Self-Isolation Compliance In The COVID-19 Era Influenced By Compensation: Findings From A Recent Survey In Israel

In December 2019, a growing number of cases with a novel Severe Acute Respiratory Syndrome (SARS) coronavirus was registered in Wuhan, Hubei, China. The virus, originally names SARS-Cov-2, spread throughout China and outside rapidly. Since February 12, 2020, the disease caused by this novel coronavirus is termed Coronavirus Disease 2019 (COVID-19), and its spread around the globe is still ongoing.^1,2 As of 31 March 2020, a total confirmed cases of 754,948 were recorded in 202 territories and countries, of which 36,571 died.³

Many efforts are being taken by governments around the world in an effort to contain the spread of the COVID-19 disease. A major component applied by public health authorities in an effort to mitigate the spread of COVID-19 is self-quarantine.⁴ Individuals at risk of exposure to COVID-19 are instructed to subject themselves to household quarantine for a minimum of 14 days, effectively excluding them from closely interacting with other people, as well as attending workplaces, schools, or public venues. Arguably, this measure could be effective in slowing down the spread of contagious diseases, as was the case with SARS in 2003.⁵

Although self-quarantine of suspected exposures is an action done by a person in order to protect others, research suggests that during time of disease outbreaks, people view favorably public health actions such as self-quarantine.⁶ Accordingly, public health official assume high compliance rates by the public for self-quarantine instructions. However, different studies suggest that a major obstacle to compliance for household quarantine is concern over loss of income or employment due to prolonged absence from work.^7,8 Acknowledging this, the governments of Canada and Hong-Kong implemented specific plans to reimburse individuals who lost income during the SARS outbreak in 2003.⁹

Crisis managers rely on public compliance with self-quarantine. Officials usually have limited capacity to enforce and monitor this measure; hence, the public health benefits of household quarantine can be achieved only if the public cooperates. Therefore, it is imperative to assess public attitudes toward compliance with household self-quarantine in light of economic considerations. The purpose of the current study was to assess public attitudes toward the COVID-19 outbreak, in particular concerning the compliance with public health regulation, such as self-quarantine, comparing between circumstances when compensation for lost wages is offered or not.

Study Data And Methods

This cross sectional study was conducted in Israel on the last week of February 2020. A randomized sample of the adult population of Israel was engaged in a study to assess public attitudes concerning the outbreak of COVID-19. Responses were collected through the iPanel online polling service. Since 2006, the iPanel provides an online platform for a wide variety of information collection services, including polls and public opinion surveys. It adheres to the stringent standards of the world association for market, social, and opinion researchers (ESOMAR).

Study Sample

The final sample included 563 respondents representing the adult population of the State of Israel. Appendix Exhibit 1 online¹⁰ summarizes the sociodemographic breakdown of the studied sample. At the time responses were collected, five cases of COVID-19 were confirmed in Israel and more than 5,000 Israelis were required to self-quarantine at home.

Questionnaire

The main tool used in the study was a questionnaire designed specifically for the purposes of this study. The questionnaire included six items assessing public attitudes toward the COVID-19 outbreak, including: news consumption (1 item), personal concern (1 item), public panic (2 items), and attitudes toward public health regulations (2 items). In addition, the questionnaire included three items assessing compliance with public health regulations on a nominal scale (Yes/No/Maybe/Do not know). The first two assessed compliance with self-quarantine using the following text: “Assuming you were requested by a medical official to stay in self-quarantine and assuming the state will (NOT) compensate you for lost wages, will you stay in self-quarantine?” The negative form of the question (using the highlighted word “NOT”) was asked after the positive form.

Analysis

Statistical analysis was conducted using SPSS (ver. 25). The analysis included mostly descriptive methods. Chi-square test was used to evaluate difference in proportions of variable between groups. In all statistical analyses performed, a p-value of 0.05 or less was determined as statistically significant.

Limitations

This study has several limitations. First, although performing the study during the crisis is important to assess situational attitudes; however, due to its cross sectional nature, the attitudes assessed in this study are likely to change as the disease progresses. In particular, compliance rates with self-quarantine may change dramatically as the threat for infection is perceived to be greater. This can be solved by performing the assessment in multiple time points to evaluate the epidemiology of studied opinions. Second, this study utilized an internet-based methodology for response collection. While this allowed for a rapid turnover of responses on a wide geographical distribution and resulted with a representative sample of the adult population of Israel, the conclusions must be limited to people with high computer skills. Third, respondents were asked to provide assessment of their intentions, rather than reporting actual behavior, which may lead to reporting biases. Lastly, the results cannot be further generalized beyond the Israeli public. Additional studies in other countries are called for to expand the database to other cultures and contexts.

Study Results

Respondents were asked to provide their attitudes toward the COVID-19 outbreak. Appendix Exhibit 2¹⁰ provides the complete results of this section. The results suggest that a majority of the Israeli public monitors the situation by consuming news reports. More than 60% reported monitoring the news “a lot” or “very much”.

When asked if they are worried about the COVID-19 outbreak, almost half of the respondents replied “a lot” or “very much”, as oppose to about 16% replying “not at all” or “a little”. The mean score for this question was 3.55 (−1.00 SD) (out of 5), suggesting a moderate level of concern. In contrast, most respondents (63%) believe there is panic in the general public. More than 80% ascribe the public concerns over COVID-19 to the media coverage of the outbreak.

When asked to what extent they trust the public health instructions issued by the Ministry of Health (MOH) during the COVID-19 outbreak, about 53% reported a high level of trust, $\sim 32\%$ a moderate level, and $\sim 15\%$ reported a low level of trust. Subsequently, respondents were asked whether they believe that taking criminal action against individuals breaching self-quarantine would increase compliance with MOH instructions. Almost 70% had favorable views of this proposal by expressing agreement with the efficacy of this step to help in containment of the disease.

