covid responsive behaviour essay

June 17, 2021

How COVID Is Changing the Study of Human Behavior

The pandemic is teaching us key lessons about how people respond to crisis and misinformation, and it is spurring changes in the way scientists study public health questions

By Christie Aschwanden & Nature magazine

National identity plays a part in how likely people are to support public-health policies such as mask wearing.

Edward Berthelot Getty Images

During the early months of the COVID-19 pandemic, Jay Van Bavel, a psychologist at New York University, wanted to identify the social factors that best predict a person’s support for public-health measures, such as physical distancing or closing restaurants. He had a handful of collaborators ready to collect survey data. But because the pandemic was going on everywhere, he wondered whether he could scale up the project. So he tried something he’d never done before.

He posted a  description of the study on Twitter  in April, with an invitation for other researchers to join. “Maybe I’ll get ten more people and some more data points,” he recalls thinking at the time. Instead, the response floored him. More than 200 scientists from 67 countries joined the effort. In the end, the researchers were able to collect data on more than 46,000 people. “It was a massive collaboration,” he says. The team showed how, on the whole, people who reported that national identity was important to them were more likely to support public-health policies. The work is currently being peer reviewed.

For social scientists, the COVID-19 pandemic has presented a unique opportunity—a natural experiment that “cuts across all cultures and socio-economic groups”, says Andreas Olsson, a psychologist at the Karolinska Institute in Stockholm. Everyone is facing similar threats to their health and livelihoods, “so we can see how people respond differently to this depending on culture, social groups and individual differences”, he says. Researchers have been able to compare people’s behaviours before and after large policy changes, for example, or to study the flow of information and misinformation more easily.

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The pandemic’s global scope has brought groups together from around the world as never before. And with so much simultaneous interest, researchers can test ideas and interventions more rapidly than before. It has also forced many social scientists to adapt their methods during a time when in-person interviews and experiments have been next to impossible. Some expect that innovations spurred by the pandemic could outlive the current crisis and might even permanently change the field.

For example, with the technology that’s now tried and tested, Van Bavel says, it’s much easier to build an international team. “Now that we’ve got the infrastructure and experience, we’ll be able to do this for all kinds of things,” he says.

Social vaccine boosters

Before Van Bavel’s massive collaboration, he and a group of more than 40 researchers got together to outline the ways in which behavioural research might inform and improve the response to the SARS-CoV-2 coronavirus at a time when people are scared, sceptical and inundated by information. They outlined previous research in the field that might influence policy, and identified potential projects on threat perception, decision-making and science communication, among other things.

Many were eager to apply their work towards understanding the public response to practices such as lockdowns and mask mandates. In the survey of more than 46,000 people, Van Bavel and his colleagues showed that countries in which people were most in favour of precautionary measures tended to be those that fostered a sense of public unity and cohesion. A sense, he says, that “we’re all in this together”. That was somewhat counter-intuitive. Right-wing political ideology correlated with resistance to public-health measures among survey participants, but, on the whole, a strong national identity predicted more support for such measures. Van Bavel says this suggests that it might be possible to leverage national identity when promoting public-health policies.

A London billboard encouraged people to follow lockdown guidance to prevent COVID-19. Credit: May James Getty Images

Other work has shown that who delivers the message really matters. A study published in February surveyed more than 12,000 people in 6 countries—Brazil, Italy, South Korea, Spain, Switzerland and the United States—about their willingness to share a message encouraging social distancing. The message could be endorsed by actor Tom Hanks, celebrity Kim Kardashian, a prominent government official from the survey-taker’s country or  Anthony Fauci , director of the US National Institute of Allergy and Infectious Diseases in Bethesda, Maryland. Respondents from all countries were most willing to share the message when it came from Fauci (although in the United States, where COVID-19 has been highly politicized, he has become a divisive figure for some). Celebrity endorsements were relatively ineffective by comparison.

Preliminary research suggests that aligning the message with recipients’ values or highlighting social approval can also be influential. Michele Gelfand, a psychologist at the University of Maryland in College Park, is part of a team running an ‘intervention tournament’ to identify ways of promoting mask wearing among conservatives and liberals in the United States.

The researchers are testing eight interventions, or ‘nudges’, that reflect different moral values and factors specific to COVID-19. The aim is to work out which are most effective at encouraging these political groups to adhere to public-health guidance. One message they are testing emphasizes that mask wearing will ‘help us to reopen our economy more quickly’—an approach designed to appeal to Republicans, who are  more likely to view the pandemic as an economic crisis than a health one . Another intervention highlights harm avoidance—a value that liberal people say is important to them. The message emphasizes that a mask ‘will keep you safe’.

“We’re pitting them against one another to see which nudge works best,” Gelfand says. It’s a study design that can test multiple interventions simultaneously, and could be deployed on a large scale across many geographical regions—a benefit made more urgent by the pandemic. The results have not yet been published.

Others started using a similar approach to encourage vaccination even before a SARS-CoV-2 vaccine was available. The Behavior Change For Good Initiative at the University of Pennsylvania in Philadelphia was testing nudges that encourage people to get the influenza vaccine. Katherine Milkman, a behavioural researcher at the university’s Wharton School, and her colleagues tested around 20 messaging strategies—everything from jokes to direct appeals. “We’re seeing things that work,” Milkman says. They’ve found, for example, that texting people to say a flu shot had been reserved especially for them boosted vaccination rates.

The findings were almost immediately put to work by researchers seeking to increase COVID-19 vaccination uptake. Researchers at the University of California, Los Angeles (UCLA), tried replicating the strategy among people being treated at the UCLA Health system in February and March, and found that it “proved quite useful for nudging COVID-19 vaccination”, Milkman says.

And, in March, Milkman received an e-mail from Steve Martin, chief executive of the behavioural-science consultancy Influence at Work in Harpenden, UK, telling her that his team had implemented her findings on the island of Jersey in the English Channel. Martin and his colleague Rebecca Sherrington, associate chief nurse for the Government of Jersey, incorporated Milkman’s insight that it was possible to increase the likelihood of someone coming in for a vaccine if they were given “a sense of ownership”—for instance, by telling them that ‘this vaccine has been reserved for you’. “We’ve had a real problem engaging care-home staff—particularly young females, many of whom are sceptical about the vaccine,” Martin says. But using Milkman’s approach, along with other insights (such as the idea that the messenger’s identity also matters), Martin’s programme attained 93% coverage of care-home staff on Jersey, compared with around 80% in other jurisdictions.

Depolarization research

Technologies such as geotracking are helping social scientists to trace the way people really behave, not just how they say they do. The response to the COVID-19 pandemic has shown a dramatic split along political lines in many places, and because so many people own smartphones that include GPS trackers, researchers can quantify how partisanship has translated into behaviour during the pandemic.

Van Bavel and his colleagues used geotracking data from 15 million smartphones per day to look at correlations between US voting patterns and adherence to public-health recommendations. People in counties that voted for Republican Donald Trump in the 2016 presidential election, for example, practised 14% less physical distancing between March and May 2020 than did people in areas that voted for Democrat Hillary Clinton. The study also identified a correlation between the consumption of conservative news and reduced physical distancing, and found that the partisan differences regarding physical distancing increased over time.

The research possibilities opened up by geotracking are “beyond my dreams”, says Walter Quattrociocchi, a data scientist at the Ca’Foscari University of Venice, Italy. “We have so much more data to measure social processes now,” he says, and the pandemic has provided a way to put these data to work.

His group used location data from 13 million Facebook users to look at how people moved around France, Italy and the United Kingdom during the early months of the pandemic. The three countries displayed different patterns of mobility that reflect their underlying infrastructure and geography. Movements in the United Kingdom and France were more centralized around London and Paris, respectively, but were more dispersed among Italy’s major population centres. Such results, he says, could help to predict economic resilience in the face of other disasters.

Researchers are also increasingly using Internet-based surveys, a trend accelerated by the pandemic. A US study of people’s daily activities during the pandemic—such as going to work, visiting family or dining at restaurants—received more than 6,700 responses per day on average. Results showed that political partisanship had a much greater role than did local COVID-19 rates in influencing safe behaviours. Self-identified Republicans were nearly 28% more likely to be mobile than Democrats were, and this gap widened over the course of the study period from April to September last year.

Post-lockdown legacy

The pandemic is clearly changing how researchers study behaviour—and in ways that could outlast the lockdowns. “I think people will continue to seek to do bigger studies with more laboratories to produce more robust and widely applicable findings,” says Van Bavel. The samples collected through these projects are more diverse than they are for typical approaches, and so the impact from these studies could be much higher, he says.

The COVID-19 crisis has also made researchers much more willing to collaborate and share information, says Milkman. And the pace of publishing and implementing findings has sped up, she says. “I wrote a paper about some of our findings over the Christmas holidays in a week,” she says—work that would have normally taken her several months. She expedited the manuscript because she felt the findings were urgent and she wanted to get them into the public domain.

The constraints of COVID-19 have nudged social science in a good direction, says Milkman. “We should be doing ‘big science’,” she says, in the way that fields such as physics and astronomy do. Instead of running single, small experiments, researchers can now conduct mega-studies that bring together large groups of researchers to test 20 or even 50 treatment arms at once, she says.

The inability to gather people indoors to conduct research has also forced innovations in how scientists recruit and study participants, says Wändi Bruine de Bruin, a behavioural scientist at the University of Southern California in Los Angeles. She is an investigator on the Understanding America Study, which has been repeatedly surveying about 9,000 nationally representative US households on questions related to the pandemic, such as ‘Do you intend to get vaccinated?’ and ‘How likely do you think it is that you will become infected?’. Being forced to develop procedures to recruit large, nationally representative samples has allowed Bruine de Bruin and her colleagues to recruit more widely. “You don’t have to stay local,” she says, and because participants don’t have to come into the lab, it’s easier to recruit a more diverse sample. “I do think it will push social science forward,” she says.

Technical workarounds spurred by the pandemic could also end up strengthening science. Alexander Holcombe, a psychologist at the University of Sydney, Australia, studies visual perception, which he describes as “a very narrow area of science where people weren’t doing online studies” before the pandemic. Social-distancing practices forced him and his team to learn the computer programming necessary to make their experiments work online. The upshot is that they’re able to get bigger sample sizes, he says—an important improvement on the methodology.

Brian Nosek, executive director at the Center for Open Science, a non-profit organization in Charlottesville, Virginia, sees the pandemic as a chance to rethink some of the fundamentals of how science is done. “It’s given us an occasion to say, ‘Well, how should we be doing this?’” he says, with ‘this’ being everything from teaching and lab work, to study designs and collaboration. The ways that people communicate in the field and engage with collaborators have “fundamentally changed”, he says. “I don’t imagine we’ll go back.”

This article is reproduced with permission and was first published on May 18 2021.

Research shows how people changed their behavior in response to COVID-19 guidance

National guidelines overruled state and local pandemic policies.

When the United States issued national stay-at-home guidelines in March 2020 in response to the COVID-19 pandemic, mobility across the country dropped significantly. New research from the Harvard John A. Paulson School of Engineering and Applied Sciences (SEAS) demonstrates that people may be inclined to change their behavior in response to national guidelines, more than state and local policies. 

“When the next pandemic hits, we need to know what kind of policies are going to have the biggest impact on human behavior and health,” said Marianna Linz , Assistant Professor of Environmental Science and Engineering and of Earth and Planetary Sciences at SEAS and senior author of the paper. “While specific, local policies based on community spread may make the most sense, we found that people seem to change their behavior more in response to national guidelines. This suggests that clear national guidelines, at least in the beginning, are going to have the biggest impact on public health.”

The research is published in the Proceedings of the National Academy of Sciences (PNAS). 

The researchers used cell phone mobility data collected by Google and Unacast, a location data company, to study how far people traveled and how many people they encountered between February 24 to May 22 and June 1 to August 28. 

The researchers found that in most states, grocery store and pharmacy visits peaked within a few days of March 13, the day the White House declared a state of emergency and banned travel from 26 European countries. The following weekend, after the release of national stay at home guidelines and school closures, people across the country started to stay put although most states then had only a few hundred known COVID-19 cases.

“Although many states delayed implementing stay-at-home orders, there was near uniformity in behavior at the beginning of quarantine across states,” said Yihan Wu ‘22, an undergraduate researcher in Linz’s Lab and first author of the paper. “It was really striking to see just how consistent behavior was at that time.”

Similarly, when the national stay-at-home advisory ended on May 1st, there was a uniform rise in mobility across the country, even though locally many schools and offices remained closed. 

“Despite different local stay-at-home orders and state reopening timelines, we see encounters increasing in a coherent way nationwide when the national guidelines expired,” said Todd Mooring, a postdoctoral fellow at Harvard and co-author of the study.

The researchers also looked at how weather impacted mobility and encounters during the quarantine period. Despite news stories featuring crowded beaches and packed pool parties, the data did not show systematic increases in close encounters on nice days.

“We found that while visits to parks increased on nice days during the shutdown, most people were still being cautious and avoiding encounters with other people during the national stay-at-home period,” said Wu. 

“While the response to COVID-19 became increasingly politicized over time, that wasn’t the case in the beginning,” said Linz. “Our results suggest that coherent national guidance could help contain virus transmission in the future. COVID-19 may be too politicized now, but this result will be useful to future pandemic planning.”

Topics: COVID-19

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• Volume 76, Issue 2
• COVID-19 pandemic and its impact on social relationships and health
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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
• Susan Patterson 1 ,
• Karen Maxwell 1 ,
• Carolyn Blake 1 ,
• http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
• Ruth Lewis 1 ,
• Mark McCann 1 ,
• Julie Riddell 1 ,
• Kathryn Skivington 1 ,
• Rachel Wilson-Lowe 1 ,
• http://orcid.org/0000-0002-4409-6601 Kirstin R Mitchell 2
• 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
• 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

• inequalities

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study. Data sharing not applicable as no data sets generated or analysed for this essay.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/jech-2021-216690

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Human Behavior in the Time of COVID-19: Learning from Psychological Science

Psychological scientists speak.

• Health Psychology
• Public Health

In the wake of the closures of their universities and labs, psychological scientists around the world are experiencing new demands on their time as they adjust to teaching remotely, overseeing dispersed labs, and managing family caregiving. At the same time, many have found themselves on the front lines of exploring the psychological factors that can help the public understand the impact of COVID-19. The comments that follow are excerpted and adapted from a variety of sources, including a virtual roundtable featuring APS members with specific areas of expertise, a series of “backgrounders” assembled in response to the crisis (see opposite page), a podcast featuring an APS Fellow, and appearances by APS members in the news media. Find links to these resources and more at psychologicalscience.org/covid-19-information .

A collective crisis heightens sensitivity to social interactions.

This is a situation that can have both positive and negative effects as a function of it being a collective crisis. On the positive side, there is a sense that we’re in it together, and we see many amazing examples of people supporting one another. On the negative side, we see some people respond to this with a sense that they need to “protect their own,” and it is “us versus them.” APS Fellow Bethany Teachman, University of Virginia, APS roundtable discussion

Many people are feeling both impulses at the same time. They’re obviously going to feel fear because of the uncertainty, the present threat, and the potential threats. And the social cues around people right now are going to raise their perception that we’re in danger. Then there’s the talk of the long-term impact to the economy too, and you have a real recipe for people to be anxious and frightened. APS Fellow Valerie Reyna, Cornell University, APS roundtable discussion

In ambiguous situations, people look for social cues from others. You say, “Well, if other people are doing it, maybe they know something about whether this is an acceptable risk.” APS Fellow Baruch Fischhoff, Carnegie Mellon University, quoted in The Atlantic

Children learn many of their own fears and anxieties from what they hear and what they see. In other words, seeing something scary on television, hearing something scary on the news, or seeing their parents look nervous or afraid are common learning mechanisms for young children. The recommendation for parents here is to be aware of the emotional information and the factual information about the coronavirus that is being transmitted to children, as they are apt to learn from whatever information happens to be around them. Vanessa LoBue, Rutgers University, APS Backgrounder series

Moral responsibility can be a powerful motivator.

