https://orcid.org/0000-0002-2523-1222
ABSTRACT
Social distancing behaviour is a primary preventive measure for reducing COVID-19 transmission. Improved understanding of factors associated with adherence to social distancing is vital for mitigating the impact of COVID-19 in South Africa. The study assessed adherence to social distancing and its associated factors during the state-implemented lockdown in South Africa. Data was analysed from a large-scale public survey conducted in South Africa from 8 to 29 April 2020, which was administered online and telephonically. Invitations to participate were distributed widely on local websites and social media networks, including on a data-free platform. Adherence to social distancing was measured by self-report of having engaged in close physical contact with someone outside the home. Simple and multiple logistic regression models examined the association between social distancing and potential explanatory variables. Of the 17,586 participants, 9.2% came into close physical contact with a person outside their home by hugging, kissing, or shaking hands during the past 7 days. The odds of coming into close physical contact with other people were significantly higher for males, students, and those with incorrect knowledge on physical distancing, angry attitudes about the lockdown, lack of confidence in the government response, high-risk perception, movement out of the local area, travelling to shops using public transport, households with communal water facilities and higher household size. The 25–59-year olds compared to 18–24-year olds, and the White and Indian/Asian compared to the African population groups had significantly lower odds of close physical contact with others outside the home. The study identifies subgroups of individuals for whom public health interventions to improve adherence to social distancing should be prioritised and tailored. Interventions and policies should take cognisance of the social determinants of health as well as culturally accepted greeting practices like hand shaking.
Introduction
Social distancing or ‘physical distancing’ has been a primary behavioural measure for reducing COVID-19 transmission (World Health Organization, Citation2020a), particularly during the early stages of the COVID-19 pandemic. Social distancing refers to avoiding close physical contact with people outside one’s household, maintaining at least a metre distance from others in public places and avoiding crowded gatherings (World Health Organization, Citation2020a). Social distancing has been associated with reduced COVID-19 infections (Cowling et al., Citation2020; Prem et al., Citation2020). The WHO recommended that social distancing be practiced with other preventive behaviours including mask wearing and hand washing (World Health Organization, Citation2020a).
South Africa implemented strict lockdown regulations to reduce movement and inter-personal interactions. However, during 2020 it had among the highest total cases globally (John Hopkins University & Medicine: Coronavirus Resource Center, Citation2020). Following its first cases in March 2020, the country began a national three-week lockdown on 26 March 2020 (The Presidency: Republic of South Africa, Citation2020) (known as level 5 lockdown). This included prohibition of mass gatherings, and closure of schools workplaces, and passenger transport, except for any service or sector deemed essential. The regulations were accompanied by public health advice on hygiene, avoiding close physical contact and maintaining a 1–2 metre distance from others outside the home. The country then transitioned to lower levels of lockdown, in which sectors of the economy reopened, but with regulations for mandatory mask wearing and social distancing in public (National Department of Health, South Africa, Citation2020).
Modelling estimates showed that if the social distancing measures were relaxed by 2%, cumulative cases could rise by 23%. These estimates were based on the cases and observed levels of social distancing during the lockdown(Nyabadza et al., Citation2020). Furthermore, Silal et al. (Citation2020) indicated that during the first wave of infections, South Africa’s epidemic peak could be delayed by 2–3 months depending on adherence to lockdown measures, including social distancing. Understanding the determinants of adherence to social distancing can inform the development of targeted and tailored public health interventions for improving social distancing. This can be relevant in informing public health messaging both in preparation for subsequent COVID-19 waves and other infectious disease outbreaks or pandemics. There are currently few empirical studies on factors associated with physical contact and social distancing behaviours during infectious disease outbreaks, particularly in low- and middle-income countries (LMICs). Studies from countries that experienced epidemics of Influenza, Middle East Respiratory Syndrome and COVID-19 found that transmission reducing behaviours, such as social distancing, were influenced by increased risk perceptions (Bults et al., Citation2011; Jang et al., Citation2020; Lee et al., Citation2016) and self-efficacy to adopt these behaviours (Bults et al., Citation2011; Seale et al., Citation2020). High knowledge about prevention and transmission of COVID-19 was also associated with behaviours including avoiding crowds, hand shaking, and distancing (Al-Hanawi et al., Citation2020; Azlan et al., Citation2020; Kebede et al., Citation2020; Yanti et al., Citation2020). Social distancing was also influenced by gender, older age, education, income, and support for and trust in the government (Azlan et al., Citation2020; Canning et al., Citation2020; Olum et al., Citation2020; Seale et al., Citation2020).
