COVID-19: Public Compliance with and Public Support for Stay-at-Home Mitigation Strategies

Objectives: Governments worldwide have recommended unprecedented measures to mitigate the coronavirus disease 2019 (COVID-19) pandemic. As pressure mounts to scale back these measures, understanding public compliance with and priorities for COVID-19 mitigation is critical. The main aim of this study was to assess public compliance with and support for government-imposed stay-at-home orders in nations and cities with different COVID-19 infection and death rates. Design: In this cross-sectional study, questionnaires were administered to nationally representative respondents from April 2-8, 2020. Setting: Regions with different disease prevalence included two nations [the United States (US, high) and Australia (AU, low)] and two cities [New York (NY, high) and Los Angeles (LA, low)]. Participants: For adults 18 years or older residing in specified regions, eligible respondents were empaneled until representative quotas were reached for age, gender, and either race and ethnicity (US, NY, LA) or ancestry (AU), matching the 2010 US or 2016 AU census. Of 8718 eligible potential respondents, 5573 (response rate, 63.9%) completed surveys (US: 3010; NY: 507; LA: 525; AU: 1531). The median age was 47 years (range, 18-89); 3039 (54.5%) were female. Exposure: The prevalence of COVID-19 in each region (cumulative infections, deaths) as of April 8, 2020: US (458610, 15659), AU (5956, 45), NY (81803, 4571), LA (7530, 198). Main Outcomes Measures: Public compliance with and attitudes regarding government-imposed stay-at-home orders were evaluated and compared between regions. Results: Of 5573 total respondents, 4560 (81.8%) reported compliance with recommended quarantine or stay-at-home policies (range of samples, 75.5%-88.2%). Despite significant disruptions of social and work life, health, and behavior, 5022 respondents (90.1%) supported government-imposed stay-at-home orders (range of samples, 88.9%-93.1%). Of these, 90.8% believe orders should last at least three more weeks or until public health or government officials recommend, with such support spanning the political spectrum. Conclusions: Public compliance with stringent quarantine and stay-at-home policies was very high, in both highly-affected (US, NY) and minimally-affected regions (AU, LA). Despite extensive disruption of respondents′ lives, the vast majority supported continuation of long-term government-imposed stay-at-home orders. These findings have important implications for policymakers grappling with the decision as to when to lift restrictions.


Introduction
To date, more than 2,500,000 confirmed cases and 175,000 deaths have been attributed to the novel coronavirus disease 2019 (COVID-19) pandemic. 3 Absent widespread testing or safe and efficacious treatments, isolation and quarantine have been recommended worldwide for the first time in a century. Disease prevalence and associated public health policies have varied across jurisdictions and changed over time, largely without systematic assessment of public responses to the crisis or the mitigation strategies.

Study Design and Recruitment
To evaluate public compliance with and support for recommended COVID-19 mitigation strategies, we collected cross-sectional surveys of nationally representative respondents using demographic quota sampling. 4 Surveys were administered to an online respondent panel by Qualtrics, LLC (Provo, Utah, and Seattle, Washington, US), a commercial survey company with a network of participant pools consisting of hundreds of suppliers. Recruitment methodologies include digital advertisements and promotions, word of mouth and membership referrals, social networks, TV and radio advertisements, and offline mail-based approaches.
Between April 2-8 2020 (a one-week period), samples were drawn from regions with markedly different infection and death rates from COVID-19 (Table 1), including nationwide samples in the United States (US, high incidence) and Australia (AU, low incidence), and two citywide samples in the New York (NY, high incidence) and Los Angeles (LA, low incidence) metropolitan areas.

Study Approval
The study protocol was approved by the Monash University Human Research Ethics Committee (MUHREC) and conducted in accordance with ethical guidelines.
Respondents were informed of the study purposes and provided electronic consent prior to commencement. Investigators received anonymized responses.

Population
Target numbers of respondent-completed surveys follows: US (3000), NY (500), LA (500), AU (1500). To be eligible to participate, respondents were required to report being aged 18 years or older with current residence in specified regions. Demographic sampling quotas were implemented for age, gender, and either race and ethnicity (US, NY, LA) or ancestry (AU), based on 2010 US and 2016 Australian census data.
Potential respondents likely to qualify based on demographic characteristics listed in their Qualtrics panelist profile were targeted during recruitment; demographic questions were included in the survey to confirm eligibility. Potential respondents received invitations and could opt to participate by activating a survey link directing them to the participant information and consent page preceding the survey. Ineligible respondents who did not meet inclusion criteria (e.g., less than 18 years of age, not a resident of a targeted region) or exceeded set quotas (i.e., maximum demographic characteristic quota already met) were disempaneled from the survey.