If your worldview is that you’re always asked to make sacrifices and you never get anything out of it, maybe you don’t want to comply with [social distancing]. But if you have a worldview that tells you it’s important to help others, then maybe you’re happy to make these sacrifices. You’re looking around to see what people are doing. If you take your cues from other people, you might be more inclined to take strong action yourself because you see other people doing it.  APS Fellow Gretchen Chapman, Carnegie Mellon University, quoted on Slate.com

You’re probably going to have a hard time not scratching your nose, no matter how much you want to. But moral responsibility can be a powerful motivator. The potential consequences start to feel real when you spend just a couple of minutes considering the people you know who are at heightened risk of complications due to COVID-19—people like your parents or grandparents, that friend whose husband has a heart condition, or your colleague with diabetes. Even if we can make only a 5-percent difference, we really should try. APS Member Adam Grant, the Wharton School of Business, writing for The Atlantic

One of the most important things crisis communications research tells us is that our leaders should be honest and transparent. Insincerity is very alienating, and it leads to distrust. Empathy from our leaders, honesty from our leaders, and being frank with the uncertainty, not promising more than can be delivered, is likely to help us through this crisis. In contrast, contradictory messages or insincerity are probably going to exacerbate the distress level. Moreover, we do know that once trust is lost, it’s very difficult to regain it. APS Fellow Roxane Cohen Silver, University of California, Irvine, APS interview/podcast

COVID-19 Backgrounders

Through an ongoing series of “backgrounders,” APS is exploring many of the psychological factors that can help the public understand and collectively combat the spread of COVID-19. Each backgrounder features the assessments, research, and recommendations of a renowned subject expert in the field of psychological science.

• Remaining Resilient During a Pandemic : George A. Bonanno, Columbia University

• Social Impact on Children : Vanessa LoBue, Rutgers University

• Social Impact on Adults : Chris Segrin, University of Arizona

• Working Remotely : Tammy Allen, University of Southern Florida

• Marriages and Close Relationships : Paula Pietromonaco, University of Massachusetts, Amherst

See the growing Backgrounder series here .

Continued exposure and chronic anxiety can worsen outcomes.

This is unquestionably a period where people are experiencing an enormous amount of stress, given the large demands the situation is placing on our daily lives—the changes in our routines and structures that we typically rely on, and the uncertainty surrounding how long this is going to last and what the ultimate impact is going to be on our families, our communities, and our workplaces. Psychological science has taught us quite clearly that in situations of mass trauma or mass stress, like a natural disaster or a terrorist attack, there’s a very clear link between the degree of media exposure that people have and their symptoms of anxiety, depression, and substance abuse. APS Member Katie McLaughlin, Harvard University, APS roundtable discussion

Decades of scientific research show that how we make meaning out of situations can leave us vulnerable to unhelpful, out-of-proportion anxiety. When our environment is inherently ambiguous—open to interpretation and unknown outcomes—our interpretations matter. They matter a lot. Ambiguity breeds anxiety; more so when the “facts” change hourly. APS Fellow Lori Zoellner, University of Washington, writing (with others) for The Seattle Times

Humans often can develop a robust and pathological fear of things that might not happen, to create realities that don’t exist. In the old days, the virus update would be a mention on the 6 o’clock news, but today, it’s tweets and Facebook posts 24/7. Fears can be learned. If you’re communicating with people online who are afraid or are seeing people online who are afraid, that exposure is more likely to invoke fear in you. APS William James Fellow Elizabeth Phelps, Harvard University, quoted in USA Today

The work that I’ve been doing with colleagues since the September 11th terrorist attacks tells me the very important role the media can play in coping with this kind of a crisis. I would be very cautious for people to seek out information from authoritative sources and to make sure that they check out the messaging that they’re receiving to ensure that it’s accurate. In addition, we want to encourage people to monitor how much time they’re spending immersed in the news about COVID-19 and try to break away, engage in some sort of downtime so that they can cope as best as possible. APS Fellow Roxane Cohen Silver, University of California, Irvine, APS interview/podcast

Human beings are inherently social, not solitary, creatures. When people’s actual or achieved social contact falls below their desired level of social contact, they begin to feel lonely, and loneliness is stressful. The stress of loneliness degrades mental and physical health (e.g., cardiovascular fitness, immune fitness) through disruption of recuperative behaviors (e.g., sleep, leisure) and corruption of health behaviors (e.g., substance use, diet, exercise). APS Member Chris Segrin, APS Backgrounder series

APS and SAGE: Fast-Tracking And Expanding Access

To facilitate the dissemination of findings on psychologically relevant aspects of the COVID-19 crisis, APS and SAGE Publications have joined together to expedite the review and fast-track the publication of Psychological Science articles that deal with COVID-19. Learn more about fast-tracking COVID-19 submissions here . In addition, APS has made its journal research pertaining to epidemics and related health issues publicly available.

Examples include:

• Distress, Worry, and Functioning Following a Global Health Crisis: A National Study of Americans’ Responses to Ebola ( Clinical Psychological Science , April 26, 2017)

• Effects of Symptom Presentation Order on Perceived Disease Risk ( Psychological Science , March 5, 2012)

• Fear of Ebola: The Influence of Collectivism on Xenophobic Threat Responses ( Psychological Science , May 20, 2016)

• It’s Not All About Me: Motivating Hand Hygiene Among Health Care Professionals by Focusing on Patients ( Psychological Science , November 10, 2011)

• Increasing Vaccination: Putting Psychological Science Into Action ( Psychological Science in the Public Interest , April 3, 2018)

• How Do People Value Life? ( Psychological Science , December 22, 2009)

• Sneezing in Times of a Flu Pandemic: Public Sneezing Increases Perception of Unrelated Risks and Shifts Preferences for Federal Spending ( Psychological Science , January 22, 2010)

Finally, SAGE has made publicly available the latest medical research related to COVID-19 as well as top behavioral and social research to help individuals, communities, and leaders make the best decisions on dealing with the outbreak and its consequences.

How we behave determines how we will cope.

Human behavior affects everything from the stock market to the actions people take or don’t take to reduce risk, like social distancing. Behavior will determine the actual public health risk in the end. If we’re able to understand why behaviors are risky, and therefore follow appropriate guidelines, we will have a far better outcome than if we don’t. APS Fellow Valerie Reyna, Cornell University, APS roundtable discussion

The human need for connection with other people is probably what fuels a lot of disease transmission. One could think of this as the price we pay for our inherently social nature. [We should] practice PHYSICAL distancing, not SOCIAL distancing. The term “social distancing” has an unfortunate connotation and is actually not an accurate descriptor of what public health officials are trying to achieve. Meaningful social contact can occur in the absence of close physical contact. APS Member Chris Segrin, APS Backgrounder series

The key psychological objective for most people is to keep stress at a minimum. Everyone is adapting to the new reality, which includes the fear of viral spread and contagion, self-quarantine, and supply shortages. More seriously, some are coping with illness and fear of death. To overcome the stresses of these situations and remain resilient throughout, it is important to use the tools we already have at our disposal, including:

• Staying optimistic
• Relying on the support of others
• Bonding with those close to us
• Keeping informed but not overindulging in media consumption
• Distracting oneself
• Finding ways to laugh and have fun through things like movies and reading
• Most especially, finding ways to minimize isolation with joint family activities and keep in touch with friends, colleagues by phone, video, email.

APS James McKeen Cattell Fellow George Bonanno, Columbia University, APS Backgrounder series

Social relationships are an incredibly important buffer against the negative consequences of stress. We know that having strong emotional support not only prevents anxiety and depression in periods of stress, but also buffers against the negative physiological consequences of stress on the immune system and physical health. One of my very favorite studies shows that the stress-buffering effects you get from receiving social support you also get when you give social support. And this is something that people can control right now—the degree of support they provide to others, including to members of our communities who are more vulnerable. APS Member Katie McLaughlin, Harvard University, APS roundtable discussion

It’s reasonable to have some anxiety and sadness. At the same time, it’s important not to get stuck there. There are a number of things that we can do to maintain as much of our normal lives as possible.

• Relationships. Social distancing does not have to equal social isolation. Those are two very different concepts and virtual interaction can make a big difference.
• Thoughts and feelings. It really doesn’t help us to spend 10 hours a day scrolling through newsfeeds and posts on COVID-19. So in a number of anxiety treatments, we encourage people to pick a couple of times a day when they focus on their worries and get the information that they need to problem-solve, but then spend the rest of their time living their lives as normally as possible.
• Behavioral self-care. A lot of what helps at this time is healthy eating, sleep, exercise, and perspective-taking so that you don’t get stuck in assuming the worst.
• To live your values. Be kind to yourself and be kind to others. This is a stressful time and anxiety is normal. We have to give ourselves permission to experience the feelings that we’re having and then to try to do as much as we can to maintain normality in the face of that situation.

APS Fellow Bethany Teachman, University of Virginia, APS roundtable discussion

Above all, psychological science tells us this:

We not only have to understand our ability in our agency, but we also have to know the limitations of our minds. We really need to spend time trying to trust the experts. We have physicians and epidemiologists who are really good at explaining the effects of the virus on society. We also have psychologists who are really good at giving advice on how to cope with isolation, fear, and anxiety. In uncertain times like now, when it is impossible to have a full understanding of the situation, we need to rely on trusted sources of information. APS Member Andreas Olsson, Karolinska Institute, APS roundtable discussion

We are not just passive recipients of what is happening. We can collectively work together to respond to this situation as a challenge, as opposed to appraising it as an impossible threat that we cannot manage. APS Fellow Bethany Teachman, University of Virginia, APS roundtable discussion

Giving support to other people is just as effective at helping to reduce stress responses and the negative consequences of stress for our physical and mental health as receiving support from others. We know very clearly that exposing yourself to a lot of media coverage about the pandemic is going to increase anxiety. The more we can create positive habits and boundaries around our exposure to media, the better. APS Member Katie McLaughlin, Harvard University, APS roundtable discussion

One of the most important fundamental findings that inform what we’re dealing with right now is that people react to the gist of the events rather than the details and the facts. It’s how people interpret reality that governs their emotions and their actions, not the actual reality itself. So we have to think about this torrent of information washing over everybody. How can we help people extract the bottom-line gist of that information so that they can take effective action? APS Fellow Valerie Reyna, Cornell University, APS roundtable discussion

We can cope with this. My research (and the research of others) has shown repeatedly that the majority of humans cope well and are resilient to just about any adversity. There is no single best way to cope for everyone. Research has shown many different factors predict resilience, but the effects of all of these factors are small because they don’t always work or they don’t work for everyone.

Research also shows that we need to be flexible and adapt. This means paying attention to what is happening to us and being nimble so we can adjust to what the situation is calling for. Each person should try different ways of coping and adapting to see what works best for them.

This is not easy but we can do it. Human beings have shown abundant psychological resilience in the face of just about any adversity imaginable. APS James McKeen Cattell Fellow George Bonanno, Columbia University, APS Backgrounder series

Prioritizing Lab Hygiene Amid a Pandemic

“With entire universities moving to remote instruction and virtually all other functions online, researchers are facing an unexpected and sudden end to on-site, in-person data collection. For psychological scientists, this moment brings both promise and peril.”

In an editorial in the May issue of Psychological Science , Dwight J. Kravitz and Stephen R. Mitroff (both at The George Washington University), along with Psychological Science editor and APS Fellow Patricia J. Bauer (Emory University), note that COVID-19 offers unique opportunities to advance psychological science, but they warn researchers not to forego rigor and transparency in the quest for expedience. The hiatus of in-person data-collection may also push researchers to run analyses of incomplete data sets or terminate data collection before reaching the predetermined sample size. The authors introduce the Airport Scanner applet to illustrate how practices that seem “logical” and “reasonable” can lead to inflated false-discovery rates and to provide suggestions for improving research practices. They also provide a series of links to other resources for reproducible and transparent research. Kravitz and colleagues believe that psychological scientists can keep improving the quality of research even during the pandemic. “As long as we are appropriately reflective—and transparent—we can maintain positive momentum, even as we shelter in place,” they write.

Read the full editorial here .

APS regularly opens certain online articles for discussion on our website. Effective February 2021, you must be a logged-in APS member to post comments. By posting a comment, you agree to our Community Guidelines and the display of your profile information, including your name and affiliation. Any opinions, findings, conclusions, or recommendations present in article comments are those of the writers and do not necessarily reflect the views of APS or the article’s author. For more information, please see our Community Guidelines .

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How Owning a Gun Raises Anxiety

In the first webinar of APS’s Science for Society series on September 20, 2023, scientists and advocates shared their expertise and perspectives on the relationship between gun violence and anxiety.

The COVID-19 Pandemic: A Psychological Science Timeline 

COVID-19 remains a reality around the world, but the pandemic itself has largely receded. We’ve created a timeline of some of the ways in which APS and psychological science more broadly have responded to COVID-19. 

Up-and-Coming Voices: Informing Public Health Through Psychological Science 

Previews of relevant research by students and early-career scientists.

Privacy Overview

• Open access
• Published: 09 March 2022

Social responsibility perspective in public response to the COVID-19 pandemic: a grounded theory approach

• Lee Lan Low 1 ,
• Seng Fah Tong 2 ,
• Ju Ying Ang 3 ,
• Zalilah Abdullah 1 ,
• Maimunah A Hamid 4 ,
• Mikha Saragi Risman 1 ,
• Yun Teng Wong 1 ,
• Nurul Iman Jamalul-lail 1 ,
• Kalvina Chelladorai 1 ,
• Yui Ping Tan 1 ,
• Yea Lu Tay 1 ,
• Awatef Amer Nordin 1 &
• Amar-Singh HSS 5  

BMC Public Health volume  22 , Article number:  469 ( 2022 ) Cite this article

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Combating viral outbreaks extends beyond biomedical and clinical approaches; thus, public health prevention measures are equally important. Public engagement in preventive efforts can be viewed as the social responsibility of individuals in controlling an infectious disease and are subjected to change due to human behaviour. Understanding individuals’ perception of social responsibility is crucial and is not yet explored extensively in the academic literature. We adopted the grounded theory method to develop an explanatory substantive theory to illustrate the process of how individual responded to the outbreak from a social responsibility perspective.

In-depth interviews were conducted among 23 Malaysians either through telephone or face-to-face depending on the participant’s preference. Both purposive and theoretical sampling were used. Participants were invited to share their understanding, perceptions and activities during the COVID-19 pandemic. They were further probed about their perceptions on complying with the public health interventions imposed by the authorities. The interviews were audio-recorded and transcribed verbatim. Data was analysed via open coding, focus coding and theoretical coding, facilitated by memoing, sketching and modelling.

Study findings showed that, social responsibility is perceived within its role, the perceived societal role responsibility. In a particular context, an individual assumed only one of the many expected social roles with their perceived circle of responsibility. Individuals negotiated their actions from this perspective, after considering the perceived risk during the outbreak. The four types of behaviour depicted in the matrix diagram facilitate the understanding of the abstract concept of negotiation in the human decision-making process, and provide the spectrum of different behaviour in relation to public response to the COVID-19 pandemic.

Conclusions

Our study adopted the grounded theory approach to develop a theoretical model that illustrates how individual response to COVID-19 preventive measures is determined by the negotiation between perceived societal role responsibility and perceived infection risk. This substantive theoretical model is abstract, thus has relevance for adoption within similar context of an outbreak.

