{"id":49329,"date":"2021-01-07T15:39:53","date_gmt":"2021-01-07T14:39:53","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=49329"},"modified":"2021-01-12T17:33:04","modified_gmt":"2021-01-12T16:33:04","slug":"pandemic-fatigue-how-adherence-to-covid-19-regulations-has-been-misrepresented-and-why-it-matters","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2021\/01\/07\/pandemic-fatigue-how-adherence-to-covid-19-regulations-has-been-misrepresented-and-why-it-matters\/","title":{"rendered":"Pandemic fatigue? How adherence to covid-19 regulations has been misrepresented and why it matters"},"content":{"rendered":"

As England and Scotland start another period of lockdown, we all have to come to terms with following stricter covid-19 restrictions, most likely for a relatively long period of time. The notion of behavioural fatigue associated with adherence to covid restrictions (so-called \u201cpandemic fatigue\u201d) has been a recurrent theme throughout the crisis. It was invoked before the first wave in March 2020 as a reason to delay restrictions<\/span>. [1] It was invoked in October 2020 as a reason to delay the imposition of the circuit-breaker<\/span> which SAGE had called for on 21<\/span>st<\/span> September<\/span>. [2,3] It was invoked in December 2020 as a reason to loosen restrictions over the Christmas period<\/span>. [4] In October, a Google search found some 200 million mentions of the term \u201cpandemic fatigue\u201d<\/span>. [5] By now, the figure has risen to over 240 million. It is a term that has entered both the academic and the popular lexicon in 2020.<\/span><\/p>\n

Linked to the notion that people in general will find it hard to adhere due to shared human psychological frailties is the idea that when particular individuals break the rules, it is due to their particular psychological failings. They are either too weak, too stupid, or too immoral to do the right thing. Hence, terms like \u201ccovidiots\u201d have become almost as familiar as \u201cpandemic fatigue.\u201d This feeds into a widespread narrative of blame whereby the spread of infections is explained in terms of individuals and groups who choose to break the rules, rather than failures of public health response.<\/span><\/p>\n

The narrative of blame is exemplified in the language used by politicians. For instance, in his televised address to the nation on 22<\/span>nd<\/span> September 2020<\/span>, the UK prime minister Boris Johnson spoke of people \u201cflouting\u201d and \u201cbrazenly defying\u201d covid restrictions. [6] It is also exemplified in a media focus on particularly egregious examples of violations such as raves and large house parties<\/span>. [7] All in all, this narrative explains the worsening pandemic in terms of widespread non-adherence to rules which is a function of poor psychological motivations, which in turn are particularly prevalent in some people and some communities.\u00a0<\/span><\/p>\n

Each of these assumptions is both problematic and indeed dangerous.<\/span><\/p>\n

Let\u2019s start with levels of adherence. To the surprise of many, adherence to stringent behavioural regulations has remained extremely high (over 90%), even though many people are suffering considerably, both financially and psychologically<\/span>. [8] Equally, despite anecdotal observations about growing violations and polling which shows that people report low levels of adherence in other people<\/span>, both self-reported data and systematic observations of behaviour in public places suggest that adherence stayed high during the second lockdown<\/span>. [9,10] Some 90% of people or more adhere to hygiene measures, to spatial distancing, and to mask wearing most of the time<\/span>. [11]\u00a0<\/span>Moreover, people generally support regulations and, if anything, believe that they should be more stringent and introduced earlier. This pattern has been repeated in the last few days, with 85% of the public endorsing the January \u2018lockdown\u2019<\/span> and 77% thinking it should have happened sooner<\/span>. [12,13]<\/span><\/p>\n

Even among those groups who have been singled out and blamed for irresponsible behaviours, such as students whose partying was widely reported in October, systematic analyses reveal a very different picture. ONS data reveals very high levels of adherence to social distancing, very low levels of social mixing, and indeed that students were far more likely than the general population to avoid leaving their accommodation altogether<\/span>. [14]\u00a0<\/span><\/p>\n

The discrepancy between what people are doing and what we think people are doing is instructive and points to what is termed the availability effect<\/span>. [15] That is, we judge the incidence of events based on how easily they come to mind \u2013 and violations are both more memorable and more newsworthy than acts of adherence. People sitting quietly at home and watching TV does not make a newspaper headline. People at a house party does. So we develop a biased perception of the level and type of violations, which runs the risk of becoming a self-fulfilling prophecy. If we believe that the norm is to ignore the rules, it may lead us to ignore them too<\/span>. [16]<\/span><\/p>\n

