‘Stay home and stay safe … but maybe you can have somebody over’: public perceptions of official COVID-19 messages during the 2020 holiday season in Canada

ABSTRACT

Background

The COVID-19 pandemic triggered extreme preventive measures, including economic and social lockdowns. Many experts and commentators, however, have argued in favor of a harm reduction approach, giving individuals the liberty to assess their risk and potentially engage in risky behavior more safely. Drawing on concepts from harm reduction literature we examine how Canadians interpreted messages intended to mitigate harm during the 2020 end-of-year holiday season.

Methods

We conducted 12 focus groups in four Canadian cities to discuss public health guidance to reduce the spread of COVID-19, how these messages influenced their holiday celebration plans, and how they interpreted harm mitigation messages.

Results

Focus group participants (n = 82) described COVID-19 public health guidance as confusing and difficult to follow. Participants considered that messages intended to mitigate harm from official sources would contribute to deepening confusion and uncertainty, allow for personal interpretation of guidelines, and discourage those who follow guidelines diligently.

Conclusion

Official public health messaging intended to mitigate harm in rapidly evolving crisis situations can be ineffective in reducing risky behaviors because it may instead encourage people to not abide the recommended guidelines. In these situations, harm reduction messaging should be limited to specific groups who cannot otherwise avoid risk exposure.

KEYWORDS:

• Coronavirus
• prevention
• crisis communication
• risk communication
• infectious disease
• public health

Introduction

In December 2020, as the world was grappling with the COVID-19 pandemic, caused by the SARS-CoV-2 virus, COVID-19 vaccines were just being approved, but they were not yet available to the public. In Canada, general infection prevention measures (such as hand hygiene, physical distancing, and mask-wearing) were still largely in place, with some jurisdictions in the midst of more restrictive public ‘lockdowns.’ As the end-of-year holidays approached, public health authorities and experts warned Canadians to be responsible and celebrate in a safe manner by observing local health orders and limiting social contact [1,2]. However, public health guidance in some provinces combined risk prevention, which aims to avoid risk exposure, and harm reduction measures, which aim to minimize harm associated with certain behaviors when exposure to the risk is inevitable [3]. For example, the Ontario Ministry of Health exhorted individuals to minimize contact with people outside their household for months with the recurring message of ‘Stay at home. Stop the spread of COVID-19’ [4]. However, towards the end of the year the province also provided guidance for how to gather safely, contradicting the previous guideline, by suggesting Ontarians to disinfect surfaces before and during the gathering, limiting the number of guests indoors, wearing masks, and providing guests with soap and water [5]. Through focus groups, we examine how individuals interpreted public health guidance, particularly harm reduction messages compared to risk avoidance ones, and whether they impacted people’s plans for the 2020 end-of-year holiday season.

Risk prevention messages can drive the undesired behavior ‘underground,’ cause shaming, and foster distrust or resentment towards the recommending authority [6]. Consequently, a more flexible harm reduction approach to mitigate the consequences of risky behavior has proven effective, for example in the case of substance abuse and sexual health education [7]. Harm reduction seeks to mitigate negative outcomes [8] by providing tools for people who are likely to engage in risky behaviors on the basis that willing compliance is a more effective approach than forced compliance with mandates [9]. Harm reduction strategies are used most-often in cases of substance abuse [10], but have also been used in various situations and with different populations, from programs to reduce alcohol consumption [11] and smoking [12], tackle eating disorders, address domestic violence [13], and reduce risks from sex work [14]. Harm reduction has also been suggested as useful in clinical interactions between doctors and patients [7]. Such calls point to a potential generalizable applicability in its principles that could benefit other domains of health risk [15]. Some, however, have criticized harm reduction as a way of endorsing risky behaviors [7,8].

At the beginning of the pandemic, rising cases and uncertainty about the transmission, virulence and severity of the virus led to strict lockdown policies [16]. As the pandemic progressed into its second and third waves, lockdowns were often re-imposed in various jurisdictions to control the spread of infection and relieve stress on overwhelmed health systems. However, some studies [16–18] and opinion discourse in news media (cf. [19–21]) began to promote harm reduction messaging as a more suitable and sustainable strategy when promoting uptake of personal protective behavior. They argued that lockdowns were costly and no longer necessary, and that people were becoming resistant to these perceived infringements on their personal liberties [22].

