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Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries

BMJ 2020; 370 doi: (Published 15 July 2020) Cite this as: BMJ 2020;370:m2743

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158章你的奶真好吃Lockdown-type measures look effective against covid-19

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Physical distancing: shifting responsibility for COVID-19 transmission behaviours from the state to the individual [response to Islam et al]

Dear Editor
Islam et al. [1] report the success of international governmental lockdown of schools, workplaces, public transport etc. in achieving reductions in covid-19 incidence. As lockdown is released, interventions to control virus-transmitting behaviours transfer from being the responsibility of the state to being the responsibility of each individual to ensure that they maintain physical distance. Using the Behaviour Change Wheel [2] classification, intervention policies transform from using ‘legislation’ and ‘environmental/social planning’ to ‘communication/marketing’ and provision of ‘guidelines’ and the function of the interventions change from ‘restriction’ and ‘environmental restructuring’ to ‘education’ and ‘persuasion’.
As part of the CHARIS project [3], we investigated how individuals who have not had covid-19 see responsibility for getting the disease in a Scottish national representative survey. The research was conducted in the weeks (June 3- June 16), following the first release from the legal requirement to stay at home except for exercise and essential activities (i.e. for basic necessities, daily exercise, basic animal welfare, medical need, travelling for work purposes). We examined the extent to which people aged 16 years or over (n=776) agreed that getting covid-19 could be attributed to their own behaviour, others’ behaviour and poor response from Scottish and UK governments, bad luck and ‘a germ or virus’.
We found that people attributed responsibility to their own and others’ behaviours rather than bad luck. Over 85% agreed or strongly agreed that failure to keep two metres distance and poor hand washing caused covid-19. Fewer, 59.6%, attributed the disease to failure to use face coverings but this was similar to the frequency of agreeing that the cause was ‘bad luck’ (56%). The behaviour of Government was also viewed as causal. Over three quarters of this Scottish sample believe a poor response from the UK Government caused covid-19, whilst only 51.6% have the same belief about the Scottish Government.
We examined whether attributions of causality were associated with performance of protective behaviours. Self-reported adherence behaviours (always or most of the time) was high for keeping two meters distance whether or not they attributed causality to these behaviours (92.0% vs 92.7%) and lower for frequent handwashing (77.9% vs 64.8%). Wearing a face covering, which was advised but not mandatory at this time, was more frequent in those attributing covid-19 to lack of face coverings (38.5% vs 14.3%). Performance of the corresponding behaviour was significantly associated with attributions for hand washing (r=.10, p<.01) and wearing a face covering (r=0.28, p<.01), but not for keeping two metres distance.
These data suggest that the population was attributing responsibility for the spread of covid-19 to their own and others’ behaviour and that these attributions were associated with, and might be causal in determining, their transmission-reducing behaviours.
While government recommendations can influence the covid-19 prevention behaviours of individuals [4] the importance of individual responsibility rather than government control has been identified as key to controlling virus transmission [5].Individual beliefs about the disease and about the behaviours causing its spread, become more important as governments release responsibility to individual citizens. Prior to release from lockdown, a UK survey found that beliefs about what other people were doing was associated with adherence to social distancing [6]. However, as release from lockdown progresses, individuals will have more exposure to how other people behave. Social norms i.e. what other people are doing and what they approve of, are associated with a wide range of preventive behaviours [7]. Rather than top-down, vertical transmission of beliefs from government to individuals, horizontal sharing of ideas and the observation of the behaviour of others is likely become more important.

References
1. Islam, N., Sharp, S. J., Chowell, G., Shabnam, S., Kawachi, I., Lacey, B., ... & White, M. (2020). Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries. BMJ 370.
2. Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6(1), 42.
3.
4. Goldberg, M. H., Gustafson, A., Maibach, E. W., Ballew, M. T., Bergquist, P., Kotcher, J. E., ... & Leiserowitz, A. (2020). Mask-wearing increased after a government recommendation: A natural experiment in the US during the COVID-19 pandemic. Frontiers in Communication, 5, 44.
5. Anderson, R. M., Heesterbeek, H., Klinkenberg, D., & Hollingsworth, T. D. (2020). How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet, 395(10228), 931-934.
6. Smith, L. E., Amlôt, R., Lambert, H., Oliver, I., Robin, C., Yardley, L., & Rubin, G. J. (2020). Factors associated with adherence to self-isolation and lockdown measures in the UK; a cross-sectional survey. medRxiv. preprint doi:
7. Goldberg, M. H., Gustafson, A., Maibach, E., Linden, S., Ballew, M. T., Bergquist, P., … Leiserowitz, A. (2020). Social norms motivate COVID-19 preventive behaviors. PsyArXiv,

Competing interests: No competing interests

07 August 2020
Diane Dixon
Health Psychologist
Chantal Den Daas, Gill Hubbard, Marie Johnston.
Institute of Applied Health Sciences, University of Aberdeen
School of Medicine, Medical Sciences and Nutrition, Health Sciences Building, Foresterhill, ABERDEEN AB25 2ZD