Social distancing measures are markedly more difficult for those with adverse social determinants such as crowded living conditions and poverty (Abrams & Szefler, Citation2020), thereby exposing these individuals to greater risk of transmission. This is particularly relevant in South Africa, one of the most unequal countries in the world. A large proportion of South Africans live in high density lower socio-economic communities characterized by overcrowding, smaller living spaces, communal water services, and inadequate sanitation (Statistics South Africa, Citation2021). 30% use public transport which is often crowded. These people have higher frequency of social interactions, making the avoidance of physical contact more difficult.
Physical contact such as handshaking, hugging, and kissing are socially acceptable behavioral norms, that are more prevalent in some societies. Physical contact greetings are dependent on culture and context. The ability to change these behaviours during the pandemic is likely to be influenced by a range of sociobehavioural factors.
This study investigates the extent to which South Africans adhered to social distancing by avoiding close physical contact with other people, in compliance with the lockdown and it identifies the socio-demographic, sociobehavioural, and household environmental determinants associated with physical contact with others outside the home.
Materials and methods
Study design
A questionnaire with closed-ended questions was administered on an online platform, as well as telephone facilitated interviews. South Africans aged ≥18 years were eligible to participate.
Recruitment of participants
The request to participate was widely dispersed on a data-free mobile messaging platform. A partnership was established with the platform, which was selected due to its large user-base. The data-free platform allowed mobile phone users to respond to the survey, without data costs.
Additionally, communication alerts to participate in the survey were widely distributed via communication and media channels, (social media, email, radio, local websites); and among a network of strategic partners in government, science councils, higher education, non-profit organisations, the private sector, and faith-based and community organisations. The communication alerts included an invitation with the survey link.
The online method was supplemented with telephone interviews, to include participants that may not otherwise have completed a survey online. An anonymized telephone list of approximately one million individuals in predominantly densely populated areas like townships and informal settlements was obtained from a government department that had an agreement with a private service provider. A targeted sample of 41500 telephone numbers was selected across the nine provinces, of which 3 602 were answered and 2682 consented and participated. On taking the call, the source of their mobile number was divulged to the potential participant and informed consent was administered and recorded. Identifying information of respondents was not recorded. Telephone interviews were administered by trained interviewers. The team of interviewers were fluent in English and in the other four languages (Afrikaans, Sepedi, iisiZulu,and isiXhosa) in which the survey could be completed.
Study procedures and questionnaire development
The survey was conducted during 8–29 April 2020, corresponding to the 2nd-4th week of the ‘level 5’ lockdown. The online survey was conducted during 8–24 April and the telephone survey during 8–29 April, due to telephone surveys taking longer time to complete.
The 55-item questionnaire was developed in consultation with behavioural and public health scientists, epidemiologists, and stakeholders in scientific and civil society networks, and was informed by previous studies on public reactions to the pandemic (Ipsos, Citation2020; Nooh et al., Citation2020; Reddy et al., Citation2020). The questionnaire covered eight domains: socio-demographic characteristics, knowledge about COVID-19 prevention, attitudes, and public concerns about the pandemic and the lockdown measures, experiences with testing and screening, travel behaviour, social distancing, access to essential services, and the socio-economic impact of the lockdown. The survey took approximately 20 minutes to complete.
Ethical procedures
The study received ethical approval from the Human Sciences Research Council Research Ethics Committee (REC) Protocol number: REC 5/03/20. Informed consent was obtained before participants proceeded to the survey questions. Participants were informed about voluntary participation, anonymity of responses and being able to withdraw during the survey.
