Likelihood of Quarantine Compliance During the COVID-19 Pandemic in the Midwest U.S.: Implications for Future Interventions

doi:10.21203/rs.3.rs-8515460/v1

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Likelihood of Quarantine Compliance During the COVID-19 Pandemic in the Midwest U.S.: Implications for Future Interventions

https://doi.org/10.21203/rs.3.rs-8515460/v1

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Introduction

The COVID-19 pandemic highlighted the crucial role of quarantine measures in controlling the spread of infectious diseases, especially during public health emergencies. However, compliance with quarantine measures was inconsistent, and little is known about the predictors of adherence in community settings. Therefore, this study seeks to understand the predictors of individuals to maintain quarantine among adults in Missouri.

Methods

This study used data from a cross-sectional survey, and the sample included 1,717 Missouri residents aged 18 and over. Data were analyzed using t-test and chi-squared tests to assess independence, and an adjusted multinomial logistic regression was constructed to understand the impact of predictors on the self-reported history of COVID-19 infection and subsequent quarantine behaviors.

Results

Approximately 34.3% of respondents participating in the study indicated that they had to undergo quarantine due to exposure to COVID-19, either voluntarily or as instructed by a healthcare professional or public health department authority. Younger, non-white individuals, parents of children under 18, those with higher incomes, and front-line workers were more likely to report quarantining than others.

Discussion

These findings can help better understand conditions in which individuals are more likely to quarantine during health exposures and infections. While this was an examination during the first year of COVID-19, responding to other infectious diseases that necessitate quarantining may use these results as a guide for supporting this type of intervention strategy. Investigating the enhancement of health policies, messaging, and communication can help refine future communication strategies for future health emergencies.

Infectious Diseases

COVID-19

Disease Outbreaks

Public Health Practice

Quarantine

Health Behavior

Quarantine is a measure taken to reduce the spread of a contagious disease by temporarily restricting the movement of those who have likely been exposed to it. It has historically been used as a front-line response during public health contagious disease emergencies (National Academies of Sciences, 2020). Beginning in December 2019, quarantine measures were heavily utilized as a preventative strategy to limit the spread of the emerging coronavirus (COVID-19) infection. The Centers for Disease Control and Prevention (CDC) initially recommended a 14-day quarantine period on January 1, 2021. Subsequently, this duration was revised to 5 days and now has limited quarantine recommendations, which account for the evolving understanding of COVID-19 science (Centers for Disease Control and Prevention, 2021). While the recommended time period for quarantine in response to COVID-19 has fluctuated, considering the continuous evolution of viral variants, implementation of pharmaceutical vaccinations, and economic pressures it poses, the Centers for Disease Control and Prevention (CDC) continues to promote quarantine as an effective preventative measure to reduce COVID-19 infections (Centers for Disease Control and Prevention, 2022). In the absence of relevant federal-level policy in the U.S., contradictory and unclear guidance during the initial stages of COVID-19 disrupted healthcare coordination, leading to inconsistent responses at state and local levels, which in turn affected the enforcement of quarantine measures and influenced individuals' willingness to comply with quarantine recommendations (Serchen et al., 2023). Quarantining recommendations, while effective in reducing COVID-19 cases, introduce a myriad of challenges for individuals.

Quarantine poses a financial burden that results in lost wages, especially difficult for those employed in low-wage earning occupations, as they often do not have paid sick leave. Thus, job attendance has been prioritized over health in order to remain financially solvent (Bodas & Peleg, 2020). Notably, over half of the low-wage occupations in the U.S. workforce were also defined as essential employment, putting a compounded risk on an already vulnerable population (Kinder & Stateler, 2021). In addition, self-isolation has been shown to be nearly impossible for families with conflicting responsibilities of childcare, elder care, and a lack of designated space within the home to isolate (Machida et al., 2020).

Among many who were able to quarantine, lengthy periods of isolation had adverse psychological impacts. Prominently, children and caregivers reported increased psychological stress, anxiety, and depression associated with isolationism during COVID-19 (Demaria & Vicari, 2021). Further, interruption to children’s daily routine due to the pandemic has been determined to be associated with numerous negative effects on sleep, personal relationships, educational performance, and overall learning skills, many of which were seen more severely in children from marginalized populations and disadvantaged backgrounds (Amin & Parveen, 2022). Adverse physical effects have also been noted in association with lengthy quarantine (Flanagan et al., 2021). Limitations in geographic movement equate to limitations in healthy food access and limitations on physical exercise, and in turn have been identified to be associated with weight gain, reduced physical activity, and adverse psychological consequences (Zeigler, 2021). Lastly, prolonged quarantine can impact compliance with quarantine regulations, which did not support infection reduction (Liu et al., 2022).

