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Pandemic fatigue? How adherence to covid-19 regulations has been misrepresented and why it matters

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n137 (Published 18 January 2021) Cite this as: BMJ 2021;372:n137

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  1. Stephen Reicher1,
  2. John Drury2
  1. 1School of Psychology and Neuroscience, University of St Andrews, UK
  2. 2School of Psychology, University of Sussex, UK
  1. sdr{at}st-andrews.ac.uk

Non-adherence is a matter of practicality, not psychology

As England and Scotland start another period of lockdown, we all must come to terms with following stricter restrictions, most likely for a relatively long period of time. The notion of behavioural fatigue associated with adherence to covid restrictions (“pandemic fatigue”) has been a recurrent theme throughout the crisis. It was invoked before the first wave in March 2020 as a reason to delay restrictions.1 It was invoked in October 2020 as a reason to delay the imposition of the circuit breaker which the Scientific Advisory Group for Emergencies had called for on 21 September.23 It was invoked in December 2020 as a reason to loosen restrictions over the Christmas period.4 In October, a Google search found some 200 million mentions of the term “pandemic fatigue.”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.

Linked to the notion that people will find it hard to adhere to the rules because of shared human psychological frailties is the idea that when individuals break the rules it is because of their personal failings. They are either too weak, too stupid, or too immoral to do the right thing. Hence, terms like “covidiots” have become almost as familiar as “pandemic fatigue.” This feeds into a widespread narrative of blame whereby the spread of infections is explained in terms of those who choose to break the rules, rather than failures of public health response.

The narrative of blame is exemplified in the language used by politicians. For instance, in his televised address to the nation on 22 September 2020, the UK prime minister Boris Johnson spoke of people “flouting” and “brazenly defying” restrictions. It is also exemplified in a media focus on particularly egregious examples of violations, such as raves and large house parties. 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.

Each of these assumptions is both problematic and dangerous.

Let’s 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.6 Equally, despite anecdotal observations about growing violations and polling which shows that people report low levels of adherence in other people, both self-reported data and systematic observations of behaviour in public places suggest that adherence stayed high during the second lockdown.7 Some 90% of people or more adhere to hygiene measures, to spatial distancing, and to mask wearing most of the time.8 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 past few days, with 85% of the public endorsing the January lockdown and 77% thinking it should have happened sooner.910

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 different picture. ONS data reveal very high levels of adherence to social distancing, very low levels of social mixing, and that students were far more likely than the general population to avoid leaving their accommodation altogether.11

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.” That is, we judge the incidence of events based on how easily they come to mind—and violations are both more memorable and more newsworthy than acts of adherence. People sitting quietly at home and watching TV do not make a newspaper headline. People at a house party do. 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.12

There is, however, one key area where the perception of low adherence is not at odds with 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%.13 Unlike hand hygiene and social distancing, self-isolation requires support from others to be possible. This includes support from others in the community, most obviously in the form of shopping. It also requires material support in the form of an income and sufficient space. The lower adherence rates for self-isolation suggest that the problems may have less to do with psychological motivation than with the availability of resources.14 This accords with data from the first lockdown 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.9 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) adherence is as high as 95%.1516

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 and explains the increase in infections among the young when the first lockdown was eased.17 It also explains the outbreaks in student halls of residence where, characteristically, many live together in small shared units.

The problem, then, is that in psychologising and individualising the matter of adherence, one disregards the structural factors that 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—doing one’s “patriotic best” according to the prime minister—and to return to work after the first lockdown). It is particularly misleading and unfair to ask people to do things and then blame them for doing so.18

The way in which matters of adherence have been portrayed and understood during this pandemic have been spectacularly wrong. If anything, the headline stories should not be of fatigue and covidiots and house parties. They should highlight the remarkable and enduring resilience of the great majority of the population—including those who have been most subject to blame, such as students and young people—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 on to the imagined frailties of public psychology.

Footnotes

  • Competing interests: SR participates in SPI-B, in the advisory group to the Scottish chief medical officer, and in Independent SAGE. JD participates in SPI-B and Independent SAGE.

  • Funding: This piece is linked to a UKRI grant: Facilitating the public response to covid-19 by harnessing group processes Ref:ES/V005383/1.

  • Commissioned, not peer reviewed.

References

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