Original Article

Lower Intent to Comply with COVID-19 Public Health Recommendations Correlates to Higher Disease Burden in Following 30 Days

Authors: Robert P. Lennon, MD, JD, Aleksandra E. Zgierska, MD, PhD, Erin L. Miller, BS, Bethany Snyder, MPH, Aparna Keshaviah, ScM, Xindi C. Hu, ScD, Hanzhi Zhou, PhD, Lauren Jodi Van Scoy, MD


Objectives: We sought to determine whether self-reported intent to comply with public health recommendations correlates with future coronavirus disease 2019 (COVID-19) disease burden.

Methods: A cross-sectional, online survey of US adults, recruited by snowball sampling, from April 9 to July 12, 2020. Primary measurements were participant survey responses about their intent to comply with public health recommendations. Each participant’s intent to comply was compared with his or her local COVID-19 case trajectory, measured as the 7-day rolling median percentage change in COVID-19 confirmed cases within participants’ 3-digit ZIP code area, using public county-level data, 30 days after participants completed the survey.

Results: After applying raking techniques, the 10,650-participant sample was representative of US adults with respect to age, sex, race, and ethnicity. Intent to comply varied significantly by state and sex. Lower reported intent to comply was associated with higher COVID-19 case increases during the following 30 days. For every 3% increase in intent to comply with public health recommendations, which could be achieved by improving average compliance by a single point for a single item, we estimate a 9% reduction in new COVID-19 cases during the subsequent 30 days.

Conclusions: Self-reported intent to comply with public health recommendations may be used to predict COVID-19 disease burden. Measuring compliance intention offers an inexpensive, readily available method of predicting disease burden that can also identify populations most in need of public health education aimed at behavior change.
Posted in: Infectious Disease68

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Table. Respondent demographic and COVID-19 health risk characteristics: unweighted (survey respondents, N = 10,650) and weighted (to generate a representative US sample)

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Fig. 1. Intent to comply with public health recommendation score by demographic, health, and geographic characteristics.

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Fig. 2. Intent to comply with public health recommendations (A) and COVID-19 case trajectory (B) by states in the United States. The maps summarize these findings by state; the generated models were at the individual survey respondent level. COVID-19, coronavirus 2019.

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Fig. 3 Correlation between intent to comply and future COVID-19 burden (subsequent 30 days): on the national level, the higher the intent to comply, the lower the future number of cases (P < 0.01). Models controlled for potential confounders including age, sex, race, ethnicity, region, self-reported social status, health conditions increasing risk from COVID-19, and trust in information sources composite score. The bars indicate the 95% confidence interval around the correlation coefficient. COVID-19, coronavirus 2019.

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