The perception of risk in contracting and spreading COVID-19 …
We recruited 27 participants for baseline interviews, 15 (55.5%) of whom completed a follow-up interview within one month. Two of these participants further consented to using photo elicitation to support their discussion during their follow-up interview. We considered that data saturation was achieved by interview 27, ceasing further recruitment. Table 2 shows the demographics of included participants. The Index of Multiple Deprivation (IMD) deciles show that many participants resided in relatively deprived areas [32], with the North West of England already representing greater levels of area derivation in relation to the South of England [33].
Through thematic analysis of the data we developed two themes and six sub-themes, as shown in the coding tree in Table 1. Where consenting participants used photo elicitation to support their interview discussion, these images have been included in the relevant subsections below (see Figs. 1, 2, 3, 4, 5, 6).
Confusion and trust in the risk prevention guidance
This theme describes how participants understood the virus, and explored their sources of information. It was found that differences in understanding around the virus led to confusion, which in turn led to mistrust of information/sources. The media played a role in sharing (mis)information during this time, and participants acknowledged a rise in “fake news” circulating, that caused further confusion and the development of conspiracy theories. In addition, the government guidance during this time changed rapidly, both within the UK and globally, and further incidents occurred where government officials were caught breaching the guidance, which led to further mistrust in the way the country was being governed.
Individuals’ knowledge and (mis)understanding of COVID-19
At baseline interview, we asked participants to describe their personal understanding of the virus, which often led to accounts of how the virus spreads from one person to another, as well as their understanding of the public health guidance. It was apparent that many had differing views and understandings. The range of views described included, that the virus originated from China due to food consumption; that the risk of the virus diminishes outdoors; that the virus is airborne and can also be transferred through direct contact with contaminated objects; and that the virus takes between five seconds and 15 min to transmit.
It seems to be a deadly…strain of the flu…it’s airborne as far as I am aware, also through direct contact. So, if somebody has the virus and picks up a cup and then [I] pick up that cup after, there’s a chance [I would catch it]… 2. P3_Baseline
The way the coronavirus is transmitted, [our household] wanted to be away from people; particularly, we were apprehensive about joggers…they’re breathing heavily and…expelling more spores from the mouth… P4_Follow-up
Just from five seconds you can catch it…pretty much a five-second conversation at my front door I could catch it…if somebody’s got it and they knock at the door with a parcel… P7_Baseline
Factors that appeared to influence participants’ views of virus risk and transmission included information sources (such as word of mouth, television or government briefings), participants’ educational and/or occupational backgrounds, and the perceived complexity of the information given to them by the UK government. It was apparent that many participants sought information on the virus due to misunderstandings, or mistrust in the sources providing it.
I try to be a little bit wary of being too in my little bubble but…I’m fairly academic, I’ve worked to Masters level so I do understand a little bit about sources [laughs] and the ones which I check out seem to give you links to things like World Health Organization news and…medical views that aren’t the government’s spokes people who seem to have towed the political line a lot of the time… P11_Baseline
Many discussed conducting extensive online searches, and/or were actively involved in other research projects as participants. These participants stated that their reasons for being involved in research were to both better their own understanding of the virus, and to support the growing body of evidence aimed at tackling the spread of the virus. Thus, their views on the virus combined learned scientific knowledge, alongside their own personal views and experiences.
I have done my own research and I know that T-cells don’t show up…so even if you haven’t got the antibody it doesn’t mean that you haven’t had [COVID-19]…At the moment we don’t know whether…you can catch it again. But my own experience was my family and particularly my young grandson and the whole of his school had a cough for quite some time and I can distinctly remember him coughing right in my mouth…and I got ill after that… P6_Follow-up
To be honest, that [research study] gave me a sense of security that I know that I’m being tested on a regular basis and…I’m hoping by doing this that it helps people… P3_Baseline
Rapidly changing guidance and trust in the government
Central public health guidance discussed during interviews included social distancing, social isolation, social bubbles (the number of people one could interact with), and the wearing of face coverings/masks. Few participants felt they had a clear understanding of the information, with many reporting concerns in understanding what was being asked of them, and a general lack of trust in the government to respond appropriately. Participants observed that lack of clarity and loss of trust in the government guidance appeared to hinder the general public’s desire to comply.