Peer Review reports

COVID-19 caught the world’s attention when it was declared a pandemic by the World Health Organisation (WHO) [ 1 ]. With its rapid spread within and between countries, COVID-19 was classified as a public health emergency of international concern that required a systematic international response [ 2 ]. COVID-19 is caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which is a novel coronavirus similar to SARS-associated coronavirus (SARS-CoV) and Middle East Respiratory Syndrome Coronavirus (MERS-Cov) that infect the respiratory tract and cause severe respiratory infections. In December 2019, the disease was first reported in Wuhan City, China, in a wholesale food market and infected different groups of people such as stall owners, market employees and regular visitors [ 3 ]. Previously, Malaysia experienced a Nipah virus outbreak from September 1998 to May 1999 which resulted in 265 human cases affected and substantial economic loss to the pig-farming industry [ 4 , 5 ]. Other viral disease outbreaks such as H1N1 and SARS have also affected Malaysia, but none have caused as deep an impact on society as the current COVID-19 pandemic. Similar to other countries, Malaysia has faced challenges in containing the virus and in urging the general public to comply with preventive measures introduced by the government. The first measure that was implemented was the restriction of entry visas from Wuhan City after three Chinese citizens tested positive for COVID-19 in Malaysia on 25th January 2020 [ 6 ]. Subsequently, with the rapid rise in local cases, a country level lock-down with a Movement Control Order (MCO) was implemented starting on 18th March 2020, raising the alarm of potential threat to national security [ 7 , 8 , 9 ].

An MCO is only effective if there is adherence by the public as the virus spreads via human-to-human transmission. With the increasing burden of cases in the country, mirroring the spread that also occurred internationally, an urgent focus of the government was to prevent the spread and reduce the number of infected cases, thus relieving the strain on health resources. Various preventive measures such as the use of face masks, personal hygiene, restriction of travelling and physical distancing were necessary since vaccines are only just becoming available [ 10 ]. The outbreak occurred in an unprecedented manner, causing a burden that was felt by every level of the society. Members of society were urged to assume relevant responsibilities in controlling the spread of this disease, by complying with the MCO. Nevertheless, the action of each individual in adhering to the MCO may vary depending on each person’s perceptions of the disease. Thus, solely relying on community mitigation measures during a pandemic has limitations as it is difficult to change habitual behaviour such as hygiene and social interaction [ 11 ]. An evaluation of public knowledge and perception of SARS in Hong Kong showed that enhanced personal hygiene and health protective measures relied critically on public psychological responses and widespread perceptions and beliefs of the community at large [ 12 ]. The research group found considerable misinformation and false beliefs among the community in Hong Kong at an advanced stage of the SARS epidemic, despite the wide coverage and substantial mass media and public service announcements. Hence, public perception is very important in improving health risk communication, building public trust and cooperating with the government’s preventive effort to control an outbreak [ 13 ].

Combating viral outbreaks extends beyond biomedical and clinical approaches; thus, public health prevention measures are equally important. Hence, it is essential to understand the Malaysian public response to COVID-19 preventive measures. Malaysians should practise social responsibility by complying with the Standard Operating Procedure (SOP) and guidelines imposed by the government [ 9 , 14 ]. Public engagement in preventive efforts can be viewed as the social responsibility of individuals in controlling an infectious disease [ 15 ] and are subject to change due to human behaviour. While human behaviour is complex, many health behaviour models have been developed to understand health, behaviour and health system phenomena by incorporating various features of individuals, communities and organisations. Other health behaviour models include the health belief model [ 16 ] and the COM-B model [ 17 ]. Although the health belief model was established to study health-related phenomena [ 18 , 19 , 20 ], it has a limitation that it does not directly incorporate societal features such as social norms and community assumptions, which are assumed in underlying demographic factors [ 21 ]. The COM-B model introduced Capability, Opportunity and Motivation into a model by focusing on promoting individual behaviour adherence to public health interventions [ 22 ].

Studying human behaviour extends beyond the individual’s level and it involves examining collective efforts and societal participation. Understanding how people conceptualise social responsibility during an outbreak can provide useful information for improving future preventive and control interventions. Hence, this study aims to explore public conceptualisation of social responsibility and to develop a model explaining the role of social responsibility during the early COVID-19 pandemic in Malaysia.

Study design

In-line with the aim of developing an explanatory substantive theory explaining the role of social responsibility during the early COVID-19 outbreak, the grounded theory methodology was adopted [ 23 ]. An in-depth interview (IDI) was used to capture emic perspectives and provided a detailed account of a person’s view, reactions (personal responsibility) and social processes (social responsibility) among the general public during the early COVID-19 outbreak in Malaysia. The purposive sampling strategy was used with the intention of exploring a range of individuals from various social backgrounds and different experiences encountered in relation to the current pandemic. Subsequently, the theoretical sampling was applied to aid the saturation of the model, which enabled enrichment of data that could illustrate the process of how individuals perceived societal role responsibility within the outbreak environment. This led to the identification of a ‘core category’ for this study and the theoretical saturation.

Recruitment & participants

Participants were purposively recruited from different demographic backgrounds to elicit their diverse experience during the early COVID-19 outbreak. Potential participants were identified from the social networks of the research team as well as referrals by the social network among their friends. All participants selected resided in different locations within Malaysia when the interview was conducted. In total, 23 Malaysian adults with various sociodemographic were interviewed. Figure  1 shows the locations of study participants.

Malaysia map with locations of the selected participants. *Notes: respondents = study participants

Data collection

The interviews were conducted between March to July 2020 by researchers who were trained in qualitative method. The movement restriction order that was implemented during the worsening stages of COVID-19 outbreak in Malaysia [ 8 ] limited physical accessibility to conduct face-to-face interviews. This limitation was surmounted by conducting telephone interview. Hence, only one IDI was conducted face-to-face at the workplace based on the participant’s request, while the other 22 IDIs were through telephone interviews. A semi-structured interview guide was developed to facilitate IDI sessions, containing a list of questions pertaining to the understanding of COVID-19, “perceptions on the outbreak progression and consequences of the outbreak on everyday lives and activities”, “experiences and perceptions upon searching for and receiving COVID-19 information”, further probing to explore their “ways in handling the information received and reasons behind their actions”. Participants were also asked about their “activities and perceptions in complying with the public health interventions imposed by authorities during the outbreak”. The interviews sessions lasted between 25 and 110 min. They were conducted either in English, Malay or Mandarin language depending on the participant’s preference. Participant information sheet which included study objective, the purpose of the interview and the interview process was shared through email or WhatsApp message prior to the interview and informed consent was obtained from all participants. Assurance of confidentiality was given that data would be used only for this study. All IDIs were transcribed verbatim and cross-checked against audio recording by another team member to ensure accuracy of the transcripts. Data collection continued until data saturation. Upon interviewing 23 participants, no new emerging theme was observed from two consecutive IDIs. No repeat interviews were carried out since the information gaps were probed in the subsequent interviews.

The interviews were audio-taped as permitted by the participants, transcribed and imported into the Nvivo 11 (Qualitative data analysis computer software) to facilitate data analysis. Participants’ identifiers were replaced with researcher-assigned codes to maintain the anonymity of the transcripts prior to analysis. Data analysis began immediately after the first interview. Theoretical saturation was observed and achieved after 23 interviews, whereby no new categories were found to add further understanding of the complex human behaviour and social responsibility in facing the early COVID-19 outbreak. Data analysis involved various stages of coding, memoing, sketching and modelling. Coding began with open coding, followed by identifying categories and grouping. The coding process started with immersion in the data, whereby the texts were read several times before they were coded. Focus coding was carried out subsequently, followed by a theoretical coding. Eventually, the core category was identified, and the study theoretical framework was conceptualised. The core category “negotiation” was identified based on its ability to subsume the main categories in explaining the entire process of an individual’s conceptualisation of social responsibility and how they exercised their social responsibility.

The research team consisted of multi-disciplinary researchers with various experiences, composing those with experience in behavioural sciences (medical anthropologist), public health and clinical research, health systems research and primary care services. Trained in qualitative research and interviewing techniques, all research team members are fluent in English and Malay languages and a few are also fluent in Mandarin.

Ethical considerations

This study was registered with the National Medical Research Register (NMRR-20-574-54389). Ethical approval was granted by the Medical Research and Ethics Committee, Ministry of Health Malaysia (KKM/NIHSEC/ P20-701(7)). Participants’ identity and data confidentiality were assured throughout the data collection. Informed consent to participate and permission for audio recording were obtained from all participants prior to interviews.

The results of this study were obtained from in-depth interviews with 23 individuals from the general public between March to July 2020 in Malaysia. Table  1 summarises the characteristics of the participants. More than half were female (69.6%), Malay ethnic group (52.2%) and 78.3% of them had at least a tertiary education level. They ranged from 29 to 73 years old, work as public civil servants (39.1%), in private sector (39.1%) and 21.8% were retirees.

From the perspective of an individual’s obligation to act for the benefit of society, the participants conceptualised social responsibility from two dimensions: (1) the individual perceived roles in their society, and (2) the individual perceived circle of responsibility. To finally exercise social responsibility would involve individuals considering the perceived risk of infection.

The individual perceived role defines their actions. The extent of the action regarding the level of societal involvement depends on how wide a person casts his or her circle of responsibility in the society. Individuals often hold multiple roles; thus, their respective circles of responsibility vary, as are their actions. The individuals’ perception of infection risk is constructed from their response to information received and their self-efficacy in possible risk modification. Under a pandemic circumstance, the recommended preventive measures such as movement restriction, personal hygiene and the use of protective equipment are negotiated from this perspective of societal role responsibility. The negotiation involves reaching an agreement [ 24 ] and in the context whether one would decide to take the preventive measures deemed necessary. This negotiation is produced by the intersection between societal role responsibility and perceived infection risk.

Figure  2 shows the theoretical model, which illustrates that the individuals’ actions of social responsibility are a result of the intersection between perceived infection risk and societal role responsibility. These two are negotiated. The individuals’ perceived infection risk is constructed from their response to the information received and their self-efficacy in risk modification.

Public response to preventive measures from social responsibility perspective during the COVID-19 outbreak

Perceived societal role responsibility

The societal role is the perception of an individual. This role varies according to the context and current time since it depends on the type of relationship involved. A person can be a member of a workplace, family or society. Each role has a sense of responsibility attached to it, with obligations to be carried out by the individuals as members of the society. The type of relationship determines how far a person casts his or her circle of responsibility. There are two dimensions of societal role responsibility: the perceived role and the circle of responsibility.

Perceived role

The perceived role, which comes with a set of expected behaviours and conduct, influences a person’s decision in determining the best action [ 25 ]. A person can and often has multiple roles, but they only assume one role at a moment in time. For example, a person could be a mother who may also be a healthcare worker and an event host. Depending on her role in each situation, she would assume the role of a mother or a healthcare worker and think of the best interest for her children in some situations, and patients in other situations respectively.

A groom’s mother who was expected to take care of the guests’ safety in a wedding function stated the following:

“I am a mother, who was just about to organise my son’s wedding at that time. It was…not MCO yet, but it’s still in warning status…where we can still organise feast…. we’d like to hold the wedding…but in a safe way, as you would have to invite a lot of guests.” (P09, female, 52 y/o).

If a person became the host for a social event, he or she would be responsible for the comfort and safety of the guests. Despite his or her desire to host the event during the outbreak, the person was driven to consider the safety of others. Therefore, on the basis of the guests’ safety, he or she might cancel the event.

A social event host who was expected to take responsibility for his guests’ safety expressed:

“I wanted to keep it going but I was persuaded by my family to cancel it. I wasn’t really concerned about the epidemic, but it was getting serious and I got scared. What if the virus infected other people?” (P05, male, 29 y/o).

Similarly, a grandmother perceiving her responsibility towards the health of her grandsons stated:

“We always wear the mask, even for small kids, my little grandson. I wear it for him even though he doesn’t want to.” (P23, female, 61 y/o).

Circle of responsibility

The circle of responsibility depends on the size of the person’s definition of his or her social responsibility. There is a continuum of self, which is the smallest circle of responsibility, to as large a definition of society as one can perceive. The large circle of responsibility can stretch to include the global society and produce a more ‘collective effort’. The word ‘circle’ indicates that the circle can expand to a degree at the personal, society, national or global levels. Thus, the definition of this circle is personal, and defining it involves identifying the weight an individual would place on the importance of his or her personal goals such as health, enjoyment, life value, financial matters and societal relationship.

“[I wear] a mask because we [healthcare provider] are contacting patient in hospital, so we have… to protect ourselves” (P13, female, 33 y/o).

With the same act of adhering to public health measures, a large circle of responsibility expands beyond the self with the intention of avoiding spreading the disease to others.

“When I’m back from work or the supermarket, I must clean myself before meeting my family. I’m staying with my mom. When I’m back, I’ll shower before meeting her because as an elder, she’s at-risk group.” (P21, female, 45 y/o).

The “perceived societal role responsibility” cannot, by itself, explain a person’s societal behaviour regarding the pandemic; however, it forms the foundation for negotiation with a person’s perceived infection risk for an action he or she would take for preventive measures. While an intention to act may be present, the decision to act is balanced with the perceived infection risk.

Perceived COVID-19 infection risk

Since the content of pandemic information includes risk of exposure and the protective measures, the perceived infection risk among members of the society is an outcome of an individual’s assessment of how high the risk of contracting the infection and the possibility of reducing the risk through protective measures. Before the government announced COVID-19 mitigation strategies, some individuals developed early risk perception and practised preventive measures after discovering local disease spread. However, other individuals perceived the risk only when the government enforced an MCO, indicating an imminent risk of infection. With increasingly government intervention, which indicated a widespread disease transmission, individuals began to perceive a higher risk of infection and considered reducing the risk through some protective measures.

“When it began to spread here [in Malaysia] at that time…two weeks before the Prime Minister announced [the MCO], I was already scared of…this virus. Then, I started wearing a mask.” (P07, female, 61 y/o).

“I was a person that not really taking serious about this [pandemic], but when the government started to announce the lock-down or the movement restriction, that kind of [action] make me nervous… [that was] the point where I think… I have changed from not care to… give more concerned about it.” (P05, male, 29 y/o).

How an individual comprehends the disease risk depends on a few factors:

Reliability of information source

Insight into COVID-19 serves as the starting point from which an individual understands the risk and determines how to respond. Initially, COVID-19 information was available from multiple sources, allowing a person to create his or her personal perception of the information. The source and type of COVID-19 information varied, each carrying a different weight and reliability as perceived by the individual. At one end of the information spectrum is the verified information from credible sources such as announcements by health authorities and global news. An individual tends to value such information, especially the information received from recognised sources and media.

“I used to buy newspapers every day. So, usually I read papers, and then you see in the TV, the CNN and…other news.” (P02, male, 73 y/o).

In contrast, unverified social media such as Twitter, WhatsApp and Facebook are also sources of information for the public. However, the information from these sources carried less weight and was perceived as being less reliable.

“At that time, they (from Facebook) said that [MAEPS 8,24 ] was for those who came back from overseas (quarantine centre). Then, I WhatsApp my sister…because those who stayed in Malaysia knew better about it (to verify the information).” (P23, female, 61 y/o).

The source and type of COVID-19 information ranged from newspaper reports to individual opinions from respectable professionals. These sources were considered in variable weight and reliability.

“We have a number of people in our group…who are politicians and doctors. There are public health doctors in the group as well. All of us… [thought that] it’s okay to go to Australia… after all, Australia is safer than Malaysia. All the reports [showed that]… all the cases in Australia were in Sydney, Gold Coast, not in Perth. We were prepared to go actually…” (P03, female, 64 y/o).

The perceived risk of contracting the infection from public exposure

Risk through public exposure is perceived as how easy an individual could contract the infection while in public places. An individual perceived risk based on risk characteristics such as the infectious nature of the disease, proximity of infection based on the geographical spread, the similarity of social-cultural factors among infected individuals and one’s own susceptibility due to health status. A high perceived infection risk indicates that the infectious agent was easily spread, as well as positive cases were occurring in close proximity and in similar socio-cultural setting. A person also perceived high risk after assessing a location with high incidence of cases within their surroundings.

“At first, when I looked at the Wuhan [condition]…I wasn’t afraid yet, I thought it only happened in Wuhan and wouldn’t reach Malaysia, it’s just Wuhan.” (P07, female, 61 y/o).

“Once it reached Malaysia, I mean, Wuhan and Malaysia are far from each other. So, when it reached Malaysia, it’s quite bad… I assumed that it could be prolonged and turn into a pandemic.” (P11, female, 29 y/o).