However, there is one key area where the perception of low adherence is not at odds with the reality. That concerns levels of self-isolation in those who are infected or else are contacts of those who test positive for the virus, which are estimated to be around 18%<\/span>. [17] Unlike hand-hygiene and social distancing, self-isolation requires support from others to be possible. This includes support from others in the community, in the form of shopping most obviously. It also requires material support in the form of an income and sufficient space. The lower adherence rates for self-isolation therefore suggest that the issues may have less to do with psychological motivation than with the availability of resources<\/span>. [18] This accords with data from the first \u201clockdown\u201d showing that the most deprived were six times more likely to leave home and three times less likely to self-isolate, but that they had the same motivation as the most affluent to do so<\/span>. [19] Non-adherence was a matter of practicality, not psychology. It also accords with the fact that in those places where support is given to self-isolate (as in New York, where people are provided with money, hotel accommodation, food, mental health support, even pet care<\/span>) adherence is as high as 95%<\/span>. [20,21]<\/span><\/p>\n

All this goes to make a simple and obvious point. People get infected because they get exposed. And they are more likely to be exposed if they are structurally more vulnerable: living in crowded housing, not able to work from home, limited to public transport. This is true of young people<\/span> and explains the increase in infections among the young when the first lockdown was eased. [22] It also explains the outbreaks in student halls of residence where, characteristically, many live together in small shared units.<\/span><\/p>\n

The problem, then, is that in psychologising and individualising the issue of adherence, one disregards the structural factors which underlie the spread of infection and the differential rates in different groups. One also avoids acknowledging the failures of government to provide the support necessary to follow the rules (most obviously in the case of self-isolation). Additionally, one overlooks the fact that some of the rules and the messaging around them, may be the problem (such as encouragement to go out to the pub \u2013 doing one\u2019s \u201cpatriotic best\u201d according to the PM<\/span> \u2013 and to return to work after the first \u201clockdown\u201d). It is particularly misleading and unfair to ask people to do things and then blame them for doing so. [23]<\/span><\/p>\n

The way in which issues of adherence have been portrayed and understood during this pandemic have been spectacularly wrong. If anything, the headline stories should not be of \u201cfatigue\u201d and \u201ccovidiots\u201d\u2019 and house parties. They should highlight the remarkable and enduring resilience of the great majority of the population \u2013 including those who have been most subject to blame such as students and young people in general \u2013 even in the absence of adequate support and guidance from government. Indeed, in many ways the narratives of blame serve to project the real frailties of government policy onto the imagined frailties of public psychology.<\/span><\/p>\n

Stephen Reicher<\/strong>, School of Psychology and Neuroscience, University of St. Andrews<\/span><\/em><\/p>\n

John Drury<\/strong>, School of Psychology, University of Sussex<\/span><\/em><\/p>\n

SR participates\u00a0in SPI-B, in the advisory group to the Scottish CMO, and in Independent SAGE. JD participates in SPI-B and Independent SAGE.<\/p>\n

Funding<\/strong>: This piece is linked to a UKRI grant: \u2018Facilitating the public response to COVID-19 by harnessing group processes\u2019 Ref: ES\/V005383\/1.<\/p>\n