Boris Johnson [UK Prime Minister] albeit too late…stood between two scientists…and he actually said something along the lines of, with a sombre expression on his face, that he’s very sorry to say that it’s inevitable that there will be a lot of people in your life, in your family, who will die before their time…That was a very hard-hitting message and since then it’s not been so hard hitting…. It’s been loosened so much so that the word on the street is it doesn’t matter, it [COVID-19]’s all gone, don’t worry about it… P4_Baseline
I think the [Dominic] Cummings thing…damaged a lot of people’s credibility but to be honest we’re stuck because where else do we go for our information if you can’t believe the government? P6_Baseline
We found that a lack of trust in the government resulted in breaching of guidance, even when later guidance was encouraging relaxed safety measures. Changing guidance, including the reduction of social distancing from two metres to one metre, left participants feeling unsafe and confused without clear reasoning. With feelings of uncertainty in the government guidance and leadership, participants reported making individual decisions, with many choosing to continue following the more stringent measures.
I have great difficulty in understanding the fact that they [the government] change the rules to suit the situation or suit the economic profile, so I maintain the two-meter distance because at the end of the day, it doesn’t matter which way the economy’s going, whether its driving ahead or whether we’re in recession, the transmission of this COVID19 disease will remain the same… P4_Baseline
When it was two metres…I felt quite safe and I went on the walks…and everyone was laughing about it sort of oh keep away from me…when it changed…from the two metre to the one metre [rule]…you’re not doing any social distancing because that conscious awareness had gone…I would have preferred it stay at two metres all the time to be honest… P5_Baseline
Media influence on risk perception, and the rise in fake news
Media sources, consisting of TV, radio, newspapers and social media, played a significant role in sharing important information about the COVID-19 virus and the government’s changing public health measures. However, with a myriad of media information dominating everyday conversation, participants became increasingly confused over time as to what information was real and what was fake, resulting in many refusing to engage with media information at all and, as such, becoming unaware of any updates or changes to government guidance.
There is a vast amount of information out there, some of it to be honest is confusing…I got to the point…of not really watching the news because there were so many different stories coming out and…it was starting to get a bit depressing and nobody seemed to have a correct answer… P3_Baseline
I think there was lots of information…There was a tonne of information thrown at people and…it started to become white noise [“background noise”], that’s what it’s become to me, a lot of…white noise… P15_Baseline
Furthermore, some participants stated they had been reading COVID-19 conspiracy theories, due to the distrust and confusion in the official information provided. Others reported frustration in observing their friends and family indulging in theories, highlighting the influencing power of social media and fake news on the internet during this time. Ultimately, where participants did not trust that the virus was real, their perception of risk, and risk-prevention behaviours, appeared to diminish.
To be honest I felt that we were so ill informed I didn’t believe any of the information coming out, I thought that they [the government] should have been onto it [COVID-19] far sooner. I totally got into conspiracy theories. I was thinking this isn’t right, they have called it COVID-19 not COVID-20 so they know it’s been around…how could it possibly have taken this long to get the message through that this was a killer virus and it’s really affecting people very badly… P6_Baseline
I’ve got friends and I’ve kind of not fell out with them but…do you know these stupid people that believe in every…conspiracy, they think it’s 5G, it’s not coronavirus we’re getting killed by, [it’s] the 5G towers…It doesn’t matter how much you try to educate people they just, once they get that stuff in their head, that’s gospel truth… P7_Baseline
There’s that much propaganda about it [COVID-19] on the telly and in the papers and on your phone, there’s conspiracies now, everyone’s saying it’s all to do with pharmaceutical companies and you’ve just got to make your own decision… P19_Baseline
Navigating risk: compliance, incompliance and non-compliance with public health guidance
This theme describes the participants’ response to the restrictive guidance in the UK, in terms of their decision to comply or not, due to their perception of risk. A finding from this section was the low perception of individual risk, compared to a higher perception of risk to others around them. Participants were influenced by the actions and views of people in their households, and communities, or as seen in the media, and made frequent comparison between their own actions, and those of others. Where it was noted that others were breaching government guidance, the participants expressed frustration and a desire for higher levels of policing (Fig. 2).
Image taken by participant showing sign outside public shop
Low perception of individual risk, and the advantages of complying
Many participants did not believe themselves to be at risk of catching and/or spreading the virus, with a range of factors influencing this lack of individual risk perception. Where participants did not possess the published demographic/health indictors of those deemed most vulnerable to the virus (old age, obesity, ethnic minority status, cardiopulmonary conditions and compromised immunity), they described being less concerned and, therefore less compliant with guidance.
I’d hope that I wouldn’t [contract COVID-19] because I’m not obese or I’m not…an ethnic minority…and I’m under 70…I would hopefully be ok…So, I’m not in a high-risk group as such, although I do have a pre-existing medical conditional albeit mild… P1_Baseline.
Likewise, some reported feeling initially concerned about the virus, but perception of risk appeared to diminish over time where participants had not personally become ill with the virus, or failed to experience themselves/others to contract the virus. P2 below described contracting COVID-19 without symptoms, but at their follow-up interview, they reported feeling no worse than usual due to previous ongoing health issues, thus reducing individual risk perception.