At the end of 2020, and with no vaccine against COVID-19 widely available yet, as many as 20–40% Canadians were planning to attend gatherings over the holidays [23]. At the time, public health guidance across Canada was mixed, with some jurisdictions asking people to avoid all social gatherings and others advocating a harm reduction approach as a way to increase adherence among those who may be exhausted with strict mandates [20,24].

In this study, we draw on harm reduction literature to examine how public health guidance that seeks to mitigate harm, such as wearing a facemask when gathering with others indoors to reduce the risk of becoming infected with COVID-19. By contrast, risk preventive measures seek to completely eliminate risky behaviors, such as becoming exposed to COVID-19, for example by prohibiting indoor gatherings. We examined how Canadians interpreted risk public health guidance to reduce the spread of COVID-19, and whether these messages, actual or potential, influenced their holiday celebration plans during the 2020 end-of-year holiday season. While there are many studies on the application of harm reduction strategies to a variety of risky behaviors (cf. [25,26]), to our knowledge there are no studies on how messages intended to mitigate harm during a pandemic could be interpreted by the general population as they struggled to balance cultural traditions and following public health guidance. Understanding the potential repercussions of harm mitigation messages during a pandemic can help guide when such messages are justifiable compared to when they might contribute to confusion and lead to increased uncertainty.

Method

We held 12 online focus groups with 82 Canadians in Vancouver, Winnipeg, Ottawa, and Toronto from December 8–22, 2020. Participants were recruited by a market research firm using a variety of methods (e.g. emails to individuals signed up as part of existing panels, random digit dialing, ads posted on Facebook/Instagram). Table 1 shows the demographic characteristics of our participants. Participants were age-segregated into one of three mix-gender groups (18–34 years, 35–54 years, 55+ years), and received an honorarium of $70 for their time.

Table 1. Socio-economic and demographic characteristics of focus group participants, N = 82.

Characteristic	Count (%)
Gender
Male	40 (48.8)
Female	42 (51.2)
Ages
18–24	10 (12.2)
25–30	11 (13.4)
31–34	8 (9.8)
35–40	9 (11.0)
41–48	10 (12.2)
49–54	8 (9.8)
55–60	6 (7.3)
61–68	11 (13.4)
69 or older	9 (11.0)
Marital Status
Single (never married)	27 (32.9)
Married or common law	43 (52.4)
Divorced, separated or widowed	12 (14.6)
Households with Children
None	57 (69.5)
1	10 (12.2)
2	10 (12.2)
3	5 (6.1)
Education
High School	4 (4.9)
Some College/University	24 (29.3)
College/University Degree	54 (65.9)
Income
Under $50,000	29 (35.4)
$50,000–$74,999	21 (25.6)
$75,000–$99,999	10 (12.2)
$100,000–$149,999	18 (22.0)
$150,000 or more	4 (4.9)
Race^a
White	40 (48.8)
Black	2 (2.4)
Indigenous	6 (7.3)
People of Color	34 (41.5)

^a Participants were asked to self-declare their ethnicity. To demonstrate the diversity of participants, individuals were grouped into broader racial categories of White, Black, Indigenous and People of Color. Participants grouped as White self-identified as White, Caucasian, Scottish, Irish, German, Danish, British, Ukrainian, Canadian, French-Canadian, Russian, European/Caucasian. Participants grouped as Black indicated African-Canadian, North African. Participants grouped as Indigenous chose to self-identify as either Indigenous, First Nations or Metis. The ethnicity for People of Color included several self-identifications as South Asian, South East Asian, East Asian, Asian, Chinese, Filipino, Filipino-Canadian, Pakistan, East Indian, Indian, Indo-Canadian, Latin American, Muslim, Middle Eastern, Mixed (e.g. West Indian mixed black/Caucasian; Latino-Caucasian).