“I did not take this [COVID-19] seriously…and then there was actually…a new virus. They firstly say it comes out from the wild animals where they [people in China] eat wild animal… Malaysian less likely to take these wild animals.” (P04, female, 33 y/o).

Possibility of risk modification through protective measures

An individual’s perceived infection risk could also be altered by their confidence in adopting some protection measures. The possibility of an individual engaging in risk modification is a personal evaluation of the effectiveness of protective measures, which may or may not be according to recommended guides or SOP. Confidence in protective measures is developed when the outcome of practising protective measures was evaluated and perceived as successful compared to the absence of protective measures.

“I have confidence in preventive measures because…before this, my child went to a childcare centre…mingled with other kids, who had fever and everything. So, my child always gets a fever. When he was staying at home, he never had any fever. I believe in… the importance of social distancing to protect us from COVID-19.” (P21, female, 45 y/o).

The negotiation

Public response to the COVID-19 pandemic, which was reflected by their actions during the pandemic, was preceded by their corresponding intentions to act. The intentions were constructed from their perceived societal role responsibility. These intentions to finally complete the act were negotiated after they considered their perception of the risk of infection. As part of the ‘negotiation’, placing a heavy weight on one’s self in the societal role responsibility may tilt the balance towards an act that benefits one’s own agenda over infection risk. For instance, a person could undervalue infection risk over an important social event.

“…but then again at that time, [it was] not so serious that you would protest against an assignment or project… So, that’s why I took the flight anyway.” (P14, male, 33 y/o).

A person has the autonomy to decide what is best for himself or herself amidst the outbreak and the government’s restriction order. Hence, his or her decision also illustrated how far a person could align himself to societal goals without disregarding personal goals.

“I’m worried because… the reception cannot be carried out. If we postpone [the wedding ceremony], we would never know when coronavirus is going to end. It could take one year, two years…five or six months. So, it would have been postponed due to an endless thing.” (P18, female, 33 y/o).

In a different context, a person’s perceived societal roles vary, as does the perceived infection risk. Figure  3 illustrates these negotiations and the resulting range of actions from a spectrum quadrant of the the two factors of perceived societal roles and perceived infection risk. The spectrums include the following: perceived high infection risk and small circle of societal role responsibility; perceived high infection risk and large circle of societal role responsibility; perceived low infection risk and small societal role responsibility; and perceived low infection risk and large societal role responsibility.

Intersection between perceived societal role responsibility and COVID-19 infection risk

Quadrant 1 Perceived high infection risk and perceived small circle of societal role responsibility

Perceived high risk of infection during a pandemic, places an individual at a “threatened” state of mind, thus invoking one’s “safeguarding” or “protecting” nature. However, from the perspective of a small role and circle of responsibility, the action was negotiated within the context of oneself and his or her safety, resulting in containing the action without intending to influence the behaviour of others.

“We have to get prepared [to wear a mask]… because the awareness of people around us is not very high, so we have to protect ourselves.” (P13, female, 33 y/o, perceived role: self).

Quadrant 2 Perceived high infection risk and perceived large societal role responsibility

Similarly, for a person who perceived a high infection risk with the perspective of a large role and circle of responsibility, the focus of his or her concerns expanded from oneself to others, especially those within the circle of care. The individual’s action was negotiated towards a proactive approach, aiming to mitigate others’ exposure to infection risk or influence others to reduce risky behaviour.

“If I go [abroad] and know that Spain is already very badly affected, I don’t want to be one of the culprits that bring back the virus. I think that [is] very irresponsible… Even though I self-quarantine at home, I don’t think it’s good…” (P06, female, 58 y/o, perceived role: a responsible citizen).

Quadrant 3 Perceived low infection risk and perceived small societal role responsibility

Perceived low risk of infection and small societal role responsibility placed an individual at ease and did not invoke the need to protect oneself or the society from the disease. As such, a perceived low infection risk of infection did not trigger an individual to adhere to preventive measures. The actions were negotiated for the benefit of oneself, guided by personal needs and interests. He or she was less concerned with the consequences of their actions on the society.

“Well, there’s nothing to be afraid of… I had this sea license by [the authority] when [the police] asked me where to go; I would just tell him that I am going to catch cockle. Our hobby is to go out to sea…and no one spreads (virus) to you.” (P17, male, 63 y/o, perceived role: self).

Quadrant 4 Perceived low infection risk and perceived large societal role responsibility

A person who perceived a low infection risk might not discern the necessity to negotiate a change of action or decision that has been made thus far. However, adequate information necessary for carrying out risk modification would be negotiated with the perceived large society role responsibility of a person. Eventually, some protective measures were adopted, and the benefit and safety of others would be taken into consideration.

“…rumours said that MCO might be enforced. People began asking me if the wedding would be continued. Since there’s no announcement yet, if Allah wills, we would continue it but after the announcement, we updated them that we could only do the marriage ceremony specifically for closed family members.” (P18, female, 33 y/o, perceived role: a host).

Action – response to COVID-19 preventive measure

Action is the outcome of the negotiation between perceived societal role responsibility and perceived infection risk. An individual might take preventive measures by complying with the SOP such as wearing a mask, cancelling his or her social event, avoiding crowded places and reducing activities or social events. However, the notion of social responsibility for each action was shaped by the negotiation. As the conceptualisation of social responsibility differs across individuals, a person’s action during a pandemic may also vary contextually.

Another action a person can take is sharing information. In a specific situation, such as the COVID-19 outbreak, delivering information about the outbreak or preventive measures was similar to risk communication. However, there was a sense of control over information sharing. For example, a healthcare worker acted as a gatekeeper for information that he or she received directly from his or her work organisation. Whether or not the worker should share information with family members or friends depended on his or her personal decision.

“Sometimes when I get news from MKN [National Security Council] or CPRC [National Crisis Preparedness and Response Centre] which I feel should be shared with my family members or friends, I will do that.” (P08, female, 56 y/o).

A person’s action can also help prevent the spread of infection for self-protection or for public good. A person who perceived a larger societal role responsibility included the safety of oneself and others in his or her actions to prevent the spread of infection by adhering to specific SOPs.

“The best thing is just to try to avoid gathering, because I got…two risk [groups]… My father-in-law…they are old….and my kids. So, I don’t want to be infected by this thing and bring it to my family.” (P15, male, 35 y/o).

The individual’s action is generally similar for those who perceive high infection risk, but there is a variation in explaining their actions from the perspective of social role responsibility. He or she would generally adhere to guidelines during a pandemic. However, one’s actions vary considerably when he or she perceives low infection risk.

This study developed a substantive theoretical model to illustrate the process of how individuals responded to an early COVID-19 outbreak from the perspective of social responsibility. Individual response to COVID-19 was directly constructed from their perceived societal role responsibilities and further negotiated after considering the risk of infection. “Negotiation” was identified as an important intersection within this process. The different spectrums of social responsibility within an individual and among the society during the pandemic were noted to be the foundation for this negotiation to take place.

A pandemic urgently requires multi-disciplinary teams to work together, including and not limited to public health, clinical scientists, pharmaceutical industry and health policy specialists. The public also plays a significant role in mitigating the situation. Hence, understanding human behaviour is equally important since personal behaviour is a key factor in reducing the transmission of respiratory viruses [ 22 ]. Social scientists have acknowledged the importance of understanding the COVID-19 pandemic response from the social and behavioural lens and have highlighted some insights for outbreak preparedness [ 26 ]. Other public health frameworks such as the Health Belief Model [ 16 , 21 ] and the COM-B Model [ 22 ] may provide behaviour diagnosis and reinforce mitigation behaviours during the outbreak of COVID-19 through careful arrangement of compliance with public health measures. The Health Belief model [ 21 ] focuses on the perceived threat, benefits, barriers and efficacy in mitigating the COVID-19 infection and focuses on the person’s perception of the disease; however, the health belief model does not incorporate society perspective although the pandemic is a condition closely related to the society [ 16 ]. The COM-B model has described a wide range of principles that can encourage individuals to engage in COVID-19 preventive behaviour [ 22 ]. The COM-B model indicates that preventive behaviour can only be practised when an individual has both the capability and the opportunity to show this behaviour; individuals are more motivated to choose personal protective behaviour. It shows that three components (Capability, Opportunity and Motivation) are closely linked to a person’s behaviour. COM-B model states that capability and opportunity are the primary parts of the model; however, during the MCO period, capability and opportunity were present, variation in behaviour remain.

Our model provides the additional contextual perspectives of the effect of infection risk, societal role and responsibilities perceived by individuals in negotiating behaviour for preventing COVID-19 infections. The government and many other authorised agencies may play a crucial role in influencing individual health behaviour but only to some extent. Our model implies that individuals exercise autonomy in determining which action to take when mitigating COVID-19 infection. Motivation to modify behaviour is contextual since it is derived from perceived societal role responsibility and infection risk. Our model provides a contextual relevance of undesirable behaviours. The MCO is seen as an undesirable event, and there was a tension between self and society as highlighted in our model. The important process of “negotiation” results in variation of behaviour, corresponding to perceived infection risk, whether low or otherwise. Importantly, our model presents a novel context – the context of pandemic; furthermore, it shows that undesirable behaviour is easy to engage with during the pandemic. Thus, capability and opportunity as highlighted in the COM-B model can be applicable during this situation. However, motivation varies across individuals, which is where our model offers substantive value.

Social responsibility is a perceived value which is significantly apparent across layers of society. However, application of social responsibility is commonly understood at the corporate level, which is defined as “any ‘responsible’ activity that allows a firm to achieve a sustainable competitive advantage, regardless of motive” [ 27 , 28 ]. The individual perspective is equally important. From the same perspective, collective efforts in facilitating health improvement have gradually emphasised personal control over individual health behaviour through health education in order to create a collective social responsibility [ 29 ]. Such efforts were driven by the assumption that each individual could change societal norms through their habits or modifications of their lifestyles [ 30 ]. In 1986, the WHO promoted health as “a process of enabling people to increase control over, and to improve their health” [ 31 ]. The conventional health education is disease-oriented and has been used extensively in managing communicable and non-communicable diseases. In this study, we found the individual’s perspective was useful in analysing public health interventions during a pandemic situation. We found that an individual’s action is shaped by the tension between individual agenda and social responsibility, before the negotiation with perceived infection risk. This model provides a framework for Malaysian social responsibility during the COVID-19 outbreak and insights into understanding the interplaying elements. The time frame of the interviews was in the early stages of the outbreak in Malaysia, around the same time the MCO commenced; this was considered in the analysis of the findings. Nevertheless, these perceptions depict an early visualisation of individuals’ response to a pandemic and potentially shifts accordingly as the pandemic progresses.

Policy implication, strengths and limitations

In terms of policy implication, our model explains that the action of a person during the early COVID-19 pandemic was the outcome of the “negotiation” between perceived societal role responsibility and perceived risk infection. In order to influence an individual’s response to an outbreak, the information provided to the public needs to articulate the exact role a person should play. Associations and organisations can empower members of the society by emphasising their potential roles during the pandemic and recommend actions. However, the spectrum of social responsibility in a different context indicates that human behaviour is complex, and a person’s action is influenced by the negotiation within a person. Hence, risk communication strategies could incorporate the element of negotiation, with clear SOPs that portray the importance of social responsibility during a pandemic. Authority figures could optimise various platforms to play their specific roles, such as an educator, adviser, or informer to alert society members and protect the public. Our model is useful for developing new norms during a pandemic and future intervention for behaviour change by emphasizing human negotiation behaviour.

By adopting a grounded theory approach, this study provides a substantive theory derived from emerging empirical data that attempts to explain the societal role responsibility during the COVID-19 outbreak. To enhance the theory, the sampling strategy used purposeful and theoretical sampling to ensure a maximum variation of demography and data collection within the context of an outbreak. In addition, the findings from this study can provide insight to various stakeholders, from health managers to policy makers, to strengthen preparedness for future outbreaks by understanding the spectrum of individual behaviours. The results from the ground up yielded valuable information with relevance to an outbreak context. Nevertheless, the context was in Malaysian, in the early stages of the outbreak, when resources and economic factors were not a major issue.

The role of social responsibility has not been explored extensively in the academic literature, though it has been mentioned by country leaders and in risk communication materials. Our study adopted the grounded theory approach to develop a theoretical model that illustrates how individual response to early stage of COVID-19 preventive measure is the outcome of the negotiation between perceived societal role responsibility and perceived infection risk. The matrix diagram with the four types of behaviour facilitates the understanding of the abstract concept of negotiation in individual’s decision-making process. It also provides the spectrum of different types of behaviour in relation to public response to the COVID-19 pandemic. Although the model was conceptualised during the early stage of COVID-19 outbreak in Malaysia, we believe the model has relevance for adoption within the similar context of a disease outbreak.

Availability of data and materials

The dataset that support the findings of this article belongs to this study (The role of social responsibility during COVID-19 outbreak, NMRR-20-574-54389). At present, the data are not publicly available but can be obtained from the corresponding author and Head of Centre for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia on reasonable request and with the permission from the Director General of Health, Malaysia.

Abbreviations

Capability, Opportunity and Motivation Behaviour

in-depth interview

Movement Control Order

Middle East Respiratory Syndrome Coronavirus

Severe Acute Respiratory Syndrome Coronavirus 2

Standard Operating Procedure

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Acknowledgements

The authors would like to thank the Director General of Health Malaysia for the permission to publish this paper. The authors are also immensely grateful to all participants who participated in this study. We would like to thank Mr Jabrullah AB Hamid, the GIS analyst for generating image for the purpose of this publication.

This study was made possible with funding from the National Institutes of Health, Ministry of Health Malaysia research grant [(110)KKM/NIHSEC/800-3/2/2 Jld.10]. Publication of this article was sponsored by the Ministry of Health Malaysia. The funder is a stakeholder of the study but did not participate in the study process.

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Lee Lan Low, Zalilah Abdullah, Mikha Saragi Risman, Yun Teng Wong, Nurul Iman Jamalul-lail, Kalvina Chelladorai, Yui Ping Tan, Yea Lu Tay & Awatef Amer Nordin

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LLL (Principal Investigator for this project), TSF, ZA, NIJ, KC, TYL, ASH were involved in conception and design of this study. LLL, AJY, ZA, NIJ, KC, TYP, AAN were involved in data collection, LLL, TSF, AJY, ZA, MAH, MSR, WYT, NIJ, KC, TYP, TYL, AAN contributed to the data analysis. LLL, TSF, AJY, ZA, MAH, MSR, WYT, ASH involved in drafting and writing the manuscript. All authors read and approved the final version of manuscript for publication and agreed to be responsible for all aspect of the manuscript that in ensuring that questions related to accuracy or integrity of any part of the manuscript are appropriately investigated and resolved.

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Low, L.L., Tong, S.F., Ang, J.Y. et al. Social responsibility perspective in public response to the COVID-19 pandemic: a grounded theory approach. BMC Public Health 22 , 469 (2022). https://doi.org/10.1186/s12889-022-12819-4

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Disease-preventive behaviors and subjective well-being in the COVID-19 pandemic

• Matthew Tokson   ORCID: orcid.org/0000-0002-3192-173X 1 ,
• Hadley Rahrig   ORCID: orcid.org/0000-0003-0175-8262 2 &
• Jeffrey D. Green 3  

BMC Psychology volume  11 , Article number:  288 ( 2023 ) Cite this article

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Safety precautions and activity restrictions were common in the early, pre-vaccine phases of the COVID-19 pandemic. We hypothesized that higher levels of participation in potentially risky social and other activities would be associated with greater life satisfaction and perceived meaning in life. At the same time, prosocial COVID-preventive activities such as mask wearing should enhance life satisfaction.

We assessed the impact of COVID-preventive behaviors on psychological well-being in October 2020. A nationally representative sample of U.S. adults ( n  = 831) completed a demographic questionnaire, a COVID-related behaviors questionnaire, a Cantril’s Ladder item, and the Multidimensional Existential Meaning Scale. Two hierarchical linear models were used to examine the potential impact of COVID-preventive behaviors on life satisfaction and meaning in life while accounting for the influence of demographic factors.