Understanding quarantine adherence in Missouri during the early stages of the COVID-19 pandemic is essential to improving future public health responses. Although there was initial resistance for a statewide stay-at-home order, one was eventually issued from April 6 to May 3, 2020 (Erwin et al., 2021). However, inconsistent public health messaging and fragmented local governance contributed to widespread confusion (Acosta et al., 2021). A study using mobile device data showed that Missouri had one of the smallest reductions in average travel distance nationally, just + 1.9 miles, indicating limited behavioral change (Lee et al., 2020). This was particularly concerning given a St. Louis–based study modeling estimated that a two-week delay in distancing may have led to nearly significantly more deaths by end of 2020 (Geng et al., 2021). Missouri’s limited outbreak data infrastructure further hampered timely decision-making (Acosta et al., 2021). As a state with a diverse population—including urban Black and African American communities and rural white and Republican residents—Missouri experienced distinct barriers to quarantine adherence and faced different challenges and levels of skepticism, that were not just anchored in race, education, and annual income (Shacham et al., 2021). These variations highlight the inadequacy of broad policy models and underscore the need to understand localized behaviors and perceptions to better prepare for future health emergencies.

The ability to quarantine, although effective in infectious diseases, including COVID-19 prevention, may not be a reasonable intervention. It is essential to explore how individuals first received recommendations for quarantining. The purpose of this study was to identify characteristics associated with the ability to quarantine during the COVID-19 pandemic in an effort to assess the likelihood of adherence to quarantine recommendations in the future management of infectious diseases. This study was conducted to better prepare for the future by enhancing quarantine prevention efforts. Understanding the barriers to self-quarantine behaviors is limited, and this may provide practical tools to support individuals and families as they navigate an infectious disease in the future.

The data used in this analysis were from a cross-sectional study that examined experiences of physical and mental health symptoms during the first 2 years of the COVID-19 pandemic among a non-probability sample of residents of Missouri. Data were collected as part of the “Messaging Development and Research in Support of Communication about COVID-19 Vaccine Utilization” study using electronic surveys from an external surveying company with a panel of participants recruited by Qualtrics. This study comes from a larger dataset, collected in February 2022 using the Qualtrics research panel service. As part of the Qualtrics panel service, the researcher worked with a program coordinator at Qualtrics to administer a survey to a pre-arranged and targeted pool of Missouri-based respondents, with additional focus on St. Louis-region respondents. Recruitment was facilitated through Qualtrics via email, and the survey was available exclusively to Qualtrics panel participants. Individuals interested in participating were directed to a web-based survey which was built using the Qualtrics survey platform.

Survey questions included current and past COVID-19 status, interacting with those known to be infected, overall psychological and physical health, and questions specific to self-quarantine practices relevant to COVID-19 prevention were also included. Due to employment status playing a prominent role in an individual’s ability to quarantine during the COVID-19 pandemic, the sample for this analysis was limited to only those who reported having COVID-19 and being employed at the time of survey completion (n = 1,717). Although not specifically a survey about the quarantining practices during COVID-19, questions on the quarantining practices and self-reported COVID-19 diagnosis were included to assess infectious disease preventative practices. Further, because most questions asked participants about their experiences in the past year, this time frame coincided with the emergence of the pandemic.

The study outcome of interest was based on a single-item survey response to the question: “Have you had to quarantine due to a known or expected COVID-19 exposure?”. Participants could choose from one or more responses to this question, listed as: (1) “Yes, I was told to quarantine by a health care practitioner or the health department”, (2) “Yes, I self-quarantined”, or (3) “No”. Responses were transformed into binary format, and participants were divided into two groups based on their adherence to quarantine: those who answered “No" to the previous question were classified as not having quarantined, while those with different responses indicated that they had to quarantine due to COVID-19 exposure.

Individual-level variables included age, gender, race, being a parent to a child aged below 18, annual household income, political party affiliation, and if the individual was a frontline worker, or if their employment required face-to-face interaction with other people.

T-tests and chi-square (c²) tests were used for continuous and categorical variables, respectively, to identify significant differences among individual and geographic characteristics according to having reported quarantining due to COVID-19. Variables determined to be significantly associated with quarantining were then used for multivariate model construction. The adjusted binomial logit regression model was constructed to determine the effects of predictors on respondents’ reported history of quarantining. All significance was assessed at α = 0.05. All data organization and statistical analysis were completed using the R programming language.