References:<\/strong><\/p>\n

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      1. In early March, the Chief Medical Officer stated \u2018There is a risk if we go too early people will understandably get fatigued and it will be difficult to sustain this over time\u2019Conn, D, Lawrence, F, Lewis, P, Carrell, S, Pegg, D, Davies, H, et al. (2020, April 29) Revealed: The Inside Story of the UK’s Covid-19 Crisis. <\/span>The Guardian <\/span><\/i>\u00a0<\/span>https:\/\/www.theguardian.com\/world\/2020\/apr\/29\/revealed-the-inside-story-of-uk-covid-19-coronavirus-crisis<\/span><\/a>\u00a0<\/span><\/li>\n
      2. https:\/\/www.politico.eu\/article\/coronavirus-circuit-breaker-model-tests-political-nerve\/<\/li>\n
      3. https:\/\/assets.publishing.service.gov.uk\/government\/uploads\/system\/uploads\/attachment_data\/file\/925854\/S0769_Summary_of_effectiveness_and_harms_of_NPIs.pdf<\/li>\n
      4. At his press conference of 16<\/span>th<\/span> December, the Prime Minister, Boris Johnson, explained that the decision to relax the rules was based upon an assumption about \u201chow people are going to behave anyway\u201d (i.e. meet up): <\/span>https:\/\/www.theguardian.com\/world\/2020\/dec\/16\/keep-christmas-small-and-short-urges-boris-johnson-covid-coronavirus<\/span><\/a><\/li>\n
      5. Michie, S., West, R. & Harvey, N. (2020) The concept of \u201cfatigue\u201d in tackling covid-19. BMJ Opinion. October 26<\/span>th<\/span>. <\/span>https:\/\/blogs.bmj.com\/bmj\/2020\/10\/26\/the-concept-of-fatigue-in-tackling-covid-19\/<\/span><\/a><\/li>\n
      6. https:\/\/www.gov.uk\/government\/speeches\/prime-ministers-statement-on-coronavirus-covid-19-22-september-2020<\/li>\n
      7. Reicher, S.D. (2020) Blaming Covid \u201arule breakers\u2018 is a distraction: support is needed, not fines. The Guardian, Weds 4th November. <\/span>https:\/\/www.theguardian.com\/commentisfree\/2020\/nov\/04\/blaming-covid-rule-breakers-support-fines-lockdown<\/span><\/a><\/li>\n
      8. Duffy, B. & Allington, D. (2020) The accepting, the suffering and the resisting: the different reactions to life under lockdown. The Policy Institute, Kings College London. <\/span>https:\/\/www.kcl.ac.uk\/policy-institute\/assets\/Coronavirus-in-the-UK-cluster-analysis.pdf<\/span><\/a><\/li>\n
      9. e.g. Atchison, C. J., Bowman, L., Vrinten, C., Redd, R., Pristera, P., Eaton, J. W., & Ward, H. (2020). Perceptions and behavioural responses of the general public during the COVID-19 pandemic: A cross-sectional survey of UKAdults.\u00a0<\/span>medRxiv<\/span><\/i>.<\/span>https:\/\/www.medrxiv.org\/content\/medrxiv\/early\/2020\/04\/03\/2020.04.01.20050039.full.pdf<\/span><\/a><\/li>\n
      10. See the regular reports of the ONS on \u2018Coronavirus and the social impacts on Great Britain, for instance the report of 20<\/span>th<\/span> November: <\/span>https:\/\/www.ons.gov.uk\/peoplepopulationandcommunity\/healthandsocialcare\/healthandwellbeing\/bulletins\/coronavirusandthesocialimpactsongreatbritain\/20november2020#physical-contact<\/a><\/span><\/li>\n
      11. See, for instance, the regular reports of the UCL Covid-19 Social study, the most recent of which is from 17<\/span>th<\/span> December (Results Release 27): <\/span>https:\/\/b6bdcb03-332c-4ff9-8b9d-28f9c957493a.filesusr.com\/ugd\/3d9db5_56829e7218df4524b304636d226a6198.pdf<\/a><\/li>\n
      12. https:\/\/twitter.com\/YouGov\/status\/1346493355795107843\/photo\/1<\/li>\n
      13. https:\/\/twitter.com\/YouGov\/status\/1346493360954109953\/photo\/1<\/li>\n
      14. https:\/\/www.ons.gov.uk\/peoplepopulationandcommunity\/educationandchildcare\/articles\/coronavirusandtheimpactonstudentsinhighereducationinenglandseptembertodecember2020\/2020-12-21#student-behaviour<\/li>\n
      15. Tversky, A., & Kahneman, D. (1973). Availability: A heuristic for judging frequency and probability.\u00a0<\/span>Cognitive Psychology<\/span><\/i>,\u00a0<\/span>5<\/span><\/i>, 207-232.<\/span><\/li>\n
      16. Bonell, C., Michie, S., Reicher, S., West, R., Bear, L., Yardley, L., … & Rubin, G. J. (2020). Harnessing behavioural science in public health campaigns to maintain \u2018social distancing\u2019in response to the COVID-19 pandemic: key principles.\u00a0<\/span>Journal of Epidemiology and Community Health<\/span><\/i>. <\/span>http:\/\/dx.doi.org\/10.1136\/jech-2020-214290<\/span><\/li>\n
      17. Smith, L.E., Potts, H.W.W., Amlot, R., Fear, N.T., Michie, S. & Rubin, J. (2020) Adherence to the test, trace and isolate system: results from a time series of 21 nationally representative surveys in the UK (the COVID-19 Rapid Survey of Adherence to Interventions and Responses [CORSAIR] study). MedRxiv. <\/span>https:\/\/www.medrxiv.org\/content\/10.1101\/2020.09.15.20191957v1<\/a>
        \n<\/span><\/li>\n
      18. SPI-B (16 Sept 2020) –<\/span> SPI-B: Impact of financial and other targeted support on rates of self-isolation or quarantine<\/a><\/li>\n
      19. Atchison, C. J., Bowman, L., Vrinten, C., Redd, R., Pristera, P., Eaton, J. W., & Ward, H. (2020). Perceptions and behavioural responses of the general public during the COVID-19 pandemic: A cross-sectional survey of UK Adults.\u00a0<\/span>medRxiv<\/span><\/i>. <\/span>https:\/\/www.medrxiv.org\/content\/medrxiv\/early\/2020\/04\/03\/2020.04.01.20050039.full.pdf<\/span><\/a><\/li>\n
      20. https:\/\/www.nychealthandhospitals.org\/test-and-trace\/take-care\/<\/li>\n
      21. Personal communication from a member of New York Mayor Bill de Blasio\u2019s COVID Advisory Group.<\/span><\/li>\n
      22. https:\/\/www.theguardian.com\/news\/audio\/2020\/sep\/15\/rule-six-covid-blame-game<\/li>\n
      23. https:\/\/www.thelondoneconomic.com\/news\/video-pm-urged-patriotic-best-go-to-pub-now-govt-minister-blames-it-for-rise-in-infections\/17\/09\/<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

        As England and Scotland start another period of lockdown, we all have to come to terms with following stricter covid-19 restrictions, most likely for a relatively long period of time. […]<\/p>\n

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