The study revealed significant positive relationships between COVID-preventive behaviors and subjective well-being. Wearing a mask was significantly associated with higher life satisfaction, while maintaining social distancing of six feet and avoiding large groups were significantly associated with higher perceived meaning in life. Social activities including dining at restaurants and visiting friends and family were also significantly associated with higher life satisfaction and meaning in life, respectively.

The study’s findings support the conclusion that disease prevention measures such as social distancing and mask wearing do not reduce, and may enhance, subjective well-being during a pandemic. Utilizing the unique context of the COVID-19 pandemic to examine relationships between behavior and subjective well-being, the study also indicates that shallow or medium-depth social activities are likely to be more central to life satisfaction, whereas narrower, deeper social interactions with friends and family are more important to perceived meaning in life.

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The early, pre-vaccine period of the COVID-19 pandemic gave rise to several atypical behavioral responses, including social distancing, mask wearing, and the avoidance of indoor social activities. These behaviors likely slowed the spread of COVID and greatly reduced the loss of life. Yet these actions and restrictions may come with substantial psychological costs. Socialization, work, and non-verbal communication via facial expression have been associated with psychological well-being, and restrictions on these behaviors may negatively impact psychological health and disincentivize engagement in public health behaviors (E.g., [ 1 , 2 , 3 ]). The present study explores this potential trade-off by examining the impact of COVID-avoidant behaviors on psychological well-being.

In the fall of 2020, the “third wave” of the COVID-19 pandemic was beginning to rise. A surge of cases began in the Upper Midwest in September 2020. It soon spread to the entire nation, and continued to rise rapidly throughout the fall and early winter, eventually becoming the deadliest wave of the pandemic to date. It lasted for months until acquired immunity, warmer weather, and the availability of vaccines led the wave to finally recede in the early spring of 2021 [ 4 ]. The present study was conducted during the early portion of this period, in October of 2020.

Responses to the COVID-19 pandemic varied widely across different nations, with some countries imposing and enforcing aggressive behavioral restrictions and others imposing moderate restrictions on businesses and some legal restrictions on personal behavior. The United States adopted a primarily voluntary approach to addressing COVID, with relatively few government restrictions on individual behavior and very little enforcement of those restrictions [ 5 ].

Correspondingly, COVID-preventive behaviors such as mask wearing and social distancing were largely undertaken voluntarily in the United States, as well as many other western countries. These behaviors appear to have been motivated by the circumstances of the pandemic, and especially by rising infection rates, rather than by legal requirements or government policies [ 6 , 7 ]. Accordingly, self-reported mask wearing was associated with significantly reduced COVID transmission in a study of several countries, but mask mandates were not [ 8 ].

Throughout the pandemic, social distancing, mask wearing, and other measures taken by individuals were somewhat effective in slowing the spread of COVID, according to existing studies and assessments [ 7 , 8 , 9 ]. However, these measures may be associated with some degree of psychological harm. Socializing with others, close contact and touch, going to work, exercising at a gym, and caring for family members can all contribute to psychological well-being, and restrictions on these behaviors may reduce psychological health [ 2 , 3 , 10 , 11 , 12 ]. Mask wearing, notwithstanding its substantial health benefits in a pandemic, may be physically unpleasant or may engender feelings of restriction or anxiety [ 13 , 14 ]. Mask wearing also proved politically controversial, as sporadic anti-mask protests arose across the country in 2020 and some mask skeptics engaged in violent noncompliance with indoor mask mandates [ 15 , 16 ]. Some researchers have theorized that masks may reduce well-being by impairing social interactions and reducing empathy and comprehension, or by increasing pandemic-related stress or depression [ 13 , 17 ].

On the other hand, people are generally psychologically resilient, and even substantial changes to their daily routine may not, on average, significantly decrease their life satisfaction [ 18 ]. Although the precise mechanisms of this resilience are unknown, complete or partial psychological adaptation to adverse circumstances has been observed in numerous settings [ 19 , 20 , 21 , 22 ]. Consistent with this phenomenon, overall levels of life satisfaction remained stable during most of 2020, dropping in the first month or so of the pandemic but then largely returning to the same level as in previous years (e.g., [ 1 , 18 , 23 ]). Yet it is unknown whether COVID-avoidant behaviors raised or lowered life satisfaction for individuals. The unusual circumstances of the pandemic and widespread COVID-related behavioral restrictions provide a unique context in which to study the effects of various behaviors and responses on well-being.

Well-being, behavior, and the pandemic

Subjective well-being (SWB) refers to people’s cognitive and affective evaluations of their lives [ 24 ]. SWB can take several forms, from positive affect and emotion, to satisfaction with one’s life, to engagement in interesting activities, to experiencing life as meaningful. The present study examines two central aspects of SWB, life satisfaction and meaning in life, each of which has been widely studied (e.g., [ 10 , 22 , 25 , 26 , 27 ]).

Life satisfaction refers to the subjective cognitive assessment of a person’s life as a whole [ 28 ]. Judgments of satisfaction generally involve a comparison of one’s circumstances with one’s internally chosen criteria for a good life [ 29 ].

Perceived meaning in life refers to a cognitive and emotional assessment of whether one’s life has purpose and value [ 28 ]. It examines the subjective experiences of human beings and asks what makes them experience meaning in their lives [ 30 ]. In recent years, a consensus has formed around a tripartite definition of perceived meaning in life. Under this definition, lives are experienced as meaningful when they are felt 1) to have purpose, 2) to have significance, and 3) to be coherent [ 26 , 30 , 31 , 32 ]. Purpose refers to having goals, direction, or a mission in life that extends into the future. Significance refers to feelings of existential mattering, feelings of mattering in the social world, and a sense of generativity, i.e., making contributions to others that extend beyond one’s personal existence [ 30 , 31 ]. Coherence involves making sense of one’s experiences in life, based on an integrative understanding of one’s self and the world [ 33 , 34 ]. Together, these concepts reflect the larger concept of a meaningful life, a life that makes sense, has purpose and larger goals, and matters in the larger social or existential sense. The present study examines life satisfaction and meaning in life in the context of the COVID-19 pandemic.

To date, there has been little research on COVID-avoidant behaviors and SWB. Newman et al. (2021), found that higher meaning in life scores on a single-item survey question were associated with more engagement in a broad set of preventative health behaviors and less engagement in risky health behaviors in the earliest months of the pandemic [ 35 ]. That study did not examine relationships between meaning and individual behaviors. The study did find that preventive health behaviors were positively associated with negative affect, likely because cancelling social plans and avoiding others increases negative feelings. Risky health behaviors, like socializing with others outside the home, were negatively related to negative affect, presumably because they enhance emotional well-being [ 35 ]. Baños et al. (2023), found that meaning in life decreased over time in a longitudinal study conducted in Spain during a strict lockdown period [ 36 ]. Meaning stopped decreasing and plateaued during the subsequent twenty days, as restrictions on movement were gradually relaxed.

A handful of studies conducted during the COVID pandemic have examined the effects of specific behaviors on well-being, although these studies do not assess COVID-specific behaviors such as mask wearing or social distancing. In a study of 55,204 UK adults conducted in the early weeks of the pandemic, time spent working, volunteering, doing housework, gardening, exercising, reading, engaging in hobbies, and communicating remotely with family and friends were all associated with increased life satisfaction [ 37 ]. In a study of Irish adults ( n  = 604) conducted March 2020, spending time outdoors, exercising, gardening, pursuing hobbies, and taking care of children were associated with greater emotional well-being, while time spent home-schooling children was associated with reduced emotional well-being [ 38 ]. A study conducted in China in February 2020 found that respondents ( n  = 369) who continued working in an office had higher life satisfaction than those who had stopped working [ 39 ].

In non-pandemic contexts, research linking social interactions and personal activities to higher SWB suggests that a decrease in such activities may be associated with reductions in SWB (e.g., [ 28 , 37 , 40 , 41 ]). Relatedly, prosocial behaviors have often been associated with increased SWB. Giving money or other forms of assistance to others has been linked to greater happiness and meaning in life in a variety of observational and experimental studies [ 42 , 43 , 44 ]. Behaviors such as charitable giving are associated with higher SWB [ 42 , 43 , 44 ], and altruistic COVID-preventive activities such as mask-wearing may also benefit well-being.

The present study

The primary goal of the present study was to examine COVID-avoidant behaviors in the midst of the pandemic and to examine the relationship between these behaviors and the life satisfaction of American adults. A secondary goal of the study was to investigate the relationship between COVID-avoidant behaviors and perceived meaning in life. Understanding how various behaviors interact with these forms of SWB can shed light on the sources and correlates of well-being. By examining the strength of relationships between pandemic-related behaviors and these forms of SWB, we may be able to better understand which aspects of daily life are associated with well-being, and how everyday behaviors are linked to psychological welfare. Based on prior findings indicating that activities, especially social-interactive activities, are associated with elevated SWB, we hypothesized that higher levels of participation in activities such as going to work, visiting friends and family, attending church, going to the gym, and going to restaurants would be associated with greater life satisfaction and greater meaning in life. Conversely, we expected that COVID-preventive practices that reduce social contact, such as remaining six feet away from others or avoiding indoor gatherings of ten or more persons, would be negatively associated with life satisfaction (e.g., [ 41 ]). The relationship between these activities and meaning in life is more ambiguous, as higher meaning in life has been linked to increased social distancing in the early months of the pandemic [ 35 ]. Mask wearing during a pandemic is in part a prosocial, altruistic behavior, which we expected to be associated with enhanced life satisfaction (e.g., [ 42 , 43 ]). The overall correlation between mask wearing and life satisfaction was uncertain, however, given the inconvenience, anxiety, and social inhibition potentially associated with mask wearing [ 13 , 14 , 17 ]. Based on prior studies of the early pandemic period, we expected that mask wearing behavior would have no significant correlation with meaning in life [ 35 ].

Participants and procedure

The study participants were a nationally representative sample of 831 United States adults from all regions of the country recruited by Qualtrics. Qualtrics compiles samples from various market and academic research panels. The survey took, on average, approximately 8.5 min to complete, and participants were compensated $4 upon completion. Participants signed an electronic consent form and completed an online survey. Of the 1019 participants originally recruited for the study, participants who failed to answer questions, completed the survey unfeasibly quickly, or failed a bot screening test were screened out and not included in the analysis ( n  = 188). In addition, 60 respondents completed an early version of the survey that did not include the Multidimensional Existential Meaning Scale (MEMS) questions, 5 respondents did not report their age, and 6 respondents did not complete all COVID behavior questions. Missing data were addressed via pairwise deletion.

Sample size selection was guided by similar, prior survey-based study designs [ 38 , 45 , 46 ]. Post-hoc sample size estimation [ 47 ], using the conservative parameters of 5% margin of error, 50% response distribution, and a 99% confidence interval, suggested a minimum N of 643 was adequately powered to detect modest effect sizes. Accordingly, recruiting 1000 participants is appropriate assuming a retention rate of 70%, to account for low quality responses.

All instruments and procedures were approved by the University of Utah’s Institutional Review Board. Participants were asked a series of questions about demographics and COVID-related behaviors, and they completed the SWB measures described below. Surveys were administered from October 14–27, 2020. Table 1 presents the demographic characteristics of the participants.

Behavioral measures

Questions regarding COVID-related behaviors were adapted from prior surveys conducted by the CDC as well as private research groups [ 48 , 49 , 50 ]. Respondents were asked about their health-related behavior “recently” with respect to remaining 6 feet away from others outside of those they live with (the then-standard social distancing recommendation), avoiding groups of 10 or more persons, and wearing a mask indoors, with potential responses ranging from “Always,” “Often,” “Sometimes,” “Rarely,” to “Never.” Respondents were asked about the frequency of their activities outside the home in the past month with respect to working in an office, socializing with friends or extended family, attending religious services indoors, and going to a gym, with potential responses ranging from “Every day”, “At least weekly”, “1–3 times,” to “Never.” Finally, respondents were asked about eating at restaurants, with responses assessing whether dining was indoors or outdoors, and if it occurred regularly, infrequently, or never.

• Life satisfaction

Life satisfaction was measured using Cantril’s Ladder, a single question assessing quality of life that asks respondents to rate their current life on a 0 to 10 scale where 10 represents the best possible life for them. It is a widely used single-item measure that shows reliability and convergent validity [ 51 , 52 , 53 , 54 ].

Meaning in life

Subjective meaning in life was measured using the Multidimensional Existential Meaning Scale (MEMS), a 15-item instrument that measures perceived meaning in life. Respondents answered each question on a 5-point scale, indicating their agreement with statements about meaning from 1 (Strongly Disagree) to 5 (Strongly Agree). The scale assesses the three aspects of meaning in life that are most often identified as central in the meaning literature: purpose, comprehension (i.e. coherence), and mattering [ 25 , 30 , 31 ]. Though relatively new, MEMS has already been used in several SWB studies (e.g., [ 55 , 56 ]). MEMS is reliable and demonstrates convergent and discriminant validity. Each of its subscales helps to predict variance in other meaning in life measures, suggesting that each is crucial to the overall meaning in life construct [ 25 ].

Demographic predictor variables with 3 or more levels were dummy-coded prior to being entered into the model. Variables coded for white race and graduate degree-holding were removed from the model due to concerns of multicollinearity (Tolerance < 0.10; VIF > 10). Assumptions were met for univariate and multivariate normality, linearity, and normality of distributed errors were checked and met. Standard residual analyses were conducted with plots indicating that assumptions of homoscedasticity were met. Data met the assumption of independent errors (Durbin-Watson values = 2.048 and 1.99). Two hierarchical linear models (HLMs) were used to examine the potential impact of COVID-avoidant behaviors on two measures of SWB (i.e., Life Satisfaction and Meaning in Life) while accounting for the influence of demographic factors (i.e., income, age, gender, marital status, military status, and education), given documented broad influence of sociodemographic characteristics on well-being outcomes [ 57 , 58 , 59 ]. Accordingly, unique associations between demographic factors and SWB were tested in step 1. In step 2, COVID-avoidant behaviors were entered into the model to examine the association between such behaviors and SWB while accounting for variance attributed to demographic factors. Two-tailed significance tests (α = 0.05) were Bonferroni corrected. HLM analyses were completed using SPSS 28.

Table 2 presents the mean scores and Cronbach’s α for each subjective well-being measure. The mean Cantril’s Ladder life satisfaction score for all participants was 6.48 out of 10 ( SD  = 2.54). The mean MEMS meaning score ( n  = 771) was 3.78 out of 5 ( SD  = 0.72), with subscale means of 3.81 ( SD  = 0.83) for comprehension, 3.91 ( SD  = 0.77) for purpose, and 3.59 ( SD  = 0.77) for mattering.

Table 3 presents descriptive statistics from our sample regarding COVID-avoidant behaviors during October 2020. In addition, 38.9% of respondents reported that they never ate at restaurants during the pandemic, while 11.6% reported eating only outdoors and only occasionally, 7.5% reported eating only outdoors regularly, 22.5% reported eating indoors occasionally, and 19.4% reported eating indoors regularly.

To evaluate the degree to which different COVID-avoidant behaviors affected SWB when controlling for demographic characteristics (e.g., income, age, gender, marital status, military status, and education), a hierarchical linear model was computed. The first level of the model indicated that demographic covariates collectively correlated with life satisfaction scores, F (13, 808) = 5.93, p  < 0.001, adjusted R 2  = 0.072. Adding COVID-avoidant behaviors to the model significantly improved adjusted R 2 , ΔR 2  = 0.024, ΔF(8, 800) = 2.74, p  = 0.005, and accounted for 2.4% greater variance in life satisfaction scores. All variables together were significantly related to Cantril’s ladders scores, F(21, 800) = 4.78, p < 0.001, adjusted R 2  = 0.088. Among COVID-avoidant behaviors, life satisfaction was significantly correlated with wearing face coverings (β = 0.087, t(800) = 2.17, p  = 0.03), restaurant attendance (β = 0.089, t(800) = 2.03, p  = 0.043), and attending religious services (β = -0.12, t(800) = 2.22, p  = 0.027). Model coefficients and parameter estimates are reported in Table 4 . See Supplement Table 1 for a full report of parameter estimates.