The study sample included a total of 1,717 participants who had reported COVID-19 infection, of which 956 (55.7%) reported not quarantining. Descriptive characteristics according to quarantining are detailed in Table 1. Among all participants who reported ever having COVID-19, 898 (52.3%) were females and had an average age of 40.2 years old (SD = 13.2). Slightly over a third of the sample reported being non-white (n = 604, 35.2%), and over a third reported being a parent to a child under the age of 18 (n = 657, 38.3%). More than half of the sample reported being a frontline worker or being employed where face-to-face in-person interaction was a requirement (n = 996, 58.0%). Among annual household income categories, the most often response was $50,000 to $100,000 (n = 705, 41.1%). Among political parties, the most prominently represented were individuals reporting as conservative or Republican (n = 605, 35.2%). Statistical testing reveals those likely to have reported previously quarantining were significantly likely to be younger (p < 0.001), non-white (p < 0.001), parent to a child 18 or younger (p < 0.001), report higher levels of income (p < 0.001), align politically Democrat or liberal (p < 0.001), and be employed in a frontline environment (p < 0.001).

Table 1

Descriptive characteristics among sample of Missouri residents (n = 1,717) among those reported quarantining due to COVID-19 infection.
	Did Not Quarantine (956, 55.7%)	Did Quarantine (761, 44.3%)	P value
Individual Characteristics
Age, mean (SD)	42.5 (14.3)	37.2 (10.9)	< 0.001
Gender, n (%)
Female	492 (51.5)	406 (53.4)	0.466
Non-female	464 (48.5)	355 (46.7)
Nonwhite, n (%)	289 (30.2)	315 (41.4)	< 0.001
Parent to a child aged < 18, n (%)	317 (33.2)	340 (44.7)	< 0.001
Annual household income (in $1,000s), n (%)
<25,000	141 (14.8)	67 (8.8)	< 0.001
25,000–50,000	232 (24.3)	143 (18.8)
50,000-100,000	355 (37.1)	350 (46.0)
>100	228 (23.9)	201 (26.4)
Political ideology, n (%)
Conservative	370 (38.7)	235(30.9)	< 0.001
Liberal	293 (30.7)	289 (38.0)
Moderate	293 (30.7)	237 (31.1)
Frontline worker, n (%)	521 (54.5)	475 (62.4)	0.001
Significant effects indicated in bold

Individual-level characteristics, identified as significantly associated with self-reported quarantining, were used as predictors in the prediction model, an adjusted binary logit model using “reported quarantining” as the response variable detailed in Table 2. Model results identified that as age increased, the probability of reporting quarantine decreased by nearly 1% per year-old (AME − 0.006, 95% CI -0.008, -0.005). Compared to participants who identified as white, nonwhite participants were nearly 7% more likely to have also reported quarantining (AME 0.067, 95% CI 0.017, 0.117). On average, parents of younger children and frontline workers, compared to their counterparts, were at a 9% and 8% increased probability of reporting quarantining (AME 0.090, 95% CI 0.043, 0.137 and AME 0.083, 95% CI 0.037, 0.129, respectively). Annual income was found to be the strongest predictor in the model, with those reporting an income of over $50,000, compared to those reporting an income of <$25,000, having a 17.1% increased likelihood of quarantining (AME 0.171, 95% CI 0.099, 0.243).

Table 2

Adjusted marginal effects of probability of quarantine among a sample of Missouri residents
	Adjusted marginal effect, %	95% CI	p-value
Age	-0.6	-0.8, -0.5	< 0.001
Race: non-white	6.7	1.7, 11.7	0.008
Parent to a child aged < 18	9.0	4.3, 13.7	< 0.001
Income
<$25000	Reference
$25-50000	6.3	-1.6, 14.1	0.123
$50-100000	17.1	9.9, 24.3	< 0.001
>$100000	16.3	8.5, 24.1	< 0.001
Political affiliation
Democratic	Reference
Moderate	-1.9	-7.6, 3.8	0.505
Republican	-4.7	-10.4, 0.9	0.101
Frontline worker	8.3	3.7, 12.9	< 0.001
Significant effects indicated in bold.

Significant differences in geographic and sociodemographic characteristics of individuals across Missouri were identified between those who reported quarantine and those who did not. Specifically, those who were younger adults, non-white adults, with higher incomes, parents, and frontline workers were more likely to have quarantined during the first year of the COVID-19 pandemic. These findings suggest insights for shaping future quarantine recommendations and public health strategies.