Measures
The primary outcome variable, social distancing, is based on the question ‘Over the past seven days, have you come into contact with people outside your home by shaking hands, hugging or kissing?’ with a yes or no response option.
The selection of explanatory variables investigated was guided by literature on factors associated with practicing preventive behaviours during respiratory disease epidemics, the Health Belief Model (HBM; Rosenstock, Citation1974) and the Social Determinants of Health (SDH) (World Health Organization, Citation2020). The HBM postulates that health behaviour is determined by the perceived risk to the health threat, self-efficacy in the behaviour change leading to improved outcomes, and the feasibility of implementing behavioural change in the individual’s environmental contexts. The SDH are socioeconomic factors such as poverty, education, and living conditions as influencing health outcomes. We considered that these social determinants of health could influence the frequency and nature of social contacts. Therefore, the domains of explanatory variables selected were: socio-demographic, psychosocial determinants of behaviour, household environmental and living conditions, area movement, and economic capability. The variables are described in .
Table 1. Explanatory variables used in the analysis.
Statistical analysis
Data were analysed in Stata 15.0. The data were benchmarked using the South African 2019 mid-year population estimates by age, race, sex, and province (Statistics South Africa, Citation2019) for the population aged ≥18 years, to increase generalizability of the findings to a national level. All analyses were conducted on the weighted data. Descriptive statistics were used to summarize sample characteristics and social distancing by selected explanatory variables. The association between social distancing and potential explanatory variables was first assessed using bivariate logistic regression models. All statistically significant variables were then entered into the final multiple logistic regression model. Odds ratios with a p < 0.05 were considered statistically significant.
Results
Characteristics of the weighted sample
The sample consisted of 17563 respondents with 53.0% female, 70.1% aged 25–59 years, 77.9% African, 33.9% residing in townships, 79.6% having a matriculation certificate (completed secondary school) or higher level of education, 36.6% in full-time employment and 37.2% unemployed (). Over 95% reported correct knowledge that staying away from both infected people and other people in general can prevent COVID-19 infection. 11.7% felt that the lockdown was unnecessary and had made them angry and 9.1% expressed low confidence in the government’s response to the outbreak. Over 80% reported basic self-efficacy in protecting themselves from COVID-19 infection while a quarter perceived themselves as having a high risk of infection. The mean household size was 4.8 people, 23.2% reported that they did not have adequate money for food during the lockdown and 26.6% reported that they share their water sources with other households.
Table 2. Characteristics of the sample.
Social distancing behaviour during the lockdown
Overall, 9.2% reported that they came into close physical contact with someone outside their homes during the preceding 7 days, by hugging, kissing, or shaking hands (). Close physical contact varied significantly by all the independent variables except for education level.
Table 3. Social distancing by selected explanatory variables.
Close physical contact was higher among males, the African and Coloured population groups, residents of townships (11.7%) and informal settlements (15.8%), those who had shared water facilities (12.8%) and who lived in households with a large number of people (14.5%). The prevalence of physical contact decreased with increasing age. Similar proportions of youth 18–24 years (15.0%) and students (14.7%) reported close physical contact. Furthermore, higher proportions of participants who thought the lockdown was unnecessary (13.7%), who had low confidence in the government’s response to the outbreak (15.5%), who had high-risk perceptions (14.0%) and who lacked self-efficacy in prevention (11.7%) reported close physical contact. Close physical contact was twice as high in participants who lacked knowledge that keeping distance from others was a prevention measure compared to those with correct knowledge.