Focus groups were moderated by a professional research firm experienced in qualitative methods. The lead researcher also attended the sessions, although they remained off camera, and occasionally suggested follow up prompts to the moderator. Focus groups were held as part of a wider COVID-19 study [27], for which we developed a focus group thematic guide with questions about participants’ opinions on the implementation of public health guidelines, compliance with infection prevention measures, information seeking behavior and trust, and attitudes towards immunization in general and specifically the COVID-19 vaccines. The moderator asked participants about their opinions and perceptions of each of the topics and asked them to provide examples. In this study, however, we focus on how participants interpreted public health messages, particularly harm reduction messages compared to risk avoidance ones, and whether they impacted participants’ plans for the 2020 end-of-year holiday season. Participants recalled the risk prevention messages they had been exposed to for almost a year, and then they were asked about potential or actual messages intended to mitigate harm and ‘safe holidays’ messages in their province. For Ontarians it was easy to recall those messages as they were both been disseminated at the time of the focus groups. In other provinces where harm mitigation messages had not been communicated yet, participants were asked about potential recommendations of staying home and not gathering, combined with guidelines for having ‘safe gatherings’. These participants commented on how they would interpret those messages if their own province adopted a harm reduction approach.

All focus groups were audio-recorded, transcribed verbatim, and audio-verified for accuracy. Transcripts were uploaded for analysis using NVivo12. To identify participants in the transcripts, we used the name participants provided consent for use. Two team members coded the transcripts, and two coding tests were performed with a third member of the research team to ensure inter-coder reliability. Coding disagreements were resolved through discussion between coders and with other members of the research team. Our Kappa coefficient score was 0.90. Ethics approval was obtained from the University of Manitoba and Toronto Metropolitan University.

Results

Participants were highly aware of the need to modify their traditional holiday celebrations in order to comply with existing COVID-19 public health regulations. However, they also expressed frustration about unclear public health guidance and considered that harm mitigation messages would not be easily interpreted and would create more confusion.

Perceptions of risk prevention messages

Most participants claimed they take the threat of COVID-19 seriously and adhere to public health rules as best as they understood them, but some expressed frustration with guidelines they thought were confusing, inconsistent, and contradictory. Common criticisms included difficulty following frequent rule changes, which left people wondering about what is permitted or not at any given time; the existence of different guidelines for different jurisdictions or activities; and being able to do certain activities in one place but not another (e.g. gather with a few friends in a park but not in one’s backyard).

Confusion over shifting guidelines expressed by participants who were unsure which guidelines were still in place and which had changed. For example, a participant explained having been invited to a friend’s house and not being sure whether that was allowed anymore: ‘I googled it and I think it says you’re not allowed to (…) At this point, to be honest, I don’t even know if you’re allowed to meet other people’ (Caitlyn, Toronto, 18–34). Another participant said ‘you don’t know what the government wants you to do or not do. It seems like they are contradicting themselves’ (Lucinda, Toronto, 35–54). Such confusion over a sustained period of time fed into a generalized sense of frustration and fatigue: ‘After a while it’s too much and it’s also not good for mental health’ (Denis, Ottawa, 55+).

Participants in Ontario expressed confusion regarding the lockdown announced by Premier Doug Ford, which would only come into effect on December 26th. This was interpreted by many as elected officials ignoring expert advice to protect public health and choosing instead to protect businesses during the holiday shopping season.

I think a large case of this increase in COVID-19 fatalities and infections is because of the government because they bend to the will of big business, and they allowed people to go shopping earlier than they should and they closed down the small shops. But the point is, we should not have catered to big business and cave to them (Raj, Ottawa, 35–54).

[T]he politicians, they say one thing and do another thing because they said they listen to the medical establishment, what they’re proposing we should be doing. And yet they don’t move on it in a timely fashion (…) Here the doctors are saying you should close down, lockdown. And they [politicians] don’t do it (Bruce, Ottawa, 55+).