Respondents were asked to report their intent to comply with self-quarantine under two circumstances. When State-sponsored compensation for lost wages was assumed, 94% of respondents indicated they would comply with a two-week self-quarantine instructed by a medical official. Less than one percent (0.7%) replied that they would not comply. However, when monetary compensation was removed, the compliance rate dropped to less than 57%, and 60 respondents ($\sim 11\%$) changed their response to “No”. See Appendix Exhibit 3.¹⁰

In an effort to characterize individuals prone to non-compliance, the socio-demographic breakdown of respondents replying “No” or “Maybe/did not decide” were compared to those of the total sample (see Appendix Exhibit 4).¹⁰ The analysis demonstrates that there are no statistical differences between the non-compliance group and the total sample. Self-employed individuals were more prone to refuse self-quarantine measures when compensation was removed, but this finding was not statistically significant (p = 0.052).

When compensation is removed, the group of undecided respondents (“Maybe/did not decide”) is over-representative of individuals earning higher than average income (p = 0.02). No other differences were observed for other socio-demographic variables between this group and the total sample.

Lastly, respondents were asked whether they would report a person in breach of a self-quarantine decree if asked to do so by the health authorities. Most respondents (58%) replied that they would report such a person to the health authorities, while 7% would refuse to report. The remainder (35%) were unsure whether they would or would not comply with this request.

Discussion

The results of this study demonstrate several interesting phenomena concerning public attitudes toward the COVID-19 outbreak. While on an individual level people tend to estimate their level of concern as moderate, on a communal level people tend to ascribe high levels of panic to others. It is this perceived irrationality by others that can lead to unwanted behavior, such as the panic buying we are witnessing during the COVID-19 outbreak,¹¹ as well as the spread of rumors.¹² Similar notions were reported after the SARS outbreak in 2003¹³ and the Swine Flu in 2009.¹⁴

In addition, the results of this study suggest that Israelis tend to conform to government regulations. They exhibit a relatively high level of trust in health authorities’ instructions and comply with a variety of regulations, including reporting disorderly individuals who breach self-quarantine, supporting taking criminal actions against them, and complying with self-quarantine. Nevertheless, the results of this study highlight an important message to COVID-19 crisis managers in this regards. Decision makers need to consider a broader view of the situation, in particular concerning reassuring people’s concern over their livelihood. Providing people with assurances about their household income during times of absence from workplace seems to be an important component in compliance with public health regulations.¹⁵ Should this aspect be ignored, health officials risk losing twice—first, in reducing the effectiveness of their measures to contain the spread of the disease by prompting people to breach self-quarantine. Second, by losing trust and becoming irrelevant to people’s decision-making processes.

When decision makers ensure that individuals placed in self-quarantine continue to receive their earning, the chances to achieve maximal compliance are very high. If for any reason there is no option to secure compensation over lost wages, then decision makers should consider ways to optimize compliance rates. However, this could prove to be quite a challenge. The lack of statistical difference between the non-compliance group and the total sample suggests that any individual can become disobedient to public health instructions issued during a disease outbreak if compensation for lost wages is removed. Nevertheless, if the state decides it cannot support monetary compensation for people placed in self-quarantine, the findings here suggest that an important group to target with compliance-supporting messages would be those who have yet to decide how to behave in case no compensation will be offered. They are about one third in size and can be characterized as individuals with higher earnings. Focusing risk communication efforts on this group can lead to higher compliance rates, even in absence of monetary compensation.

Decision makers should note the trade-off between the decision to compensate or not compensate individuals placed under self-quarantine. The economic implications of monetary compensation for individuals placed in self-quarantine can be enormous, especially as numbers of suspected exposures rise. Nonetheless, increased numbers of compensated individuals should not necessarily discourage the State from considering compensation with the excuse of excess expenditure. Choosing to discontinue or revoke compensation could lead to higher rates of non-compliance with self-quarantine, which can lead to increased morbidity and mortality that have their own price tags. In turn, increased numbers of exposures may lead to more drastic measures, such as placing entire areas under quarantine in an effort to control the spread of the disease. Under such circumstances, crisis managers should weigh in the costs of loss of production and disturbance to the economy and critical infrastructure due to absence from work of large quantities of workers, as well as the costs of logistics for distributing water and food to quarantine populations, etc. These might prove to have an even greater price tag than reimbursement for lost wages.

Moreover, governments may adopt compensation programs in a disease outbreak for reasons other than to encourage compliance with self-quarantine orders. For instance, during the current COVID-19 outbreak, the United States enacted payments to individuals without regard to whether they self-quarantined as a way to promote economic stability and reduce hardship to individuals who became unemployed or had additional expenses associated with social distancing measures.

Conclusion

In some emergencies, such as the outbreak of COVID-19, public health officials request members of the public to self-quarantine. This action could potentially have dramatic implications to a household’s income and livelihood. This study demonstrates that decision makers should pay attention to the economic implications of self-quarantine. If each household’s income during the self-quarantine period is assured, high levels of compliance with public health regulation can be expected. This would not be the case if the decision makers do not guarantee such economic safety. Continuous earning is a crucial factor in determining public compliance with public health regulations, in particular self-quarantine. This is particularly important in countries relying on public compliance with regulations.

ACKNOWLEDGMENTS

The authors wish to thank the National Center for Trauma & Emergency Medicine Research at the Gertner Institute for Epidemiology and Health Policy Research for the financial support. [Published online April 9, 2020.]

NOTES

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