An additional hierarchical linear regression was conducted to determine if and to what degree COVID-avoidant behaviors influenced meaning in life, as indexed by mean subjective ratings on the MEMS scale, while controlling for demographic characteristics. The first model suggested that demographic variables alone significantly affected meaning in life, F(13, 754) = 9.37, p  < 0.001, adjusted R 2  = 0.124. Thus, 13.9% of the variance in subjective meaning in life was accounted for by demographic variables alone. Adjusted R 2 was significantly improved by adding COVID-related behaviors to the model, ΔR 2  = 0.089, ΔF(8, 746) = 10.774, p  < 0.001, and contributed 8.9% greater explanation of variance. The full model accounted for 22.8% of the variance in meaning in life ratings, F(21, 746) = 10.506, p  < 0.001, adjusted R 2  = 0.207. Investigation of parameter estimates indicated that after controlling for demographic variables, subjective meaning in life was significantly related to maintaining 6 feet of social distance (β = 0.11, t(800) = 2.75, p  = 0.006) and avoiding groups of 10 or more persons (β = 0.084, t(800) = 2.09, p = 0.037). However, avoiding friends and family members due to COVID was significantly, negatively linked to meaning in life (β = -0.20, t(800) = -4.45, p < 0.001). Controlling for demographic and other COVID-avoidant behavior revealed a small significant negative correlation between meaning in life and avoiding friends and family (i.e. semipartial r  = -0.16). Model coefficients and parameter estimates are reported in Table 5 . A full report of parameter estimates is shown in Supplement Table 2 .

Associations with life satisfaction and meaning in life

Several altruistic anti-COVID measures were positively associated with subjective well-being. Mask wearing was significantly associated with life satisfaction, while social distancing and avoiding large gatherings were significantly associated with meaning in life. The prosocial contributions to life satisfaction of these social distancing measures may be counterbalanced to some degree by a negative impact of avoiding shallow social interactions. Meaning in life, by contrast, may not be affected by the loss of relatively shallow social interactions.

The positive association between mask wearing and life satisfaction may be a function of the prosocial nature of mask wearing, as people who feel connected with their community may be more likely to wear a mask to protect their fellow community members [ 60 ]. It is also possible that wearing a mask itself enhanced life satisfaction in the fall of 2020. It may have done so by making the wearer feel as though they were acting for the benefit of others [ 42 , 43 , 44 ], or by reducing anxieties regarding COVID that otherwise reduced life satisfaction among individuals who voluntarily chose not to wear a mask (e.g., [ 13 ]).

Higher levels of participation in social activities were associated, albeit non-significantly in most cases, with higher life satisfaction scores. Restaurant attendance was significantly associated with greater life satisfaction, even after adjusting for income level. Restaurant attendance may serve as a useful proxy for socialization with friends or enjoying the simple pleasures of pre-pandemic life.

Frequency of religious service attendance was negatively associated with life satisfaction scores when controlling for other variables. This was surprising, given the positive correlation found in prior studies between religious practices and life satisfaction [ 61 , 62 ]. The pandemic may have reduced the number of people who regularly attend religious services, lessening the communitarian benefits of attending such services that likely play an important role in the correlation between religious practice and well-being [ 62 ]. Alternatively, persons suffering from lower life satisfaction might be more apt to risk illness to attend religious services in search of consolation.

Visiting friends and family outside of the home was associated with higher meaning in life, indicating that social and familial connections are an important foundation of meaning [ 28 , 63 ]. But shallower or more casual social interactions do not appear to be a basis of meaning in life. In fact, maintaining six feet of distance from others outside the home and avoiding groups of ten persons or more were positively and significantly associated with higher meaning in life scores. This may reflect a positive relationship between engaging in altruistic behaviors and greater perceived meaning in life [ 44 ]. In addition, coupled with the positive association between visiting friends and family, it suggests that meaning in life was strongest among persons who formed small, tight-knit groups of friends and family while avoiding larger groups and maintaining social distance from strangers. In the pre-vaccination COVID era, some people formed “pods” of trusted friends and family while avoiding spending substantial time with others outside of the pod [ 64 ]. This type of social grouping, especially in difficult circumstances, may produce greater perceived meaning in life relative to other social arrangements or practices. While there is a lack of empirical evidence on the effects of such pods, some pod participants have noted the deeper social connections and feelings of closeness associated with the pods and expressed regret at their dissolution as COVID risks decreased [ 64 ].

Contrasting correlates for life satisfaction with correlates for meaning in life suggests that shallow or medium-depth social interactions and activities like dining in restaurants may be more central to life satisfaction, while deeper and narrower social interactions with family and friends are more central to meaning in life. In addition, fostering a small, tight-knit social group is likely an effective strategy for maintaining well-being during adverse world events. Such social groupings may increase perceived meaning in life and, perhaps as a result, help maintain life satisfaction [ 27 ]. Meaning in life is also a central aspect of people’s conception of a good life, independent of any effect on life satisfaction [ 65 ], and promoting it in adverse circumstances can enhance overall quality of life for an affected population. More broadly, these findings can help shed light on the foundational sources of psychological meaning or life satisfaction, a burgeoning area of research (e.g., [ 22 , 66 ]). The absence of a relationship between shallow social interactions and meaning in life, for example, can help refine previous hypotheses that social interaction generally enhances perceived meaning (e.g., [ 31 , 67 ]). The importance of shallow social interactions to life satisfaction may in part explain why many people to return to baseline levels of life satisfaction following the loss of a deep relationship [ 22 ].

This study’s findings, though correlational, suggest that disease prevention measures such as social distancing and mask wearing do not reduce, and may increase, SWB for adults during the early to middle stages of a pandemic. Authorities should not hesitate to encourage such measures out of concern for reduced well-being. It may also be helpful to emphasize the prosocial, charitable aspects of disease prevention measures, which could encourage people to adopt such measures or help increase SWB among those who do [ 42 , 68 ].

Authorities might also use the present study as a template for measuring important aspects of subjective well-being in the midst of a pandemic. Such measures could help to gauge the psychological health of a population in real time and uncover the direction and strength of relationships between public health measures and subjective well-being. By accurately measuring the psychological effects of disease-preventive measures, authorities may be able to determine when such measures become counterproductive, or when compliance with legal mandates or non-mandatory public health guidance is likely to decline.

Subjective well-being scores in a pandemic

The present study assessed subjective well-being in a nationally representative sample of US adults in October 2020—a critical moment in time during the pandemic. Generally, life satisfaction was relatively low compared to scores reported prior to the COVID-19 pandemic. The mean Cantril’s Ladder score of 6.48 was significantly lower than mean scores reported in comparable prior studies. It was significantly lower on a two-sample t-test than the average Cantril’s ladder scores of 6.94 (SD = 2.58, n  = 3,000, p < 0.001) in surveys of U.S. adults conducted annually from 2017 to 2019, and the 7.03 score (SD = 2.53, n  = 1,006, p  < 0.001) in a survey conducted largely after March 15, 2020 [ 23 ]. This may in part reflect the tendency of respondents to report relatively higher SWB scores in live or telephone interviews and relatively lower SWB scores on questionnaires or online surveys, such as the one used in the present study [ 69 , 70 , 71 ]. Alternatively, it may reflect a decrease in life satisfaction or general well-being over the long course of the COVID-19 pandemic [ 72 ].

Meaning in life scores were, by contrast, relatively high compared to those reported prior to the COVID-19 pandemic. For example, on a two-sample t-test, the average MEMS score of 3.78 in the instant study was significantly higher than that reported in a pre-COVID study of 262 MTurk participants. Suh & Chong (2022), reported a mean MEMS score equivalent to 3.3 out of 5 (SD = 0.90, p  < 0.001) [ 73 ]. Interestingly, MEMS meaning in life scores in the instant study were significantly lower on a two-sample t-test than those in a study conducted in April 2020, during the first full month of the pandemic in the United States. That study found among 575 US adults on MTurk an average MEMS score equivalent to 3.86 out of 5, significantly higher than the 3.78 score in the instant study (SD = 0.75, p  = 0.047) [ 74 ].

These patterns may reflect a phenomenon that has begun to emerge in surveys of meaning in life: negative life events, personal struggle, and difficult situations may counterintuitively increase perceived meaning in life while also reducing subjective happiness or life satisfaction. For example, perceptions of struggle and stress may correlate with relatively higher levels of perceived meaning and lower levels of happiness [ 28 ]. Material deprivation was also correlated with higher meaning in life scores in surveys comparing average national scores between richer and poorer nations [ 75 ]. In general, people appear to engage in processes of meaning restoration following threats to their well-being [ 76 , 77 , 78 ]. They may do so in a variety of ways, such as interpreting a difficult situation to fit with their existing concepts of global meaning; revising their global beliefs to accommodate a new situation; achieving a sense of acceptance of a difficult new reality; and cultivating personal growth, improved relationships, better coping skills, or greater appreciation for life [ 79 ]. In studies controlling for the effects of happiness, stress and negative life events actually increased perceived meaning in life, possibly because of these meaning-making coping behaviors [ 28 ].

Reported rates of COVID-preventive behaviors were high, with a supermajority reporting frequent mask use and social distancing behaviors. This is consistent with the findings of prior studies conducted during the summer and fall of 2020 [ 6 , 7 ]. Respondents reported high rates of gym and church attendance, at rates similar to those reported in non-academic surveys conducted before and during the pandemic [ 80 , 81 , 82 , 83 ].

Limitations

The present study relies on self-reports of COVID-related behaviors, which may not match respondents’ actual behaviors. However, in public health studies, self-reports of COVID-related behavior were strongly and significantly correlated with objective indicators of behavior. For example, self-reported mask wearing was significantly associated with reduced COVID transmission, even when mask mandates themselves were not [ 8 ]. Likewise, self-reported social distancing measures were significantly associated with fewer steps recorded by an iPhone pedometer app activated on the phones of all study participants [ 84 ].

Respondents may overreport activities such as going to the gym because gym attendance is generally considered to be socially desirable. In addition, while our question was carefully phrased (“In the past month, how often did you go to a gym outside of your home?”) some respondents may have construed it as inquiring about how often they exercised outside of their home. Church attendance is also commonly overreported, and actual attendance may be far lower (as much as 50% lower) than reported attendance [ 85 ]. The social desirability of church attendance may motivate respondents to overreport, especially respondents who identify as religious believers [ 86 ].

One limitation of comparing our SWB scores to those reported in other studies is that, in general, comparing scores obtained in the present study to those obtained in prior studies using similar or different methods is an inexact process, as subtle differences in survey design or administration may account for some of the differences between survey scores. Further surveys of subjective well-being during various points of the pandemic and the post-pandemic era would help to confirm the effects discussed here.

The present study did not assess respondents’ Big-5 personality traits (e.g., [ 87 ]). Accordingly, it cannot rule out the possibility that personality traits drive both COVID-related behavior and SWB levels, confounding the relationship between them. This limitation regarding the potentially confounding nature of personality is a common one in studies of behavior and SWB [ 28 , 42 , 43 , 63 , 88 ]. In addition, individuals with high levels of life satisfaction may value their lives more highly and be more likely to take preventative health measures such as wearing a mask. While we posit that mask wearing is more likely correlated with prosociality or directly improves life satisfaction by alleviating anxiety, we cannot rule out this possibility.

An additional limitation of the present study was that it did not determine respondents’ political affiliations. COVID-avoidant behaviors likely differed based on the political affiliations of individuals even prior to vaccine roll-outs. For example, Gollwitzer et al. (2020), reported that US counties that voted for Donald Trump over Hillary Clinton in 2016 exhibited 14% less physical distancing as measured by smartphone geolocation data between March and May 2020 [ 89 ]. The present study cannot rule out that political differences might drive both divergent COVID-related behavior and differences in SWB scores. Evidence is mixed on the relationship of partisanship to SWB [ 90 , 91 ]. Some studies have indicated that self-identified conservatives generally report higher SWB than self-identified liberals [ 92 ], while more recent studies have found no significant difference [ 93 ]. It is possible that conservative respondents were more likely to report higher SWB, and this effect may account for the positive associations reported for restaurant attendance and visiting friends and family. However, the theory that conservatism is driving both fewer COVID precautions and higher life satisfaction scores is not consistent with our data showing that mask wearing is positively related to life satisfaction scores, or that church attendance [ 94 ] is negatively related to such scores. Likewise, a theory that conservatism explains both fewer COVID precautions and higher meaning in life is not consistent with the correlation between social distancing practices and higher meaning in life scores.

Although the COVID pandemic is constantly changing, as are people’s behavioral responses to it, major world events can provide opportunities for researchers to examine relationships between subjective well-being and behavior in unique contexts. The present study examines these relationships in the unique environment of the United States in October 2020. It finds significant positive relationships between COVID-preventive behaviors and subjective well-being. This study’s findings support the conclusion that disease prevention measures such as social distancing and mask wearing do not reduce, and may enhance, subjective well-being during a pandemic.

Further, by comprehensively assessing subjective well-being in the midst of a pandemic, the present study can help shed light on how populations respond psychologically to adverse, nationwide events. The study indicates that shallower social activities are likely to be more central to life satisfaction, while narrower, deeper social interactions are likely to be more important to perceived meaning in life.

Availability of data and materials

The dataset supporting the conclusions of this article is available in the figshare repository, https://doi.org/10.6084/m9.figshare.21514056 .

Abbreviations

Multidimensional existential meaning scale

Subjective well-being

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Supplement Table 1. Results of Full Hierarchical Regressions of Cantril’s Ladder Scores. Supplement Table 2. Results of Full Hierarchical Regressions of MEMS Scale Meaning in Life Scores.

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Tokson, M., Rahrig, H. & Green, J.D. Disease-preventive behaviors and subjective well-being in the COVID-19 pandemic. BMC Psychol 11 , 288 (2023). https://doi.org/10.1186/s40359-023-01316-x

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COVID-19 behavioral health and quality of life

• Tonya Cross Hansel 1 ,
• Leia Y. Saltzman 1 ,
• Pamela A. Melton 1 ,
• Tanisha L. Clark 1 &
• Patrick S. Bordnick 1  

Scientific Reports volume  12 , Article number:  961 ( 2022 ) Cite this article

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In addition to concern about physical health consequences of COVID-19, many researchers also note the concerning impact on behavioral health and quality of life due to disruption. The purpose of this paper is to explore pathways of COVID-19 behavioral health and quality of life. We found increased anxiety, depression, and alcohol misuse and that the pandemic exacerbated prior problems. Further community indicators also lead to poorer behavioral health and overall decreased quality of life. The nature of COVID-19 and vast reach of the virus suggests that behavioral health concerns should take a primary role in pandemic recovery.

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Introduction

Decreased cases and death rates, along with increased vaccination coverage rates and lifted restrictions, are all markers that the COVID-19 pandemic is nearing the recovery phase of disaster response. While many are looking forward to their new normal or returning to pre-pandemic lifestyle, continued threat, vaccine uncertainties, and strain variation serve as cautionary reminders that the global pandemic is ongoing. Regardless of how long it takes for full recovery, more than a year of heightened fears, loneliness, economic consequences, and grief suggest that behavioral health will have longer term consequences 1 . In disaster mental health, when the threat has dissipated and individuals move out of survival mode, behavioral health problems become more apparent, and consequently services, such as psychoeducation, therapy and brief treatments, are needed 2 , 3 .

Limited research from previous pandemics suggest demographic indicators of poorer mental health, specifically for females, youth, and lower education levels 4 , 5 . Pandemic-related resource loss also contributed to mental health problems, including increased work, family, and financial stress coupled with decreased social support 4 , 6 , 7 . Direct exposure to the virus, including being a healthcare worker, being sick, or having sick family members, all had elevated symptomatology 8 , 9 , 10 , 11 . Whether it is a social determinant, exposure to SARs, H1N1, and Ebola help understand that pandemics can result in elevated and long lasting mental health symptoms 6 , 9 , 12 .