I’ve got my own [pre-existing] health issues but generally speaking I’ve been pretty much ok really. I haven’t had any [new] symptoms of the COVID but already I do have good [and bad] days with me health, as it is normally…the conditions I’ve got…don’t put me in that position [at high risk]… P2_Follow-up
Furthermore, those who observed a lack of significant changes to their normal working day in comparison to the time before the pandemic often reported a low perception of individual risk that increased over time. Despite media reports highlighting global impacts to people’s lives, including the UK furlough scheme and requirements to work from home, many other staff were still required to carry on working as they did pre-pandemic. The lack of change (in contrast to the warning media reports) coupled with the lack of COVID-19 cases observed in their workplace, reduced risk perception and subsequent compliance with risk-prevention measures. This finding was particularly evident by the follow-up interview, and exemplified below by P3, whose perception of individual risk reduced as their employer’s guidance to comply with face coverings lessened over time.
For months we didn’t have face coverings…as far as my boss was aware, the government advice was that they weren’t compulsory so he didn’t get us them…[He] never gave us all direct guidelines on when we’re meant to wear them or not so because we’d gone through months not wearing them, even though we’ve got them most of us aren’t wearing them… P3_Follow-up
I’ve been going to work every day throughout, I use public transport, I have young children in school, so yes, I think there’s a reasonable risk that I could contract it or I may have already contracted it. I think I’m very low risk… P15_Baseline
No-one that I’ve actually worked with erm has had COVID… up to now I’ve not come across anyone with COVID…Apart from the restrictions that have been in place, has gone on mostly as normal… P24_Follow-up
Moreover, whilst some participants reported feeling “at risk” of the virus, their attitudes appeared to be influenced by the views and actions of their family, friends and colleagues. Even where participants admitted to disagreeing with others’ views, there was a strong desire to follow suit and avoid deviating from general public opinion. In these cases, participants reported breaching public health guidance to comply with social norms.
You try to think [about complying] but…you become relaxed and you follow other people…you mirror them and they get close to you and you don’t want to stand back and say oh get away from me you just sort of go into the flow…you don’t want to be rude to a person… P5_Baseline
For some, the public health measures were viewed primarily for navigating society under strict lockdown measures and so, compliance with guidance was described in terms of personal gain, rather than to reduce viral spread. For example, face coverings were worn by some participants in order to gain entrance to shops where this was required, but were not seen as a risk prevention measure at an individual level (Fig. 3).
Image taken by participant showing face mask in supermarket carpark
I was in the supermarket today…I put a mask on to go in but as soon as I got in I took it off because only half the people in there had them on, even the staff never had them on so I don’t know why they’re telling people they’ve got to wear things in the shops when the staff aren’t wearing them… P19_Baseline
The perceived threat to others, and a responsibility to protect
In contrast to how risk was perceived at an individual level, participants reported that a greater risk was felt from the people around them. Participants described a sense of control for their own actions in preventing risk, but their inability to control the actions of those around them was a greater cause of concern. These participants further reported a sense of reassurance in the company of others who openly complied with the restrictions (Fig. 4).
Image taken by participant showing outdoor dining
The option to go out is still there for me and I take it, and…my wife…can go out if she wants…but I suspect a lot of what’s fuelling [my wife’s] side of it is the worry for her mother because…[COVID-19] will probably be a death sentence for her mother… P3_Baseline
I do feel safe…when I visit my friends, they’re all sort of careful, put the hand gel on, etc.… P5_Baseline
They [friends] had been isolating and I knew I’d be safe there … It was so hard not to hug … It was really rather sad… P6_Follow-up
As a result, compliance with public health guidance appeared to be greater in those with a caring responsibility, as participants feared they would transmit the virus to those more vulnerable. This included participants with a caring job role, or who voluntarily cared for another person in their community. Participants were mostly concerned for relatives and friends who were considered to have pre-existing health conditions classing them as “vulnerable”[2, 34], or who worked in areas of employment that involved exposure to others (Fig. 5).