Studies seem to agree that younger adults may be more likely to follow recommended COVID-19 preventative guidelines (Yang et al., 2020). According to this research, motivation to quarantine among young adults may be due more to altruism rather than self-protection, with young adults more likely to participate in preventative behavior in order to protect older family members. Also aligned with these results, non-white populations are more likely to participate in preventative COVID-19 behaviors (Gibbons, 2021). However, these studies also found that while non-white populations adhere more strongly to social distancing, they were more likely to be more mobile after locations re-open, suggesting a dynamic complexity likely due to structural discrimination, as being able to stay home was likely an economic and familial burden due to limited paid sick leave and health insurance to receive medical care (Gibbons, 2021; White et al., 2021). Clear and effective communication through trusted sources can encourage adults and people of different races to respect healthcare measures.(Webster et al., 2020) Disseminating clear and consistent information (Webster et al., 2020) and involving medical practitioners in social media campaigns (Guillen & Nelson, 2021) can be beneficial for quarantine adherence. Along with this, it can be crucial to reinforce social norms in designing strategies,(Webster et al., 2020) promoting a positive attitude to health information,(Guillen & Nelson, 2021) and involving family members in communication and managing disease (Bazo-Alvarez et al., 2023) can reduce hesitancy in being compliant with quarantine recommendations.

While the recommended time-period for quarantine in response to COVID-19 has fluctuated throughout the pandemic, studies concur that the safety of frontline workers needed to be prioritized throughout the pandemic (Gómez-Durán et al., 2020). Research shows that frontline workers have a greater risk of being exposed to COVID-19, which leads them to undergo quarantine (Gómez-Durán et al., 2020). Yet, during times of high risk, healthcare workers were unable to quarantine due to workforce shortage at the time,(Kerr et al., 2021) grocery store and food service workers lacked paid sick leave (Henning-Smith et al., 2023). While studies show that parents can have adverse effects on wellbeing, including suffering from post-traumatic stress disorder due to quarantine measures,(Sprang & Silman, 2013) parents were more likely to engage in COVID-19 preventative measures, including hand-washing and mask-wearing, yet unable to quarantine (Ayran et al., 2022). Taking timely and sustainable actions to ensure proper compliance with quarantine measures can reduce adverse impacts from infectious diseases. Ensuring the availability of self-protective equipment (PPE, such as gowns, gloves, N95 masks, goggles, etc.) and getting PC (infection prevention and control) training for pathogens can be crucial for reducing life threats during emergencies (Carlucci et al., 2020). Further, this one example of quarantining for a respiratory infectious disease does not reflect its replicability across other infectious diseases. Learning and communicating the correct prevention methods for each infectious disease is the most important thing to do efficiently and effectively. Knowing that there are significant barriers to quarantining or other preventive recommendations is necessary to better connect with the populations at the highest risk in order to realistically minimize the risk of infectious disease transmission.

Limitations

This study was limited by the timing of the data collection due to changing quarantine recommendations and limited to data collection in Missouri only. This study highlights the characteristics of individuals who were able to quarantine. These self-reported quarantine behaviors are likely limited as well, and as the pandemic wore on, the requirements of in-person life likely overpowered the intention to quarantine. However, this study cannot offer suggestions that will promote adherence in all future quarantined populations; the insights from our analysis could serve as a helpful initial guide for those evaluating these scenarios.

This study highlighted the key demographics associated with willingness to quarantine in the absence of any relevant Federal-level policy. The implications of this study suggest the need to develop a policy that promotes compliance with quarantine guidelines supported by data-driven evidence. It underscores the importance of advocating for quarantine when it is considered essential, while also prioritizing the provision of timely and consistent information and ensuring access to self-protective items and essential supplies, with sustainable measures to encourage adherence to quarantine protocols. However, quarantine guidelines had not been consistent throughout the pandemic and had a significant economic impact on the world. Pandemic planning should be implemented to develop guidelines that take geographic and sociodemographic characteristics into account.

Conflict of Interest Statement

The Authors declare that there is no conflict of interest

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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The authors declare no competing interests.

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Likelihood of Quarantine Compliance During the COVID-19 Pandemic in the Midwest U.S.: Implications for Future Interventions

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Abstract

Introduction

Methods

Results

Discussion

INTRODUCTION

METHODS

RESULTS

DISCUSSION

Limitations

Conclusions

Declarations

Conflict of Interest Statement

Data availability statement

References

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