Early studies from the COVID-19 pandemic identify similar concerns to past pandemics regarding mental health 5 , 13 , 14 , 15 . Age appears to be a predictor of mental health problems—younger adults have more difficulty 16 , 17 , 18 , 19 . However, another study found that persons older than 85 years had worsened mental health, suggesting a potential U-shape distribution 20 . Female study participants also tend to report higher symptomatology 21 , 22 , 23 . Financial loss, lack of social interactions, and COVID-19 experiences also contribute to mental health concerns, which is consistent with past pandemics 21 , 23 , 24 . Overall studies point to increased mental health problems; yet there is limited information beyond demographics and COVID-19 disruption on factors that contribute to concerning outcomes.

Substance use

One particular concern is the increase in unhealthy coping mechanisms, such as alcohol misuse. Long-term disasters like the current pandemic place individuals and communities at increased risk for exhausting positive coping skills and turning to negative ones such as alcohol misuse 25 , 26 , 27 . Numerous studies report increases in stress, anger, anxiety, and depression, resulting in substance abuse and relapse post disaster 28 , 29 , 30 , 31 . For example, data from the National Survey on Drug Use and Health from 2007–2011 indicate that alcohol and marijuana use increased post disaster 32 , which may have resulted from perceived or real loss of income, loss of confidence in authorities, and loss of one's culture or way of life 33 . Given these experiences are likely to occur during the pandemic 2 , 34 , there is an emergent need to understand the magnitude and impact of these negative factors on alcohol misuse from COVID-19.

Physical health

Adverse physical health conditions (e.g. respiratory problems, headaches, musculoskeletal problems, and somatic complaints) are the most commonly reported symptomology among disaster survivors 35 , 36 . A study of Hurricane Ike survivors concluded that 45.1% of the study population exhibited functional impairment in performing essential daily living skills (e.g. maintaining social connectedness and academic and work-related responsibilities), 52.6% reported poor health (e.g. disability), and 74.9% experienced depression 37 . Similarly, the 2019 novel coronavirus disease (COVID-19) global pandemic is a disaster of unprecedented measure. Individuals have feared for self and family members' well-being, have been socially isolated from family and friends, and have endured interrupted, prolong, and unresolved grief 2 , 38 , 39 . Consequently, behavioral symptoms (e.g. depression, anxiety, and psychological distress) are increasingly prevalent among COVID-19 survivors, and behavioral health symptoms are also underdiagnosed, undertreated, and under researched 40 .

In addition to having an increased prevalence of behavioral health concerns, COVID-19 survivors have an increased prevalence of comorbid conditions that lead to worsened clinical outcomes 41 . Empirical evidence supports a bidirectional link between mental health and physical health, thereby increasing the risk of comorbid sequelae for disability, morbidity, and mortality, a frequent cause of emotional distress, and is associated with a diminished quality of life for COVID-19 survivors 19 , 42 .

Quality of life

Quality of life and overall well-being are highly attributed resources available and can be a protective factor for mental health. In studies following flu epidemics, those recovering reported decreased quality of life 43 , 44 . Recent COVID-19 studies have shown the interconnection of quality of life and mental health problems for recovery 45 . Liu and colleagues 46 found that individuals with prior mental health problems had poorer health-related quality of life and reported more COVID-19-related disturbances. An early study found an increase in positive well-being since COVID-19, but it may have been due to looking at their past rather than future perceptions 47 . Other studies have shown significant declines in subjective well-being 48 and quality of life 49 . Studies have shown that well-being may be beyond the individuals and influenced more by socio-environmental and community factors, such as GDP, healthcare access, and pandemic communication and response 50 , 51 . Quality of life and well-being are important to foster and are of great concern for individuals and for overall community recovery.

In a systematic review of recent studies regarding COVID mental health, common risk factors associated with mental distress during the COVID-19 pandemic include female sex, 40 years of age or younger, presence of mental or physical illnesses, and financial loss or unemployment 12 . However, only one study included U.S. participants, and more studies are needed to better inform local recovery plans regarding additional protective factors. Behavioral health is important for overall individual well-being, and also plays a role in collective prevention and risk 52 . The purpose of this paper is to explore pathways of COVID-19 behavioral health and quality of life. We hypothesize behavioral health indicators will have increased from 2019 population estimates and from participant perceived problems prior to COVID-19.

Sample selection for this cross-sectional study included responses from April 7, 2020, through July 26, 2020, and respondents ages 18–65. Electronic recruitment was conducted through Tulane University School of Social Work website and media promotions requesting voluntary participation through a Qualtrics link. Participants gave virtual consent by continuing the online survey and were informed they could skip any questions or stop at any time—there was no compensation for time. Adults (18 years of age or older) and access to the technological platform were the only limiting factors. The SAMHSA national hotline was provided at the end of the survey to connect participants with resources or if they incurred distress. Tulane University Institutional Review Board approved study protocol and were performed in accordance with relevant guidelines and regulations.

Demographics (age, race, marital status, and income) were collected, along with participants completed dichotomous pre-existing COVID items. Participants were asked if they experienced mental health, physical health, or alcohol problems prior to the COVID-19 pandemic. In addition, valid measures of behavioral health, quality of life, and COVID impact were used.

Behavioral health

Behavioral health was assessed by anxiety, depression and alcohol misuse. Anxiety was measured by the General Anxiety Disorder 2 item scale, which asks in the past 30 days, were participants bothered by 1) feeling nervous, anxious, or on edge; and 2) not being able to stop or control worrying 53 . The GAD2 cut point was 3 and 53% met the cut-off ( M  = 4.9, SD  = 1.9; α = 0.88). Depression was measured with the 2-item Patient Health Questionnaire, which asks if, in the past 30 days, participants were bothered by 1) little interest or pleasure in doing things and 2) feeling down, depressed, or hopeless 54 . The PHQ2 cut point was 3 and 28% met the cut-off ( M  = 3.9, SD  = 1.7; α = 0.86. Alcohol misuse was measured by the CAGE, which asks participants if, in the past 30 days, they have: 1) felt you should C ut down on drinking; 2) been A nnoyed when people have commented on drinking; 3) felt G uilty or badly about your drinking; 3) had an E ye opener first thing in the morning to steady your nerves or get rid of a hangover 55 . The CAGE cut point was 1 and 14% met the cut-off; ( M  = 0.4, SD  = 0.9; κ = 0.66.

Overall quality of life was measured with items selected from the World Health Organization WHOQOL-BREF quality of life assessment 56 . Participants were asked how good or satisfied they have felt over the last 2 weeks with their: quality of life, health, sleep, performance of daily living activities, capacity for work, conditions of your living place, and access to health services ( M  = 25.1, SD  = 4.9; α = 0.74).

Impact was assessed through COVID experiences and COVID disruption. Participants were asked to respond to whether they had experienced the following as a result of COVID 19: loss of usual way of life, social isolation, work from home, children and adolescents being out of school, loss of income or revenue, personal health effects, participated in response or emergency services, and COVID-19 suspected or diagnosed, loss of job or business, COVID-19 diagnosis. A COVID experience index was created where 1 point was given for experiences listed. Items for the COVID disruption were adapted from the Sheena Disability Scales 57 . Participants were also asked to what degree the pandemic had disrupted their work/school life, social/leisure activities, and family/home responsibilities activities ( M  = 11.6, SD  = 2.4; α = 0.61).

Community behavioral health

County-level data was accessed from the Robert Wood Johnson Better Health Data 58 . Data were matched to participants’ zip codes and included: percentage of excessive drinking, average number of mentally unhealthy days, and average number of physically unhealthy days. County-level COVID death and diagnosis rates through October 2020 were also accessed from the Center for Disease Control COVID Data Tracker 59 .

Participants

The participants ( N  = 296) represented many states, including Louisiana (55%), Texas (6%), California (5%), Florida (3%), Georgia (3%), Illinois (3%); 2% percent from Mississippi, Pennsylvania, Virginia, North Carolina, and Massachusetts; and 1% from New Jersey, New York, Arizona, Iowa, Maryland, Michigan, Missouri, Connecticut, South Carolina, Kentucky, Ohio, Minnesota, Oregon, Washington; and less than 1% (0.3%) representation from Rhode Island, Delaware, Alabama, Tennessee, Indiana, Wisconsin, Nebraska, Colorado, Wyoming, Alaska.

The minimum age was 19 and the maximum was 65 ( M  = 43.6, SD  = 12.5); 85% identified as women, 14% as men, and 1% as nonbinary. Participants were allowed to select multiple racial/ethnic identities, the majority identified as White (86%); 8% identified Black or African American, 6% were Latinx, Latin@ or Hispanic, 3% identified as Asian, and 1% identified as Native American or Alaskan Native. The median 2019 income was $60,000– $69,999. All participants had at least a high school education (18%) and 72% had a 4-year or professional degree, 10% had a doctorate. The majority of participants (65%) were married or cohabitating; 26% were single, 8% were divorced or separated, and 1% were widowed.

Data analysis

Data analyses were conducted using Statistical Package for the Social Sciences (SPSS) version 27. Point biserial correlations were conducted among COVID-19 experiences and behavioral health variables. McNamara Chi square analyses were conducted to compare current cut-off scores (meeting cutoff for either anxiety or depression) or alcohol misuse cutoff with previous mental health and substance use problems. One sample Z tests were used to compare participant cut-off scores (anxiety, depression, and alcohol misuse) with 2019 population estimates. Zero order (Pearson product moment) correlations were conducted to assess associations among variables. The structural model was tested using SPSS analysis of moment structure (AMOS) version 27. Assumptions of normality and linearity were met; missing data was less than 5% and imputed using linear interpolation. Significant zero-order correlation paths were added to the model but did not reveal good fit (RMSE > 0.05). After reviewing regression weights, the dichotomized married versus nonmarried and minority versus nonminority were removed due to their lack of contribution to the model.

Prior behavioral health concerns were asked and 30% noted physical ( n  = 88) health problems, 29% mental health problems, and 4% substance use problems. Results suggest an increase in current mental health concerns (33%), compared to preexisting problems (25%), Χ 2 (1) = 37.61, p  < 0.001. Current alcohol use (12%) was also increased over previous substance use (2%), Χ 2 (1) = 16.42, p  < 0.001. Increased levels of anxiety 53% compared to 16% for 2019 population estimates 60 , Z (296) = 17.4, p  < 0.001. Increased levels of depression 28% for moderate compared to 19% for the population estimates 61 , Z (296) = 4.4, p  < 0.001. Alcohol misuse (14%) was also increased compared to 2019 population estimates (6%) of heavy alcohol use 62 , Z (296) = 5.6, p  < 0.001.

Participants were asked to report on COVID-19 experiences. Over one third of respondents reported COVID-19 experiences as social isolation, working from home, loss of income, and children and adolescents being out of school (see Table 1 ). Participants noting social isolation and personal health effects had higher anxiety and depression and lower quality of life. Participants with suspected or diagnosed COVID-19 reported more alcohol misuse and lower quality of life (see Table 1 ).

Zero order correlations are presented in Table 2 . COVID-19 experiences and disruption were associated with increases in anxiety and depression and decreased quality of life. Younger participants reported more COVID-19 experiences and prior mental health concerns. Anxiety and depression were positively associated, and both were negatively associated with quality of life, suggesting that as depression and anxiety increase, quality of life decreases. Current anxiety and depressive symptoms were associated with prior physical and mental health problems. Females and whites reported more anxiety, while higher income was associated with higher quality of life scores. Respondents with higher anxiety scores lived in communities with a higher number of physically unhealthy days.

Respondents who reported prior physical health problems were older, had more alcohol misuse, had decreased quality of life, and were less likely to live in communities with excessive drinking. Respondents who reported prior mental health problems had lower quality of life, lower incomes, and were younger. As current alcohol misuse increased, depression increased, and respondents also tended to live in communities with higher COVID-19 rates. Individuals reporting prior substance use problems had higher alcohol misuse scores, were less likely to be married, and reported prior mental health problems. Communities with more physically unhealthy days also had increased percentages of excessive drinking. Respondents who were older lived in communities with higher numbers of physically unhealthy days. Respondents with lower 2019 income reported higher depression. They were more likely to live in communities with more physically and mentally unhealthy days. Communities with higher COVID-19 rates also had higher averages of mentally and physically unhealthy days and percentages of excessive drinking.

Structural model

The final model was acceptable given the smaller sample size and use of dichotomous pre COVID-19 behavioral health variables, χ2 (93) = 123.7, p  = 0.018, CFI = 0.976, RMSEA = 0.033 (lower 0.15, upper 0.48); PNFI of 0.623, suggests the overall model accounts for approximately 62% of the variance in behavioral health and quality of life. Table 3 presents the path coefficients and model estimates. The largest contributors to the model are as follows: mental (β = 0.39, p  < 0.001) and physical health (β = 0.24, p  < 0.001) problems prior to COVID-19 were predictive of current mental health (latent variable including anxiety and depression). Mental health was predictive of quality of life (β = -0.55, p  < 0.001). Younger age was predictive of prior mental health problems (β = -0.31, p  < 0.001). Prior substance use problems were predictive of current alcohol misuse (β = 0.29, p  < 0.001) and COVID-19 disruption was predictive of mental health (β = 0.42, p  < 0.001). Figure  1 presents the final model, where significant standardized estimates are shown next to each path, and the coefficient for each variable’s contribution to the model is also included.

COVID-19 Behavioral Health Model.

Increased anxiety during a pandemic has led to preventative behaviors, such as increased handwashing and following safety restrictions, demonstrating a protective factor of mild anxiety 52 . However, ongoing stressors become cumulative and can lead to longer-term mental health problems 64 . Biological disasters like the COVID-19 pandemic create a large amount of disruption, uncertainty, and public fear—globally impacting communities for over a year. There is a significant gap in the literature regarding behavioral health and quality of life during global pandemics. Overall results of this study suggest complex pathways to COVID-19 behavioral health and subsequent quality of life.

The current study revealed that COVID-19 disruption to participants’ work, family, or social life uniquely contributed to poorer mental health. Specifically, participants noting social isolation and personal health effects exhibited worsened mental health. These findings are in line with existing research on pandemic contributors to mental health concerns, including loneliness 1 and direct exposure 10 . As one study noted, increased experiences of COVID-19 at the height of the pandemic produced occurrences of psychological distress that created or increased mental illness in China 64 . Our study found that COVID-19 experiences likely exacerbated existing problems, where prior mental and physical health were predictive of current anxious and depressive symptoms. Similarly, Young and colleagues 65 found those who experienced mental health symptoms in the past were at an increased risk for severe mental health diagnoses. Further, early studies and our results support the growing literature of concerns for longer-term mental health problems due to COVID-19 17 .

In a systematic review of recent literature surrounding COVID-19 Xiong and colleagues 12 , found that increases in depression, anxiety, and PTSD symptoms were associated with certain risk factors. Similarly, our study found indirect pathways to mental health, where younger participants reported prior mental health problems and older participants reported prior physical health problems. In the current study, younger participants also had more indirect stressors associated with the pandemic 16 and reported more COVID-19 experiences. Females and whites reported more anxiety, although this association did not hold in the structural model. Similar results have been found in other studies regarding females 20 , but the opposite regarding race and ethnicity 22 , 66 . Discrepancies are likely due to the significant association among older participants identifying as members of a minority grouping.

Another contributor to poor behavioral health is substance use. Early COVID-19 studies estimate over 10% started or increased substance misuse as a coping mechanism 67 . Our study supports the increase of substance due to COVID-19, where current alcohol misuse was associated with prior substance use. Further, prior substance use was associated with prior mental health problems; this connection was continued for current usage, where alcohol misuse was also associated with depression. Following the Ebola outbreak, one risk factor identified was increased substance use, which can exacerbate negative mental health outcomes 68 . In the current study, participants with suspected or diagnosed COVID-19 or who lived in communities with higher rates reported higher alcohol misuse, suggesting use of alcohol as a potential negative coping mechanism.

