Study: Compliance with Covid-19 Guidelines among Israel’s Older Population

• We studied the consistency of compliance with Coronavirus guidelines on masking and social distancing with actual behavior among a large group of English-speaking Israelis over the age of 60, considered an “at-risk” group for Covid-19.
• We asked respondents how they felt about the guidelines and then asked them how they follow these guidelines when it comes to their own adult children and grandchildren who do not live with them.
• Our results showed striking differences between theoretical compliance (in principle) with guidelines and actual behavior, with over 41% completely relaxing masking and social distancing within their own homes and over 37% agreeing to visit their children/grandchildren’s homes even though masking and social distancing would not be fully observed.
• Over 77% admitted to spending time indoors (a “risk” environment) with adult children and/or grandchildren in their homes, while over 66% did so in the homes of their adult children and grandchildren.
• When asked if they would behave the same way if the risk of illness would be to their children and grandchildren, the percentages dropped considerably.
• Policy implications include understanding that theoretical guidelines are likely not to be strictly followed, and anticipated gains for various restrictions need to take this behavior into consideration.

Covid-19, National Security, and Compliance

Covid-19 has been described as a national security concern both in the United States¹ and Israel.²

An earlier study³ by this author discussed the influence of psychological and behavioral factors on compliance and, more importantly, noncompliance with guidelines set by governments and health authorities.

In the months following the initial outbreak of the pandemic, we have learned about several factors related to paths of infection, as well as who is considered “at-risk” for serious complications of the virus if infected. In discussing family (household) transmission of the virus,⁴ Hao Lei and colleagues reported in a U.S. National Institutes of Health study in August 2020 that:

• Infection risk from household contacts is 10 times higher than other contacts.
• Risk of household transmission in adults is about 3 times higher than that in children.

In Israel, reports have noted cases of high infection rates taking place within families,⁵ with one report of a nuclear family sharing a holiday meal with grandparents where all the participants were infected. The grandparents fell seriously ill and were hospitalized as a result of being infected with Covid-19.⁶ Among the ultra-Orthodox population, 52% of infections have been in the “over 65” age group, prompting a campaign “calling for extra diligence in observing the health guidelines to reduce infection and protect seniors in particular.“⁷

Israelis have been repeatedly warned of the danger inherent in older people (60+) being exposed to younger, possibly asymptomatic, carriers of Covid-19, even within families. While initial guidelines following Israel’s exit from its first lockdown stressed masking and social distancing but allowed limited indoor meetings⁸ with grandparents, subsequent guidelines quickly recommended no contact whatsoever indoors.⁹ Guidelines for ensuring non-physical contact between family members and grandparents were published by the IDF¹⁰ and other authorities.

Studying Consistency in Adherence in the Older Population

We were interested in the adherence of the over-60 population with two of the most central guidelines – masking and social distancing. Moreover, we were interested in how consistent this population was in applying these guidelines even when applied to immediate family, such as adult children and grandchildren.

We created a survey that sampled 466 Israelis over 60, whose mother tongue was English. The sampling took place during the nationwide holiday-related lockdown that began with the Rosh Hashanah holiday. We focused on English speakers, building on the assumption that their exposure to news and information regarding the Coronavirus may be higher to non-English speakers due to the plethora of information in English as opposed to Hebrew. Our respondents consisted of a random convenience sample that responded to a request to participate on various social networks in the “Anglo” community in Israel.

Besides providing information on the critical variable of compliance within family units, where the potential for infection is high, this research provided a window into the consistency between stated behavior and actual behavior with regards to Covid-19 compliance guidelines.

In short, do people accept the notion that masking and social distancing are essential, and do they behave consistently with that belief?

We also challenged the stated behavior of our sample by providing them with a theoretical reversal of roles and asking how they would behave if older people were silent carriers, but immune and younger people were highly susceptible to infection and could suffer serious consequences as a result.

Overwhelming Inconsistency between Stated Belief and Actual Behavior

Our results point to a stark contrast between what people say they believe and how they act regarding their own families. They also point to a “double standard” in risk-taking when their adult children and grandchildren and they themselves are potential victims.

Theoretical Compliance

Our sample was initially asked a direct “yes-no” question on their belief regarding the importance of wearing a mask and social distancing in controlling Coronavirus. There was near unanimity, with 98.5% saying “yes” to wearing a mask, and 99.3% saying “yes” to social distancing.

We further probed the belief in masking in practice by asking respondents how compliant they are with wearing a mask in public. Here, over 88% responded “a great deal,” with another 8.5% saying “a lot,” indicating consistency between stated belief and actual practice.

Comparing Stated Belief with Actual Practice

When we asked about social distancing, however, we conditioned the question specifically with reference to one’s children and grandchildren. Here, we found a stunning difference in compliance, with only 42.4% saying they comply a “great deal” and 27.7% complying “a lot.” In other words, while the overall stated compliance still appears to be strong (over 70%), it is decidedly less than the general question on social distancing (where over 99% definitively said “yes”) and the question on complying with wearing a mask in public (where the overall compliance was over 97% and those saying “a great deal” was more than double, at 88.6%).

