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U.S. state and city leaders issued mask-wearing and social distancing directives in 2020 to contain the spread of the coronavirus pandemic. Residents applied the directives differently in their daily lives—reflecting how unevenly these public health messages are understood and followed, new research shows.

These findings are among results from new research supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) that aims to inform policy responses to the pandemic.

People Say They Wear Masks as Directed But Remove Them Around Trusted Individuals

Focus group participants in July 2020 said they wore face coverings frequently when in public, indoor settings—including grocery stores, health care facilities, and religious services—according to University of North Carolina researchers.¹ But participants report forgoing masks while indoors with trusted friends, relatives, or co-workers. Why?

“The interactions were not perceived as occurring in public,” write the researchers. “These perceptions are problematic, as cluster infections among family, friends, and colleagues remain a common pattern for COVID-19 transmission.” The researchers conducted six virtual focus groups with diverse groups of rural and urban North Carolina residents.

Study participants said they were primarily motivated to wear masks to protect and respect the safety of others, especially family members at higher risk of complications from infection by the coronavirus and the disease it causes, COVID-19. Issues related to identity—such as political affiliation or the perception that masks were “uncool,” “not masculine,” or an infringement on individual rights—created challenges to compliance. According to the study, “even participants who consistently wore face coverings disliked being told what to do.”

Positive messaging could play a key role in increasing people’s compliance with coronavirus mask guidelines, the researchers suggest. During discussions of communication strategies, focus group members indicated that concise, positive messages about togetherness and unity were more appealing than messages that inspired fear or had an instructive tone. Stories that conveyed the personal effects of COVID-19 were particularly motivating, such as accounts from health care workers or those who had lost a loved one to the virus.

Another recent study echoes the UNC team’s findings: Nearly all Americans use a mask at some point each week, but very few consistently wear their mask during many common, potentially risky activities—such as when visiting friends.²

This behavior holds true even among adults whose older age or preexisting health conditions put them at higher risk for severe complications from COVID-19, researchers from the University of Michigan, Syracuse University, and University of California, Los Angeles report.

Among adults with three or more medical risk factors, only about one in 10 reported always wearing a mask when visiting a friend’s home or hosting visitors in November and early December 2020, according to the study.

“Family gatherings may be difficult settings in which to wear masks and ask others to do so as well. The low prevalence of mask wearing in small gatherings may indicate the role of social networks and peers in influencing behavior,” says lead investigator Robert Schoeni of the University of Michigan.

Americans’ Perceptions of Coronavirus Risk and Need for Social Distancing Differed Even Early in the Pandemic

In March 2020, young U.S. residents without college degrees perceived they had a lower risk of infection by the coronavirus but a higher probability of running out of money compared with other groups, new research shows.³

During the week of March 10-16, 2020, when the coronavirus was officially declared a pandemic by the World Health Organization and new U.S. infections were more than doubling every three days, researchers at the University of Pennsylvania and University of Southern California surveyed a representative sample of 5,400 Americans.

Most respondents were pessimistic about COVID-19’s health and economic consequences, the research team found, but their perceptions of their own risk varied widely depending on their age and education levels. Older adults felt they faced the greatest risk from COVID-19.

Most individuals (70%) reported taking some steps to distance themselves from other people, but researchers identified important differences based on respondents’ primary source of COVID-19 information. Specifically, Fox News viewers reported their odds of contracting COVID-19 were 5 percentage points lower than CNN viewers, even after considering demographic and regional differences.

On average, Americans perceived that their chance of dying if infected by the coronavirus was 14%, which is 10 times the actual COVID-19 mortality level, according to the researchers. The COVID-19 death risk Americans imagined was similar to rates during the pandemic’s 2020 peak in areas such as Lombardy, Italy, where the health system was overwhelmed and testing was restricted to the sickest patients.

“Perceptions of the health risks closely followed the number of COVID-19 cases in the country, and perceptions of the economic consequences and the prevalence of social distancing were driven upwards by both national and state-level cases,” the researchers reported based on their analysis.

Writing in early May 2020, the research team raised prescient concerns questioning “the ability of the U.S. to implement and sustain the widespread and restrictive policies that are required to curtail the pandemic,” given the widely different perceptions among different groups.

Residents of U.S. Counties With Healthy Habits Are More Likely to Comply With Social Distancing

In the early stages of the pandemic, people who lived in areas where healthy habits were widespread were more likely to practice social distancing in the form of limited movement outside the home, a team of researchers mainly from Duke University find.⁴

Residents in counties with less obesity and smoking and more physical activity, flu vaccinations, and mammograms were more likely to remain within one mile of home and drive fewer vehicle miles per day, they report based on GPS data. These findings concern the researchers because obesity and smoking are tied to the risk of severe complications from COVID-19.

People with low incomes are more likely be inactive, obese, and smoke, they note. Taking county poverty levels into account, the link between existing health behaviors and compliance with social distancing remains but the connection is somewhat less strong, they report.

Targeting more intensive public health interventions in counties with residents with higher levels of unhealthy behaviors—particularly high obesity and physical inactivity—could be a cost-effective approach to promoting social distancing and masks to help reduce COVID-19 cases and deaths until vaccines are more widely available, the researchers suggest.

The U.S. Centers for Disease Control and Prevention (CDC) reported in late March 2021 that new COVID-19 infections had begun to increase. Acknowledging that it has been a long and tiring year, CDC director Dr. Rochelle Walensky urged Americans “to hang on a little while longer in terms of the masks and mitigation strategies, so that we can get the majority of people vaccinated.”⁵

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This article was produced under a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The work of researchers from the following NICHD-funded Population Dynamics Research Centers was highlighted: University of North Carolina at Chapel Hill (5P2CHD050924-15), University of California, Los Angeles (5P2CHD041022-19), University of Michigan (5P2CHD041028-18), Duke University (5P2CHD065563-10), and University of Pennsylvania (5P2CHD044964-17). Communications staff at University of North Carolina and University of Michigan contributed to this report.