Factors associated with close physical contact
The multiple logistic regression model () showed that the odds of coming into close physical contact with other people were significantly higher for males than females (Adjusted odds ratio (AOR) = 1.79, 95% CI: 1.49–2.16), students than full-time employees (AOR = 1.72, 1.24–2.39), individuals who felt that the lockdown was unnecessary and were angered by it (AOR = 1.50, 1.14–1.97), those with moderate (AOR = 1.29, 1.03–1.61) or low (AOR = 1.79, 1.36–2.36) confidence in the government’s response to the outbreak than high confidence, moderate (AOR = 1.43, 1.15–1.78) and high (AOR = 2.22, 1.73–2.85) risk perception than low-risk perception, movement out of the local area (AOR = 2.18, 1.78–2.68), being able to get to shops within walking distance from the home (AOR = 1.29, 1.00–1.67) and having to travel to shops using public transport (AOR = 1.51, 1.09–2.08) than by personal vehicle, shared household water facilities (AOR = 1.42, 1.16–1.75) and larger household size (AOR = 1.05, 1.02–1.08). The odds of close physical contact were significantly lower for 25–59 year olds than 18–24 year olds (AOR = 0.67, 0.52–0.85), White (AOR = 0.54, 0.35–0.82) and Indian/Asian (AOR = 0.43, 0.26–0.69) than African population groups, and those with correct knowledge that staying 2 m away from others can prevent COVID-19 infection (AOR = 0.58, 0.42–0.78) than those with incorrect knowledge.
Table 4. Multiple logistic regression model showing factors associated with having been in close physical contact with someone outside of the home in the past 7 days.
Discussion
Overall, about 90% of South Africans practiced some degree of social distancing between 12 and 33 days into the country’s lockdown. Similar results were observed with substantial increases in social distancing in the United States since the start of the pandemic (Andersen, Citation2020), and in the United Kingdom and Germany, where compliance increased with empathy for vulnerable groups (Pfattheicher et al., Citation2020). However, this study found that during the lockdown, almost a tenth of South Africans were in close physical contact with people outside their homes by hugging, kissing, or hand shaking. At the time of the survey, mask wearing was newly introduced and only became mandatory on 29 April 2020 (South Africa, Department of Co-operative Governance and Traditional Affairs. Disaster Management Act Citation2002, 2020). We did not assess whether those who had close physical contact had worn a mask. However, these individuals can be seen as non-compliant with social distancing regulations and could have contributed to the rapid community transmission rates in the ensuing weeks.
The likelihood of coming into close physical contact with other people was significantly higher for males, students, the African population group, those with incorrect knowledge on physical distancing, negative attitudes about the purpose of the lockdown, lack of confidence in the government response, high-risk perceptions, those who moved out of their local area, those who travelled to shops using public transport or by walking, and those who lived in households with communal water facilities and larger household sizes.
The findings correspond with research indicating that men have lower compliance with COVID-19 public health measures including social distancing (Baker et al., Citation2020; Ewig, Citation2020), that is partly attributed to men’s socialisation (Gupta, Citation2020), and the tendency to downplay risk (Griffith et al., Citation2020). Less social distancing among young people was also reported in the US, where people older than 50 years reported far less close contacts than 18–29-year-olds (Canning et al., Citation2020). Social distancing among youth is relevant in LMICs like South Africa due to more intergenerational contact than high-income countries (Walker et al., Citation2020), thereby increasing transmission risk in the elderly. Other studies reported lower engagement in social distancing among youth in South Africa during the first and second epidemic waves (Kollamparambil & Oyenubi, Citation2021).
In congruence with current findings, studies show that non-compliance and no support for preventive measures, including social distancing, are affected by poor knowledge and negative attitudes regarding the preventive measures (Austrian et al., Citation2020; Kebede et al., Citation2020; Zhong et al., Citation2020). Therefore, clear public health information provided to high-risk communities, on the rationale for quarantine and the ways in which the virus is transmitted, would likely increase their willingness to adopt distancing behaviours. In contrast to other studies, individuals with high-risk perceptions were more likely to engage in close physical contact. Further research is recommended to delineate this association. It could be posited that individuals at increased risk of COVID-19, due to unfavourable living conditions or underlying health conditions are aware of their risk but did not refrain from personal contact due to various reasons including personal beliefs or cultural norms. Furthermore, a study showed that perceived fatalism of COVID-19 predicted lower intention to practice preventive behaviours such as avoiding social contact (Jimenez et al., Citation2020). More importantly, the relationship between risk perceptions and behaviour cannot be fully examined in a cross-sectional study because one’s current risk perception can be reflective of their risk behaviours over time (Brewer et al., Citation2004).