Despite the seemingly overwhelming belief in the importance of masking and social distancing, we see a striking difference between stated belief and actual practice when it comes to one’s immediate family. We further focused on the practice of allowing non-resident children and grandchildren in one’s home, something that, in an indoor setting, increases the risk for Covid-19 transmission.¹¹

Here, as well, we found a clear difference between stated or theoretical belief and actual practice, with over 41% of our sample admitting to not following either masking or social distancing guidelines. Only 22.4% of our sample said they do not interact with their children and grandchildren indoors in their homes. We also found over 19% of our sample that simply did not answer the question when confronted with it. While we can speculate as to why, the refusal to answer may indicate an inconsistency between belief and practice as it pertains to the issue of one’s children and grandchildren.

We found similar results when we asked about the behavior of our 60+ sample when it comes to interacting with children and grandchildren in other indoor settings or the children’s or grandchildren’s homes. Here again, we found a discrepancy between previously stated beliefs in compliance and actual behavior, with over 37% admitting to not following masking and social distancing guidelines in other indoor settings, and another 29% saying they interacted but maintained masking and social distancing practices.

Our sample showed that the respondents acted differently with their children and grandchildren than they claimed they did with the general public, but only a minority believed that their risk was less. Only 11.8% said that they believed their children or grandchildren were less likely to be carriers who presented little risk to them. Over 65% understood the risk of interacting with children and grandchildren, yet less than half of that amount actually acted consistently with that belief in indoor settings.

Asymmetry in Behavior

We asked a hypothetical question that reversed the risk paradigm and presented a situation where younger people would be highly at risk and older people generally immune from infection. Would the older sample, who were generally willing to expose themselves to infection now, also be willing to expose their children and grandchildren if the situation were reversed?

Here we found another example of inconsistent behavior, as we saw a decrease in willingness to interact with children and grandchildren if they were the “at-risk” group. Our question was as follows:

“Coronavirus disproportionately affects older people, with younger people being silent carriers but usually not suffering serious symptoms. If the situation was reversed and older people were generally immune but were silent carriers and younger people like your children and grandchildren were at high risk for serious illness and possible death, which of the following would be true of you:”

We found the following:

Here we see a total of close to 67% of respondents who claim that they either do not interact indoors with children and grandchildren or who, under these defined circumstances, would not interact with them. This compares to 71% who, under reverse risk conditions, do interact indoors in their own homes and 66% in other indoor settings. Thus, an almost symmetrical reversal of risk-taking takes place in the older group when it is the younger population that would be at risk for infection. Another interesting finding here is whereas over 32% claimed that they do not interact at all indoors with their children or grandchildren, our previous questions found no more than 22.4% do not interact with them in their own homes, a difference of about 10%. This inconsistency demonstrates a break between what people think they are doing and what they actually do with respect to keeping to guidelines.

Policy Implications

Our results point to behavior that has critical policy implications with regard to deciding on and then estimating what the compliance rate would be for any given recommended guideline. In our sample, two conclusions are clear. First, despite a theoretical agreement with a given guideline or restriction, individuals do not consistently comply with guidelines, even those they agree should be adhered to in principle. In our example, this was seen with regard to loosening compliance when it came to one’s immediate family. Second, there is an asymmetry of sorts between the standards one would hold for themselves (here, risk-taking) and the standards they would adhere to in placing others at risk (here, adult children and grandchildren).

While we studied the “what” with regard to compliance, we did not study the “why,” and that remains an area that would require additional inquiry. Informally, we did have comments left by respondents that had the common denominator of “yes, but…” in providing a reason why they were less stringent with their adult children and grandchildren than they are in general. For example, we had comments like “we already were infected months ago, so we thought it was ok,” “we had to help out caring for a newborn,” “our children are very careful,” “we are not at-risk,” or “I had a good mask to protect me, so I was able to hug my grandchildren.”

In general, it may be safe to say that the principle of rationalization, where individuals allow themselves to believe that their behavior is fine even though it clearly is not, is in play. In lay terms, people do what they convince themselves to be right and safe even though it is not. It is also possible that people do consider the risks and simply decide to take that risk. We received few, if any, comments from individuals who felt that contact between themselves and adult children and grandchildren is not a risk for them. They were simply willing to take that risk, for whatever reason. Indeed, the strong differential between the risks they would be willing to take for themselves and the risks they would take that could place children and grandchildren in danger tends to support that hypothesis. However, it also begs the question of why children of older “at-risk” Israelis do not exhibit the same concern for infecting their parents as their parents show they would have for infecting them (as our data has shown).

These findings reinforce the difficulties policymakers face in deciding which restrictions to enforce and which to recommend. We see that what people say is not as telling as what people actually do. In Israel, this was also seen in the widely publicized cases of several high-ranking government officials who, like in our sample, theoretically – and publicly — supported family visiting restrictions but did not keep them in practice.¹²

What has been demonstrated here is that theory and practice are likely not to be congruent. Calculations made on the basis of theory may not be accurate once actual practice is looked at. From our data, it appears that this would be an important consideration in determining what may be the consequences of any particular guideline or restriction. What we think we see is not what we will always actually get.

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Notes