may be sev-
eral factors at play here that account for the perceived level of risk. Firstly, people may be
unaware of true risk since little reporting has focused on attack rates during the time of the
study. Secondly, people may be subject to optimism bias–a phenomenon where people down-
play their own risk of an outcome [18]. Thirdly, it is likely that some people assess their risk as
being low due to already factoring in a change towards anticipated or already accomplished
protective behavior [19]. During events that people deem ‘familiar’, we often see unrealistic
optimism because the risk is perceived to be under control, as was the case in 2009 with the
influenza pandemic, when adoption of precautions was low and there was a sense of personal
security [4]. However, COVID-19 presents as an unfamiliar risk (for the large majority of the
population had not experienced outbreaks of SARS or MERS) making the risk less tolerable
for those who perceive the situation as uncontrollable [20]. When it comes to perceptions of
risk, there are numerous studies documenting how they are associated with the uptake of pre-
ventive and/or avoidant behaviors. Studies conducted during/after the 2003 SARS outbreak
reported that higher levels of perceived risk/susceptibility of SARS was associated with the
adoption of preventive behaviors and also avoidance behaviors [21–24].
While understanding a person’s perception of risk is important, it is not the only condition
needed for engagement. Higher risk perceptions may only predict protective behavior when
people believe that effective protective actions are available (response efficacy) and when they
are confident that they can engage in such protective actions (self-efficacy) [25]. According to
Bandura social cognitive theory, an individual’s self-efficacy plays a crucial role on the individ-
ual’s likelihood to engage in a desired behavior. If an individual does not believe that he/she
can carry out the behavior (i.e. physically distance themselves), there is little motivation to
engage [26]. Three-quarters of the study respondents agreed that they could adopt the avoid-
ance-related strategies, with lower scores for working from home and self-isolation at home.
When asked whether they had adopted any of the hygiene related strategies, washing or sani-
tizing hands were the most common responses. These findings have also been replicated in an
online survey of 5974 residents from the US and UK, that found that 92% of the cohort would
adopt hygiene related behaviors [27]. These represent more readily adoptable strategies, as
people in the community understand how to engage in them, believe that the strategy will pro-
tect them, and usually have the resources to carry them out. These easy to adopt actions have
also been a focus of government mass media messages.
When it came to avoidance behaviors, our respondents were less inclined to rate them as
being effective or to have adopted them, in comparison to the preventive behaviors listed
above. Perceptions regarding the efficacy of the strategy (as opposed to self-efficacy) have also
been found to impact on intentions/likelihood to adopt or actual uptake [23,28]. It is not sur-
prising that some strategies including social distancing, scored low as people may not under-
stand what the strategy entails, the rationale for its use, or what impact it may have on one’s
health. It should also be noted that individuals may not have the capacity or resources to com-
ply with physical distancing measures because they: (1) have extended families living in their
households; (2) they have a responsibility to provide care for someone outside of their home;
(3) they may reside in share accommodation; (4) may not have access to internet/computer in
the home setting or (5) because of the type of job they have they cannot simply shift to working
from home. In these settings, providing mass media education is not going to suffice. What is
needed is pragmatic solutions that support people financially and socially to participate. Exam-
ples including increases in social support and charities to assist with delivery of groceries and
meals, home delivery from chemists, telehealth consultations bulk billed, drive through vac-
cine clinics etc.
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It has been suggested that we start to prime people about what additional strategies may still
need to be introduced [29]. This would entail talking with them about why the strategy would
be implemented; the end-goal of implementing it; what could be the potential impacts; how
members of the public engage; and the criteria for its de-escalation. In order to promote cooper-
ation with social (physical distancing) strategies, governments may need to use realistic portray-
als (community stories) and role modelling by influential actors in social networks. Observing
competent role models perform actions that result in success conveys information to observers
about the sequence of actions to use to be successful [30]. Motivation may be helped by creating
media campaigns that foster awareness of the recommended behaviors and encourage people to
share their strategies for complying with self-isolation and working from home.
Amongst our respondents, older age was associated with the adoption of precautionary behav-
iors, which aligns with the findings from Singapore and Hong Kong during the 2003 SARS out-
break [7,23] and some studies during the 2009 H1N1/A pandemic [31,32]. However, the pattern
of age is not straight forward. In contrast to the above studies, others have reported higher levels
of adoption of preventive behaviors amongst younger people (18–24 years) in the context of the
2009 influenza pandemic. When it comes to gender, we found that females were more likely to
report uptake of both preventive and avoidance behaviors, consistent with studies during SARS
and H1N1 pandemic influenza [4,7,23,33]. Earlier studies have indicated that women are more
likely to perceive themselves to be susceptible and hence adopt the behaviors [21,34]. When it
comes to country of birth, we found that people born outside of Australia were less likely to
adopt behaviors. This finding may relate to the capacity to access information, which at the time,
was being disseminated in English and largely through mainstream media conferences and health
department websites rather than community and language groups. Further work is needed to
explore the associations between country of birth and pandemic-related behaviors.