Factors linked to lower socio-economic status, that is, communal water sources, large households, and using public transport or walking to shops instead of owning a car, were all associated with engaging in physical contact. While adverse living conditions do not directly imply more physical contact such as hand shaking, people in densely populated neighbourhoods and those who use public transport have a higher likelihood and frequency of meeting and socially interacting with other people and are less likely to self-quarantine. Johnstone-Robertson et al. (Citation2011) found a high frequency of close physical contacts among residents in an urban South African township. Furthermore, social engagement and sense of security are affected by where people live (Citation2020). Due to poverty, overcrowding, and unemployment in township areas, economic and social activities are all often constrained to smaller common spaces in yards and on the streets. These physical environments thereby influence social environments, and behavioural and cultural norms (Brookes, Citation2014). Other studies highlight challenges of complying with socio-behavioural preventive measures including social distancing (and thereby the avoidance of social interactions) in impoverished or informal housing environments with constrained communal spaces (Dahab et al., Citation2020; Gibson & Rush, Citation2020), and in overcrowded minibuses (Botes & Thaldar, Citation2020). This study also showed that social distancing was higher in the population groups that have higher average incomes in South Africa. Many South Africans live in conditions that are challenging and unfavourable to public health measures, especially for those unable to stay home and forego their means to earn income (Botes & Thaldar, Citation2020). Given that social determinants of health such as poverty, physical environment, and race can have substantial effects on COVID-19 morbidity (Abrams & Szefler, Citation2020), it is critical to protect these vulnerable groups from infection.
The physical contact behaviours studied are culturally accepted greetings and/or promoting social cohesion. The initial lockdowns were often accompanied by panic, scepticism, and uncertainty given low knowledge about the disease transmission and relatively new public health messaging. Kollamparambil and Oyenubi (Citation2021) found that social distancing (including avoiding physical contact) in South Africa decreased over time as sanitiser use increased, suggesting the need for sustained health communication to combat preventive behavioural fatigue. Notably, associations between social distancing and low socio-economic environments persisted over time Kollamparambil and Oyenubi (Citation2021).
Other reasons for physical contact include lack of knowledge, pandemic denial, mistrust in information or social norms. Kollamparambil and Oyenubi (Citation2021) found that adherence to social distancing was lower among South Africans whose communities also reported low adherence. Furthermore, stigmatization and misconceptions about a disease can lead to not practising preventive behaviours to avoid discrimination (Citation2020; Bruns et al., Citation2020).
The findings highlight the importance of developing health promotion interventions adapted to specific subgroups. The development and dissemination of simplified and targeted behaviour-change messages should be a consultative process involving vulnerable groups and community members. An inclusive community-led approach to intervention development will likely increase public accountability and support and adoption of social distancing and other public health measures. Effective health messaging needs to be understandable, be delivered by credible sources, involve community engagement, address uncertainty immediately with transparency, and unify messages from multiple sources and increase social responsibility (Ghio et al., Citation2021). In addition, health education initiatives need to account for cultural norms such as hand shaking and hugging and promote alternative greetings (Bruns et al., Citation2020).
This study has some limitations. Firstly, adherence to social distancing was self-reported and there may be over-reporting of compliant behaviours due to social desirability bias. Secondly, the cross-sectional survey design limits causal interpretations. Thirdly, only one form of social distancing, namely physical contact was investigated. In addition, the survey was conducted during the early stage of the pandemic and its findings may not necessarily generalize to later waves. Finally, online surveys are subject to selection bias, reflecting the digital divide and access to technology and the internet among lower socio-economic groups. To minimise the impact of these limitations, the data was benchmarked to increase generalisability to the South African population. The telephonic surveys were also conducted to increase participation from individuals who would not have completed a survey online. A strength of the study is its use of rapid online surveys to provide real-time results and the use of physical contact behaviour is a direct measure of non-compliance.
Acknowledgments
We wish to thank all the residents of South Africa who participated in and distributed the survey.
Data availability statement
The data supporting the findings of this study are available from the corresponding author on reasonable request.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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