Image taken by participant showing visiting restriction during the pandemic
[My son] was actually in a house with someone who got COVID because…the person he was living with was…a junior doctor… I was very worried… P1_Baseline
Certainly, we have more fears [for the family] than we have for our [household] because they’re younger, they work, they…expose themselves to a greater number of other people. So, there is a sort of a fear if you like at the back of my mind… P4_Baseline
We observed the social distancing like massively … We [could only look] through the window … We just can’t take the chance… P6_Follow-up
In addition to the aforementioned non-compliance, in which participants expressed a refusal to comply, additional reports of “incompliance” with social distancing directives emerged. In these cases, incompliance described participants’ perceived inability to comply despite awareness of the risks. It was identified that social isolation itself negatively impacted people, meaning participants felt they had no other choice but to breach guidance and visit their relative as a means of protecting their emotional wellbeing during the pandemic. Therefore, it was apparent that at times, the government directives were not deemed to be the safest or most practicable choice, and participants had to make their own decisions: whether to comply with public health guidance, or breach guidance and support their family’s wellbeing.
It wasn’t that long ago…she [daughter with mental health issues] said, please Mum, please can I have huggle and…I had to give her a hug, I had to, she was so low and…she washed her hands and did all of that [hygiene] and…so and it’s pretty much [remained] like that now P6_Baseline
Blaming and shaming others
Participants directly compared their own actions with those of people they considered to be less compliant, or more likely to spread the virus. Blaming language was often used to justify their actions, in instances where they admitted to breaching government guidance. Participants’ lack of compliance was minimised by their awareness of others complying to an even lesser degree. Often, participants compared demographics, such as ethnicity, age, health status, and lifestyle behaviours.
Young…people in unis are the ones that spread it far and wide because they have closer contact with each other because of their age group and…then they go and see friends and relatives and they give it to them and then the friends and relatives spread it a bit farther afield… P2_Follow-up
[The city] has a massive…financially viable Asian community: in other words, they can afford to buy tickets to and from… they have been bringing in the infection for three months before we locked down… P18_Baseline
Overtime, judgment between groups was widespread, affecting people on either side of the argument. Participants described feeling frustrated after observing others breaching guidance, and called for higher levels of policing to be enforced in order to control high rates on non-compliance. By follow-up, participants reported feelings of judgment by society, due to aspects of their demographic, where they chose not to comply with public health guidance (Fig. 6).
Image taken by participant showing supermarket queue
[Shop staff] have had no mask on…I’ve seen security fellas on the door with all the gear [PPE]…and people walking in with not a mask on and they haven’t stopped them…I’ll be honest, I had to go into [shop]…and I went straight for what I wanted and [immediately got] out…no, these were people [non-compliant shop staff] walking round putting stuff out and…they weren’t on the till where they have a screen… P27_Baseline
I think people would look at a person who’s older and think they obviously can’t wear a mask. But for someone younger, I don’t really want someone to start…saying to me, why aren’t you wearing a mask? So, I wear one, but I don’t feel very happy wearing one for very long… P1_Follow-up
Despite national guidance declaring that older age (> 70) made a person “high-risk” of severe impact from the virus, some older participants did not consider themselves to be more vulnerable due to their age, if they viewed themselves as healthy otherwise. These participants expressed frustration around younger people’s risk behaviours, declaring that the careless nature of younger people posed a greater threat to themselves. In addition, these older participants further blamed younger people for prolonging lockdown measures, due to persistently high rates of COVID-19 nationally.
No, I don’t think I’m more vulnerable…as I say, I’m 75, [but] I’m quite a young 75… P16_Baseline
I’d be perfectly happy knowing that I can socially distance and exercise all the logical and sensible precautions to not put myself in harm’s way but you see them [young people], everybody sees them. I only need to look at the TV…and see what I would describe as absolutely idiotic people [breaching government guidance]… P4_Baseline
I know they’ve got the facilities and everything else but not all [university] students are clean, some of them are dirty gits, and they’re not bothered about spreading the disease; they think it’s fun…It isn’t fun for the people that get it…I think [students] should all be taken…[to] see people in intensive care with the lung ventilators…they should all be traipsed through there P27_Baseline
A similar attitude was identified among the younger participants, who agreed that they had a lower risk of severe impact from COVID-19 due to their age, and expressed concerns that they may be putting elders at risk. However, these participants worried that their elderly relatives were indeed, the deviant group, not doing enough to protect themselves from the virus.
Sometimes say like a neighbour’s kids will run up to me and just come for a hug or something and so, not to be mean to a kid I will just pick them up, which I know is…not within the letter of the guidelines but…you can kind of do the mental maths…[but] the elderly, it’s just not fair to them to put them in any risk… P26_Baseline
I went…to my parents’ [house] and… he [my Dad] said are you going to come in? I said no…because we are being told not to…and he said I find this very odd and surprising…I said…there’s rules in place for a reason…My parents complain about people round the corner…having parties… It’s OK to complain about other people not following rules than think about your own behaviour… P22_Follow-up
Overall, these accounts further highlighted the general loss of control that participants (of all ages) felt regarding the actions of others, in comparison to their own risk-prevention actions.