Survey Instruments
The surveys contained 86 [United States (US), New York (NY), Los Angeles (LA)] or 85 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted April 24, 2020. . https://doi.org /10.1101/10. /2020 [culturally adapted for Australia (AU)] items, with each item requiring a response, and was designed to take approximately 15 minutes to complete. Respondents were required to self-report demographic characteristics and respond to questions about COVID-19 and mitigation strategies including compliance, priorities, sources of concern, and comparisons of current lifestyle versus lifestyle between October and December 2019 (i.e., before COVID-19 and mitigation strategies). Additional health-related questions were asked independent of COVID-19. When possible, brief validated instruments were used, including the Short-Form Sleep Condition Indicator (SCI-01) for insomnia risk assessment, Patient Health Questionnaire-4 (PHQ-4) for anxiety and depression risk assessment, the Perceived Stress Scale-4 (PSS-4) for perceived stress assessment, and the Mini Z for burnout risk assessment. 5

Quality Screening
To verify response quality, Qualtrics conducted standardized quality screening and data scrubbing procedures. Techniques included algorithmic analysis for attention patterns, click-through behavior, duplicate responses, keystroke analysis, machine responses, and inattentiveness. Country-specific geolocation verification via IP address mapping was used to ensure respondents were from the country specified in their response. All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Respondents who failed an attention or speed check, along with any responses identified by the data scrubbing algorithms, were excluded from the final sample.

Results
Between April 2 and April 8, 2020, respondents completed 5573 surveys (US: 3010; NY: 507; LA: 525; AU: 1531) with a 63.9% response rate ( Figure 1). Overall, 3039 (54.5%) were female; the median age of participants was 47 years (range, 18-89). See Table 2 for respondent characteristics. Cross-sectional results of COVID-19-mitigation compliance, public priorities, and life impact for each sample are reported by region ( Figure 2; Table 1). Altogether, 4560 respondents (81.8%) reported quarantining or voluntarily self-isolating (range of samples, 75.5%-88.2%). Moreover, 5022 (90.1%) believe a government-imposed stay-at-home order is warranted (range of samples, 88.9%-93.1%). Of these, 90.8% believe the order should last at least three more weeks (9.1%), a month or longer (43.8%), or until public health (31.1%) or government officials (6.8%) determine it is safe to lift the restrictions. Of 5304 respondents (95.2%) who made predictions, the average predicted date by which COVID-19 would no longer affect their daily lives was between mid-June and mid-August, though there was high variability in predictions. Strong support for a government-imposed stay-at-home order spanned the political spectrum (Table 1)

Discussion
Resounding compliance with and support for disruptive mitigation measures evidenced in these nationally representative samples, despite belief by 91.4% of respondents that they will never be infected with COVID-19 (range of samples, 89.2%-92.6%), suggests that controlling COVID-19 is a top public priority. 15 We used quota sample surveys to rapidly assess public compliance, priorities, and life impact related to COVID-19 and mitigation strategies. We recognize the potential for self-selection bias; however, the high response rate (63.9%) and consistency of responses across cities and countries despite different rates of infection, governments, and mitigation strategies indicate that these results are robust. Contrary to public attitudes and compliance with recommended mitigation during the last pandemic [16][17] declared by the World Health Organization for novel influenza A (H1N1) in 2009, 18 the public response to the COVID-19 pandemic represents a hitherto unprecedented and rapid level of compliance with public health emergency measures that have and will continue to have a profound impact on economics and public life. These results demonstrate an escalated public response compared to before shelter-in-place orders were widely implemented, 19 and contribute to a growing body of evidence that mitigation strategies for COVID-19, like those for previous outbreaks, are associated with significant disruption of life and general health consequences. 20-25 These findings may also provide insight into behavioral countermeasures related to sleep, exercise, and diet that may reduce adverse health consequences of COVID-19 mitigation measures. As controversies over the legality 26 and balance between duration and nature of mitigation strategies and related consequences continue to mount, and with the recent prospect of repeated and All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted April 24, 2020. . https://doi.org/10.1101/2020.04.22.20076141 doi: medRxiv preprint protracted stay-at-home orders being recommended over the next two years, 27 assessment of public priorities, compliance, and life impact is paramount.
Compliance with and support for COVID-19 mitigation strategies, alongside concerns and life impact, were assessed in nationally representative samples in the United States and Australia. These timely findings indicate that the public is not only willing to accept current mitigation measures and their associated costs, but that people endorse their continuation until the COVID-19 pandemic is controlled.
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Additional Contributions
We thank Qualtrics, LLC for their support of survey administration and data collection. All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020.  17692 Potential respondents received survey invitation 17 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020.  Australian census data. Of 8718 eligible potential respondents, 5573 completed surveys, providing a 63.9% response rate.
18 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. 20 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. , Productivity, Physical Activity, Sexual Activity, and Sleep Patterns, respondents had the option to select "does not apply." These answers are not included in the table and account for difference between the sum of "Not at all affected", "Disrupted", and "Improved" and 100%. O v e r a l l U S N Y L A All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. where means and standard deviations are reported, the to the right is left blank. For the "Concerns Related to COVID-19 and Mitigation Strategies" section, only respondents rating moderate to extreme concern are reported (respondents reporting no or slight concern, or that the concern does not apply, are not shown). Country-level cumulative cases and deaths for US and AU were retrieved from World Health Organization COVID-19 Situational Reports. 1,28-29 City-level cumulative cases and deaths for NY and LA were retrieved from The New York Times Coronavirus (Covid-19) Data in the United States project, based on reports from state and local health agencies. 2 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted April 24, 2020. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.