Participants also expressed frustration that the reasons for changing rules were not shared with them by political or health authorities. A participant, for example, said ‘I would like clarification on some of the conversations that drove decisions. I would like to know how much of it was scientifically based versus politically based’ (Jan, Winnipeg, 55+). Another participant did not understand the reasons for banning some activities but allowing others: ‘Why is the government saying it's not okay to go to the gym but it's totally okay for your kids to go to school?’ (Allison, Ottawa, 18–34). This participant explained that ‘there's really no clarification when a lot of people are saying they don't understand’ the rules.

Furthermore, participants across focus groups expressed feeling exhausted (physically, emotionally, financially) with the prolonged restrictions to social life and the economy. Some of them mentioned having a hard time avoiding family and friends for so long, particularly not visiting elderly family members. This exhaustion, some argued, led people to follow the rules less rigorously. One participant explained that his level of adherence to public health guidelines has become less strict over time: ‘when my daughter was born earlier this year, I wouldn’t allow anyone to go near her for three months … [but now] I’m not going to stay away from my family.’ (Steve, Winnipeg, 18–34).

Perceptions of messages intended to mitigate harm

All participants reacted critically to the possibility of harm mitigation messages and pointed to the danger of unintended consequences. Some participants anticipated that introducing guidance to mitigate harm would likely be disregarded by those who intended to host or attend gatherings and socialize. One person explained that ‘the people who are likely to break law aren't going to take the advice anyways’ (Anitha, Winnipeg, 18–34). Similar opinions were expressed by other participants, arguing that ‘the people who are having the large Christmas gatherings are already the ones not listening in the first place. So that doesn't make sense’ (Ben, Ottawa, 18–24), and ‘more guidelines would not change whether people follow the rules or not’ (Monique, Winnipeg, 35–54).

Many participants argued that guidance to mitigate harm would create more confusion among an already perplexed population. They considered that simultaneously promoting risk messages about limiting contact with others outside your household along with guidance on how to safely gather with others ‘would create mass confusion because they’d be saying ‘don’t go but here’s how you go safely’.’ (Christian, Winnipeg, 18–34). Participants considered that anything other than clear and unequivocal direction to ‘do or do not,’ would introduce ambiguity, leaving much open to personal interpretation. They argued that without a hard, unambiguous rule people may find it difficult to determine where to draw a safe line between accepting and avoiding risk and might instead be encouraged to bend or disregard the rules. One participant explained:

The second that public health changes their directive from “stay home and stay safe” to “maybe, you can have somebody over” that becomes a slippery slope. There are so many gray areas, and everyone's circumstances are so different (Michelle, Winnipeg, 35–54).

Instead of guidelines to mitigate harm, participants tended to support explicitly demarcated rules, and explained that most people would not understand nuanced guidelines: ‘if it’s a little ambiguous or confusing, people will interpret it the way they want to interpret it’ (Mark, Winnipeg, 18–34). Participants said that public health needs to ‘spell things out very clearly so that [the public] can understand. I can see [the public] getting mixed messages and playing dumb, and not really understanding’ (Sharon, Vancouver, 35–54). One participant, who considered harm mitigation a bad idea for holiday celebrations, said ‘I think the government should just say don’t get together’ (Delaney, Winnipeg, 18–34), and another person suggested appealing to the need to protect at-risk loved ones: ‘They should say that this is a time of the year you normally go see your elderly parents and this and that. ‘Don’t put them at risk. It’s not worth it. Do it over skype.’ You have to spell it out’ (Dennis, Vancouver, 35–54).

Some participants also considered that harm mitigation would discourage those complying with restrictions: ‘we’re going to make people who wouldn’t have gone out, go out, because they say the government says it’s ok to do ‘this’’ (Adam, Winnipeg, 35–54). Another person explained that messages intended to reduce harm ‘gives people literally permission to do the thing that [public health is] saying not to do’ (Laura, Vancouver, 18–34). Furthermore, some participants viewed harm mitigation guidance as throwing away all of the progress achieved by the strict lockdowns.