When asked what would motivate respondents to comply with a social distancing strategy,
they nominated ‘I believe it is the right thing to do’ as the primary response. While this answer
did not have any significant relationship with the outcome measures reviewed, it is still rele-
vant when it comes to planning communication messages. It suggests that respondents may be
influenced by a desire for social approval from others, an idea linked to the model of moral
motivation. The model, developed by Brekke et al. (2003), assumes that individuals have pref-
erences for achieving and maintaining a self-image as a socially responsible person [35]. In
Brekke et al.’s model, self-image improves when the individual’s actual behavior gets closer to
her/his view of the “morally ideal” behavior (i.e. the behavior that would maximize social wel-
fare if chosen by every member of society). However, individual’s participation can be condi-
tional on whether they think others are also contributing [36]. Mass media campaigns that
frame their messages around a social collective action/power or the inclusion of the general
public within a team to assist the community response may be effective. The promotion of pro-
social behaviors has been shown to be effective in vaccination uptake and could be adapted in
promoting COVID-19 mitigation behaviors, such as how one’s actions can contribute to pro-
tecting their grandparents [37]. This idea has been picked up by celebrities and the wider com-
munity on twitter under the #LockDownForLove, with people nominating who they are social
distancing for. Whether these strategies work, needs to be further examined.
Early results from a study conducted across the US, UK and Germany has suggested that
inducing empathy for those most vulnerable to the virus promotes the motivation to adhere to
physical distancing [38]. The use of empathy in messaging is not a new concept and has been
applied in a range of ways from the promotion of testing/treatment for STIs, through to increas-
ing our acceptance of robots [39,40]. Empathy is a skill which enables understanding of another
person’s experience. Here, people could be asked to imagine the perceptions, needs and impact
(health, financial, social) of pandemic COVID-19 amongst our family members/friends.
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Our study includes a large, representative cross-section of the adult Australian population.
People who could not communicate in English were excluded from the sample, which may
have affected representation of ethnic minorities. We also had under-representation of
Aboriginal Australians and Torres Strait Islanders and from those in remote settings. Sec-
ondly, as participation in our study was on a voluntary basis, this study has potential for self-
selection bias by community members who are particularly concerned about this pandemic.
We relied on self-reports of behaviors which may have led to over-reported (social desirability
bias) However, this may have minimized as the survey was self-complete and anonymous.
Lastly, we did not collect information about income level and so unable to comment on varia-
tions in behaviors by income.
Based on the available data, it appears that older individuals (aged >60 years) and people
with chronic underlying health conditions are particularly susceptible to severe disease. This
presents a challenging situation. In the media there is reporting that ‘COVID-19 is causing
mild illness’ in the majority but it’s in the best interest of the country to stay home in order to
‘flatten the curve’. This will cause two responses–those who continue with their normal prac-
tice (not adopting or complying with the recommendations around social distancing/mitiga-
tion strategies) as identified in a proportion of our respondents. Motivating this group
(especially those less likely to be at risk or suffer the health impact of COVID-19) to adopt
behaviors that require marked change in their routines, beyond those related to personal
hygiene. It may prove difficult unless people understand the required behavior, the rationale
for it, are given clear and sufficient information about how to comply, and they believe the
strategy will have an impact and are motivated to act [9,23,41]. They also need to have capac-
ity and opportunity to comply with new behaviors for another 4 to 6 months. In order to
engage a community, they need to feel like they are a valued part of a team, and that their con-
tributions are valued and key to the response. Lastly, it is essential that governments ensure
that resources, legalization and support measures are in place in order to facilitate community
participation in community mitigation strategies.
Supporting information
S1 Table. List of original and recoded predictor variables.
(DOCX)
Acknowledgments
We would like to thank the respondents for their time in participating in the research study.
Author Contributions
Conceptualization: Holly Seale.
Data curation: Holly Seale.
Formal analysis: Holly Seale, Anita E. Heywood, Rajneesh Kaur.
Methodology: Holly Seale, Anita E. Heywood, Julie Leask, Meru Sheel, Susan Thomas, David
N. Durrheim, Katarzyna Bolsewicz, Rajneesh Kaur.
Resources: Susan Thomas.
Writing – original draft: Holly Seale, Anita E. Heywood, Julie Leask, Meru Sheel, Susan
Thomas, David N. Durrheim, Katarzyna Bolsewicz, Rajneesh Kaur.
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