Drop in Adherence to Nonpharmaceutical Interventions Reflects Pandemic Fatigue


Adherence to nonpharmaceutical interventions such as staying home and avoiding eating in restaurants dropped during the pandemic, while use of face masks increased, according to a new report.

Adherence to nonpharmaceutical interventions to combat the coronavirus disease 2019 (COVID-19) pandemic declined overall between early April and late November, but use of face coverings increased, according to a research letter published in JAMA.

The study, by investigators at Johns Hopkins University, Yale Institute for Global Health and USC Leonard D. Schaeffer Center for Health Policy and Economics, analyzed survey responses from 7705 participants involved in the Understanding America Study (UAS) conducted by the University of Southern California Center for Economic and Social Research.

“This work provides support to the often-discussed idea of ‘pandemic fatigue,’” study author Matthew A. Crane, an MD candidate at Johns Hopkins University School of Medicine, told Contagion®. “We find that many nonpharmaceutical interventions aiming to combat the COVID-19 pandemic have decreased over time.”

Those nonpharmaceutical interventions (NPI) include staying home except for essential activities, staying 6 feet apart from people outside of the household, avoiding restaurants, avoiding large gatherings, working from home and washing hands several times a day.

“Despite substantial efforts in public health messaging, there has been a ‘plateau’ effect for many months,” Crane said. “With difficulty in increasing public adherence to NPIs and decreasing transmission through protective behaviors, it's even more important that vaccination efforts are accelerated to end the pandemic.”

The national NPI index, which includes reported adherence to 16 protective measures, decreased from 70 in early April to the high 50s in June before increasing to 60.1 in the final survey, the study authors reported. Overall declines were reported in all US Census regions, declining most in the Midwest from 70.3 to 54.4, followed by drops of 70 to 60.5 in the South, 71.5 to 62.2 in the West and 70.8 to 62.4 in the Northeast.

Measures that showed the largest decreases in adherence included:

Remaining in residence except for essential activities or exercise (79.6% to 41.1%),

Having no close contact with non–household members (63.5% to 37.8%),

Not having visitors over (80.3% to 57.6%), and

Avoiding eating at restaurants (87.3% to 65.8%).

Survey participants reported a significant increase in adherence to wearing face coverings (39.2% to 88.6%), which aligns with other national surveys.

“Clinicians and health care providers should understand that ‘pandemic fatigue’ is a real effect, but it is also a complicated phenomenon. While it is important from a public health standpoint to promote protective behaviors, it is also important to recognize that people make risky choices, and an approach of risk mitigation may ultimately resonate the most with patients," Crane said.

“Many people will decide to go to restaurants, bars, or see friends despite risk of infection. It is important that when they do, we provide them with effective and evidence-based infection prevention strategies such as physical distancing, mask-wearing, and environment redesign.”

Limitations of the study include its reliance on self-reported behaviors. The adherence index used in the study has not been validated.

“Next steps in this research on our part involve more detailed analysis of the reported behaviors,” Crane said. “We hope that others will perform additional research to analyze which nonpharmaceutical interventions are most effective in preventing COVID-19 infection to better inform policy decisions in this area.”

While health experts have widely encouraged the use of face masks, some have cautioned that masks can’t replace social distancing precautions for people at highest risk for severe COVID-19.

A recently published simulation model funded by the National Institute for Allergy and Infectious Diseases (NIAID) showed that the timing and adherence of social distancing measures in New York had a significant impact on the spread of COVID-19, suggesting that implementing measures a week earlier would have reduced cases by 80% and implementing them a week later would have increased cases seven-fold.

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