While the majority of participants opposed the prospect of harm mitigation messaging, a handful of others indicated that they would support such an approach. One participant noted that if authorities believed that a harm minimization approach was appropriate to keep people safe, they would be fine with it, as they firmly believed that public health officers ‘are acting in the best of our interest by preventing COVID from getting worse’ (Eva, Vancouver, 35–54). Another person suggested that if authorities tell people not to gather over the holidays, yet expect that some may break that rule, it is more responsible to provide guidance on how to bend the rules safely:

I personally would like that […] some people will not go with the recommendation, so [harm mitigation] is the best way to do it. But I feel like some people may see that as the government encouraging people to go. So, I feel like maybe that’s the one caveat. (Kenneth, Toronto, 18–34)

Some participants opposed public health restrictions in general. They referred to the pandemic response as paternalistic and firmly believed they had the ability to assess their risk and make their own risk decisions. For example, one participant considered the restrictions ‘over-reaching’ and he was willing to accept a penalty for breaking the rules before adhering to social restrictions over the holidays:

You can’t tell me what to do. It’s too iffy in my mind and if I want to see my family than I’m going to do that. If they want to fine me for seeing my family at Christmas, then so be it. I’m still going to see them (Steve, Winnipeg, 18–34).

Participants who opposed public health restrictions in general explained how they conduct their own risk assessments and adjust their personal protective behavior which at times seemed to overlap with principles of harm reduction. For example, some participants acknowledged that they break the rules and gather with others, but they do so while still taking protective measures. A participant explained:

I have critical thought and can think for myself, and I know the risks that are out there. I know what I need to be doing. I don’t need to be reminded to wash my hands […] we are self-governing people who can make our own decisions and we know what we need to do. Or at least I do. If I’m going to see my nieces, I’m going to wear a mask, even as much as I want to hug and kiss them and love them up, these are our sacrifices. I know that I am not high risk. I know that I have confidence in my body to be able to fight something if I were to get it, but I would never want to get it and give it to someone else (Ana-Laura, Toronto, 18–34).

Discussion

Harm reduction has proved to be an effective approach for populations that cannot avoid risk exposure ([14,26]; cf. [10]). In these cases, messages of harm reduction seek to provide groups at risk with information and mechanisms to minimize the worst outcomes as much as possible [9,28]. In the context of the COVID-19 pandemic, however, recurring guideline changes left many struggling to understand how to best adhere to existing restrictions to protect themselves and others. In this context, messages to mitigate harm when risky behaviors cannot be avoided, can lead to confusion and frustration.

Focus group participants considered public health guidance about COVID-19 confusing and difficult to follow. In this context, participants considered that messages that seek to minimize harm – that is, how the general population could safely bend public health rules during the holiday season – would only contribute to deepening confusion and uncertainty. Some highlighted that nuanced recommendations would leave too much space for personal interpretation of guidelines and discourage those who have been diligent in following the rules.

Proponents of a harm reduction argue that this approach would empower individuals to assess their own risk and adopt the preventive measures they consider appropriate [16,22,29]. While giving space for voluntary compliance could be more effective in reducing risk behavior than strict forced lockdowns and other COVID-19 response measures [9], most participants opposed the idea of guidance to mitigate harm and preferred hard rules that leave no room for ‘slippery slopes.’ Most participants complained that guidelines were confusing and at times contradictory, but still they tried to adhere to them as best they could, even if they did not understand the reasons behind them. This suggests that in moments of health crisis, when there is high uncertainty in a rapidly evolving situation, individuals defer to experts to assess the risk and provide them with clear parameters of what is or is not acceptable behavior.

Despite a general preference for strict guidelines, a number of participants adopted their own risk reduction strategies intuitively and rationalized they did not create unnecessary risk by bending the rules. This suggests that some people may be already intuitively and unconsciously adopting harm mitigation measures. These behaviors, however, were based on participants’ individual assessments, which tended to underestimate the risk and overestimate their ability to adopt precautions.

Two years after our focus groups, at the end of 2022, 82% of Canadians have received two doses against COVID-19 [30]. This high rate of vaccination has permitted a wider implementation of harm mitigation guidelines and messages in various jurisdictions across the country. However, before the COVID-19 vaccines were available to Canadians, messages intended to minimize harm aimed at the general population were considered premature and confusing.