Most would expect quality of life to be challenged during a global pandemic; however, when we assessed behavioral health as a component of overall quality of life, longer term outcomes became concerning. Both past and current mental health were strong predictors of quality of life. Other studies have demonstrated this connection for individuals recovering from COVID-19 45 , 46 , 69 . COVID-19 experiences play a large role in quality of life, where participants who felt socially isolated reported personal health effects, or COVID-19 suspected or diagnosed participants reported lower quality of life. Similar to a large international study by Alzueta and colleagues 13 , the number of experiences related to COVID-19 played a role in overall well-being. Specifically, we found that increased COVID-19 experiences predicted lower quality of life, demonstrating an allostatic load effect and the accumulation of pandemic-related stressors toward negative health outcomes 63 . Individuals who do not adapt well to taxing life events tended to experience increased rates of anxiety and depression, which lowers quality of life.

Place matters

Place matters with regards to COVID-19, where behavioral health and community factors contributed to overall health. A community consists of individuals one can identify with. Specifically, the community is place-based or labeled as a locality where individuals who comprise the community interact to share social capital. The social capital theory contends that social connectedness is a resource that guides the growth and accumulation of interpersonal relationships 70 . Community-based findings from this study found that participants with higher anxiety scores and who were older lived in communities with more physically unhealthy days. Respondents with lower 2019 income were less likely to live in communities with more physically and mentally unhealthy days. Respondents who reported prior physical health were less likely to live in communities with excessive drinking. Yet communities with overall poorer health also had increased percentages of excessive drinking. Communities with higher COVID-19 rates also had higher averages of mentally and physically unhealthy days and percentages of excessive drinking. Similar results demonstrated that higher individual and community stressors result in poor mental health and inadvertently decrease quality of life 12 , 71 , 72 . Communities' social capital works as a protective factor against the accumulative effects of COVID-19 (e.g. social isolation, depression, psychological distress, and deaths) 73 , 74 .

Limitations and future research

Future studies are needed to understand protective factors (e.g. self-care, technology-aided connectedness) that can buffer more negative effects. Researchers from Turkey observed a reduction in COVID-19 anxiety and depression symptomology following physical activity programs to increase optimal health functioning, social connectedness, decreased anxiety and depression symptoms 75 . Similar programs and studies are needed to understand buffering effects on U.S. populations. Respondents were largely female (85%) and while consistent with existing studies that more females respond to surveys 76 , this may impact results. Timing is a major consideration for this study, as behavioral health needs and concerns are likely to change over the course of the pandemic 2 . Future studies are also needed to understand longer term behavioral health implications, social media effects, and family impacts, including parenting, adult caregiving, and youth 77 .

Summary and impact

The nature of COVID-19 and vast reach of the virus suggest that behavioral health concerns should take a primary role in pandemic recovery. While we can expect many individuals with elevated symptoms or substance use problems to remit over time, the ongoing nature of the current pandemic is likely to yield longer-term reactions 5 , 6 , 78 , 79 . The continued direct and indirect effects of the pandemic alludes to the pandemic hindering improvements in people’s health and overall well-being. This study supports the urgent need for enhanced behavioral health service capacity moving into the recovery phase of the pandemic 80 . Based on past disasters, brief services such as Skills for Psychological Recovery 81 are still needed to normalize mental health symptoms and awareness of risk factors and acknowledge problematic coping, such as alcohol use. Brief interventions may be necessary to boost coping skills that may be diminished due to COVID-19. At this point in the disaster, more intensive treatments should also be made available 82 , especially for those who exhibit specific risk factors, such as young and middle-aged adults, those with limited income and prior behavioral health concerns, and those living in communities with poorer health. Perhaps some of the gains made toward telehealth over the past year 83 can continue and increase access and capacity to support improved behavioral health and quality of life.

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Hansel, T.C., Saltzman, L.Y., Melton, P.A. et al. COVID-19 behavioral health and quality of life. Sci Rep 12 , 961 (2022). https://doi.org/10.1038/s41598-022-05042-z

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Editor in Chief's Introduction to Essays on the Impact of COVID-19 on Work and Workers

On March 11, 2020, the World Health Organization declared that COVID-19 was a global pandemic, indicating significant global spread of an infectious disease ( World Health Organization, 2020 ). At that point, there were 118,000 confirmed cases of the coronavirus in 110 countries. China had been the first country with a widespread outbreak in January, and South Korea, Iran and Italy following in February with their own outbreaks. Soon, the virus was in all continents and over 177 countries, and as of this writing, the United States has the highest number of confirmed cases and, sadly, the most deaths. The virus was extremely contagious and led to death in the most vulnerable, particularly those older than 60 and those with underlying conditions. The most critical cases led to an overwhelming number being admitted into the intensive care units of hospitals, leading to a concern that the virus would overwhelm local health care systems. Today, in early May 2020, there have been nearly 250,000 deaths worldwide, with over 3,500,000 confirmed cases ( Hopkins, 2020 ). The human toll is staggering, and experts are predicting a second wave in summer or fall.

As the deaths rose from the virus that had no known treatment or vaccine countries shut their borders, banned travel to other countries and began to issue orders for their citizens to stay at home, with no gatherings of more than 10 individuals. Schools and universities closed their physical locations and moved education online. Sporting events were canceled, airlines cut flights, tourism evaporated, restaurants, movie theaters and bars closed, theater productions canceled, manufacturing facilities, services, and retail stores closed. In some businesses and industries, employees have been able to work remotely from home, but in others, workers have been laid off, furloughed, or had their hours cut. The International Labor Organization (ILO) estimates that there was a 4.5% reduction in hours in the first quarter of 2020, and 10.5% reduction is expected in the second quarter ( ILO, 2020a ). The latter is equivalent to 305 million jobs ( ILO, 2020a ).

Globally, over 430 million enterprises are at risk of disruption, with about half of those in the wholesale and retail trades ( ILO, 2020a ). Much focus in the press has been on the impact in Europe and North America, but the effect on developing countries is even more critical. An example of the latter is the Bangladeshi ready-made-garment sector ( Leitheiser et al., 2020 ), a global industry that depends on a supply chain of raw material from a few countries and produces those garments for retail stores throughout North America and Europe. But, in January 2020, raw material from China was delayed by the shutdown in China, creating delays and work stoppages in Bangladesh. By the time Bangladeshi factories had the material to make garments, in March, retailers in Europe and North American began to cancel orders or put them on hold, canceling or delaying payment. Factories shut down and workers were laid off without pay. Nearly a million people lost their jobs. Overall, since February 2020, the factories in Bangladesh have lost nearly 3 billion dollars in revenue. And, the retail stores that would have sold the garments have also closed. This demonstrates the ripple effect of the disruption of one industry that affects multiple countries and sets of workers, because consider that, in turn, there will be less raw material needed from China, and fewer workers needed there. One need only multiply this example by hundreds to consider the global impact of COVID-19 across the world of work.

The ILO (2020b) notes that it is difficult to collect employment statistics from different countries, so a total global unemployment rate is unavailable at this time. However, they predict significant increase in unemployment, and the number of individuals filing for unemployment benefits in the United States may be an indicator of the magnitude of those unemployed. In the United States, over 30 million filed for unemployment between March 11 and April 30 ( Bureau of Labor Statistics, 2020 ), effectively this is an unemployment rate of 18%. By contrast, in February 2020, the US unemployment rate was 3.5% ( Bureau of Labor Statistics, 2020 ).

Clearly, COVID-19 has had an enormous disruption on work and workers, most critically for those who have lost their employment. But, even for those continuing to work, there have been disruptions in where people work, with whom they work, what they do, and how much they earn. And, as of this writing, it is also a time of great uncertainty, as countries are slowly trying to ease restrictions to allow people to go back to work--- in a “new normal”, without the ability to predict if they can prevent further infectious “spikes”. The anxieties about not knowing what is coming, when it will end, or what work will entail led us to develop this set of essays about future research on COVID-19 and its impact on work and workers.

These essays began with an idea by Associate Editor Jos Akkermans, who noted to me that the global pandemic was creating a set of career shocks for workers. He suggested writing an essay for the Journal . The Journal of Vocational Behavior has not traditionally published essays, but these are such unusual times, and COVID-19 is so relevant to our collective research on work that I thought it was a good idea. I issued an invitation to the Associate Editors to submit a brief (3000 word) essay on the implications of COVID-19 on work and/or workers with an emphasis on research in the area. At the same time, a group of international scholars was coming together to consider the effects of COVID-19 on unemployment in several countries, and I invited that group to contribute an essay, as well ( Blustein et al., 2020 ).

The following are a set of nine thoughtful set of papers on how the COVID-19 could (and perhaps will) affect vocational behavior; they all provide suggestions for future research. Akkermans, Richardson, and Kraimer (2020) explore how the pandemic may be a career shock for many, but also how that may not necessarily be a negative experience. Blustein et al. (2020) focus on global unemployment, also acknowledging the privileged status they have as professors studying these phenomena. Cho examines the effect of the pandemic on micro-boundaries (across domains) as well as across national (macro) boundaries ( Cho, 2020 ). Guan, Deng, and Zhou (2020) drawing from cultural psychology, discuss how cultural orientations shape an individual's response to COVID-19, but also how a national cultural perspective influences collective actions. Kantamneni (2020) emphasized the effects on marginalized populations in the United States, as well as the very real effects of racism for Asians and Asian-Americans in the US. Kramer and Kramer (2020) discuss the impact of the pandemic in the perceptions of various occupations, whether perceptions of “good” and “bad” jobs will change and whether working remotely will permanently change where people will want to work. Restubog, Ocampo, and Wang (2020) also focused on individual's responses to the global crisis, concentrating on emotional regulation as a challenge, with suggestions for better managing the stress surrounding the anxiety of uncertainty. Rudolph and Zacher (2020) cautioned against using a generational lens in research, advocating for a lifespan developmental approach. Spurk and Straub (2020) also review issues related to unemployment, but focus on the impact of COVID-19 specifically on “gig” or flexible work arrangements.

I am grateful for the contributions of these groups of scholars, and proud of their ability to write these. They were able to write constructive essays in a short time frame when they were, themselves, dealing with disruptions at work. Some were home-schooling children, some were worried about an absent partner or a vulnerable loved one, some were struggling with the challenges that Restubog et al. (2020) outlined. I hope the thoughts, suggestions, and recommendations in these essays will help to stimulate productive thought on the effect of COVID-19 on work and workers. And, while, I hope this research spurs to better understand the effects of such shocks on work, I really hope we do not have to cope with such a shock again.

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• International Labor Organization (2020b) COVID-19 impact on the collection of labour market statistics. Retrieved May 6, 2020 from: https://ilostat.ilo.org .
• Kantamneni, N. (2020). The impact of the COVID-19 pandemic on marginalized populations in the United States: A research agenda. Journal of Vocational Behavior, 119 . [ PMC free article ] [ PubMed ]
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Mr. Berliner’s essay has ignited a firestorm of criticism of NPR on social media, especially among conservatives who have long accused the network of political bias in its reporting. Former President Donald J. Trump took to his social media platform, Truth Social, to argue that NPR’s government funding should be rescinded, an argument he has made in the past.

NPR has forcefully pushed back on Mr. Berliner’s accusations and the criticism.

“We’re proud to stand behind the exceptional work that our desks and shows do to cover a wide range of challenging stories,” Edith Chapin, the organization’s editor in chief, said in an email to staff on Tuesday. “We believe that inclusion — among our staff, with our sourcing, and in our overall coverage — is critical to telling the nuanced stories of this country and our world.” Some other NPR journalists also criticized the essay publicly, including Eric Deggans, its TV critic, who faulted Mr. Berliner for not giving NPR an opportunity to comment on the piece.

In an interview on Thursday, Mr. Berliner expressed no regrets about publishing the essay, saying he loved NPR and hoped to make it better by airing criticisms that have gone unheeded by leaders for years. He called NPR a “national trust” that people rely on for fair reporting and superb storytelling.

“I decided to go out and publish it in hopes that something would change, and that we get a broader conversation going about how the news is covered,” Mr. Berliner said.

He said he had not been disciplined by managers, though he said he had received a note from his supervisor reminding him that NPR requires employees to clear speaking appearances and media requests with standards and media relations. He said he didn’t run his remarks to The New York Times by network spokespeople.

When the hosts of NPR’s biggest shows, including “Morning Edition” and “All Things Considered,” convened on Wednesday afternoon for a long-scheduled meet-and-greet with the network’s new chief executive, Katherine Maher , conversation soon turned to Mr. Berliner’s essay, according to two people with knowledge of the meeting. During the lunch, Ms. Chapin told the hosts that she didn’t want Mr. Berliner to become a “martyr,” the people said.

Mr. Berliner’s essay also sent critical Slack messages whizzing through some of the same employee affinity groups focused on racial and sexual identity that he cited in his essay. In one group, several staff members disputed Mr. Berliner’s points about a lack of ideological diversity and said efforts to recruit more people of color would make NPR’s journalism better.

On Wednesday, staff members from “Morning Edition” convened to discuss the fallout from Mr. Berliner’s essay. During the meeting, an NPR producer took issue with Mr. Berliner’s argument for why NPR’s listenership has fallen off, describing a variety of factors that have contributed to the change.

Mr. Berliner’s remarks prompted vehement pushback from several news executives. Tony Cavin, NPR’s managing editor of standards and practices, said in an interview that he rejected all of Mr. Berliner’s claims of unfairness, adding that his remarks would probably make it harder for NPR journalists to do their jobs.

“The next time one of our people calls up a Republican congressman or something and tries to get an answer from them, they may well say, ‘Oh, I read these stories, you guys aren’t fair, so I’m not going to talk to you,’” Mr. Cavin said.

Some journalists have defended Mr. Berliner’s essay. Jeffrey A. Dvorkin, NPR’s former ombudsman, said Mr. Berliner was “not wrong” on social media. Chuck Holmes, a former managing editor at NPR, called Mr. Berliner’s essay “brave” on Facebook.

Mr. Berliner’s criticism was the latest salvo within NPR, which is no stranger to internal division. In October, Mr. Berliner took part in a lengthy debate over whether NPR should defer to language proposed by the Arab and Middle Eastern Journalists Association while covering the conflict in Gaza.

“We don’t need to rely on an advocacy group’s guidance,” Mr. Berliner wrote, according to a copy of the email exchange viewed by The Times. “Our job is to seek out the facts and report them.” The debate didn’t change NPR’s language guidance, which is made by editors who weren’t part of the discussion. And in a statement on Thursday, the Arab and Middle Eastern Journalists Association said it is a professional association for journalists, not a political advocacy group.

Mr. Berliner’s public criticism has highlighted broader concerns within NPR about the public broadcaster’s mission amid continued financial struggles. Last year, NPR cut 10 percent of its staff and canceled four podcasts, including the popular “Invisibilia,” as it tried to make up for a $30 million budget shortfall. Listeners have drifted away from traditional radio to podcasts, and the advertising market has been unsteady.

In his essay, Mr. Berliner laid some of the blame at the feet of NPR’s former chief executive, John Lansing, who said he was retiring at the end of last year after four years in the role. He was replaced by Ms. Maher, who started on March 25.

During a meeting with employees in her first week, Ms. Maher was asked what she thought about decisions to give a platform to political figures like Ronna McDaniel, the former Republican Party chair whose position as a political analyst at NBC News became untenable after an on-air revolt from hosts who criticized her efforts to undermine the 2020 election.

“I think that this conversation has been one that does not have an easy answer,” Ms. Maher responded.

Benjamin Mullin reports on the major companies behind news and entertainment. Contact Ben securely on Signal at +1 530-961-3223 or email at [email protected] . More about Benjamin Mullin

Katie Robertson covers the media industry for The Times. Email:  [email protected]   More about Katie Robertson