As the Omicron variant of COVID-19 continues to spread across Canada, some public health messaging has shifted towards recommending a wider harm minimization approach, by suggesting that COVID-19 is now endemic, and that Canadians need to ‘learn to live’ with it [31]. These messages, however, have caused mixed reactions in expert and opinion discourse, as it comes at a time when case counts remain high in the country and many provinces continue to have strained health systems [32–35]. Due to the high transmissibility of the Omicron variant, even fully vaccinated individuals are becoming infected, potentially undermining confidence in vaccines. In this context, messages that seek to minimize harm remain challenging as they could deepen uncertainty and frustration.

Our findings suggest that in circumstances of high risk and high uncertainty, like the 2020 end-of-year holiday season, messages that seek to mitigate harm can be perceived as contradictory and confusing, leaving people feeling unsure about how to protect themselves. Therefore, we recommend that in crisis situations, such as the COVID-19 pandemic during the 2020 end-of-year holiday season, a clear, consistent risk prevention message should be prioritized for the general population. In this context, harm reduction messaging should be limited to specific groups who cannot avoid risk exposure, such as people requiring shelter and those experiencing violence (c.f. [36,37]). In these cases, harm reduction messaging should be developed through existing public health partnerships and in collaboration with the front-line organizations that interact more closely with the targeted communities.

This study has two main limitations. First, our sample is limited. Focus group participants were all Anglophone and recruited in three provinces. Future research could broaden the geographical scope and include Francophone Canadians. Second, data were collected during the second wave of COVID-19 infections and with no vaccine widely available. Future studies could seek to evaluate public perceptions of COVID-19 harm reduction messages after vaccines became available. Future research could also examine how certainty is affected by risk prevention and harm reduction messages in crisis situations. Additionally, our analysis could be expanded to examine and compare perceptions of harm reduction in jurisdictions with lower and higher vaccination rates.

Ethics approval

Approval for this research was granted by the University of Manitoba Research Ethics Board (Reference number: H2020:510, Linked with H2020:164) and through Toronto Metropolitan University Research Ethics Board (REB 2020-445).

Consent to participate

All participants gave informed consent to participate in this study, where publication was identified as one form of dissemination. Information and Study Consent Forms available upon request.

Availability of data and material

Focus group guides available upon request.

Code availability

Coding guides are available upon request.

Acknowledgements

GC collected, coded and analyzed data and wrote and edited the manuscript. RM collected, coded and analyzed data and wrote sections of the manuscript. JT edited the manuscript and offered input on research design. CJ edited the manuscript and offered input on research design. SMD designed the research project, collected data, led the analysis, wrote and edited the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was funded by a grant from the Canadian Institutes of Health Research (OV6-170370).

Notes on contributors

Gabriela Capurro

Dr. Gabriela Capurro is a postdoctoral fellow in the Department of Community Health Sciences, University of Manitoba. Her research examines risk communication during health crises, lived experiences of health risks, and mediated discourses of health and illness.

Ryan Maier

Ryan Maier is a research analyst at the University of Manitoba. His research focuses on infectious disease outbreaks, vaccine hesitancy, risk communication, health history, and colonialism.

Jordan Tustin

Dr. Jordan Tustin is an Assistant Professor in Public Health at Ryerson University. Her research interests lie in the fields of communicable disease epidemiology, field epidemiology, epidemiologic methods, global health, vaccinology, and environmental health.

Cynthia G. Jardine

Dr. Cynthia (Cindy) Jardine is a Professor and Canada Research Chair in Health and Community at the University of the Fraser Valley. Her research examines health risk communication, focusing on underserved populations, and pandemic and vaccination communications to promote informed decision making.

S. Michelle Driedger

Dr. S. Michelle Driedger is a Professor in the Department of Community Health Sciences at the University of Manitoba and a former Tier II Canada Research Chair in Health Risk Communication. Her program of research examines harms and benefit communication in primary care and public health.