Exploring barriers and facilitators of physical distancing in the context of the COVID-19 pandemic: a qualitative interview study

Ethical approval

Ethical approval was sought and granted for this work by the Research Ethics Committee at the National University of Ireland (NUI), Galway (Ref no.: HRB20-Apr-18).

Study design

The study employed a qualitative interpretative design.

Sample selection and recruitment

Participants were adults aged 18 years or older who were resident in Ireland from September to October 2020. A purposive sampling strategy, which involved choosing participants deliberately based on the specific qualities they possess (Etikan et al., 2016), was employed. For this study, participants were selected to ensure the sample was diverse in terms of age, gender, and occupational category.

Recruitment for the study was publicised through targeted social media advertisements via Facebook, Twitter and Instagram platforms and email advertisements circulated via community groups, professional organisations, and personal networks. All participants who expressed interest were directed to a Google Forms link by a member of the research team and asked to fill out demographic and contact information. Participants were then selected using a sampling matrix to ensure maximum variation. Selected participants were given the information leaflet to review, and the interview date and time was scheduled via email.

Sample size

A total of 42 individuals expressed interest in participating via email. Of these, 25 were recruited to participate. This aligns with published recommendations of 10–20 participants for qualitative studies utilising thematic analysis approaches (Braun & Clarke, 2013). These participants were selected based on their fit within the purposive sampling matrix. The remaining 17 people who expressed interest were respectfully declined and thanked for their interest in the study. Due to resource constraints, it was not possible or feasible to interview everyone who expressed interest. Initial data analysis took place alongside data collection and interviews continued until data was collected that was adequate in both amount and variety to answer the research question (Vasileiou et al., 2018).

Data collection

Participants were presented with the option to participate in a one-to-one semi-structured interview via phone or a secure web-based platform (e.g., Microsoft Teams); all elected to complete the interview via phone. A topic guide of open-ended questions was used to flexibly guide the interviews (see Extended data; Durand et al., 2020b). In brief, the topic guide addressed participants’ personal experience of COVID-19, what they understood by the term ‘physical distancing,’ perceived barriers and facilitators of physical distancing in public and in private, and their perceptions of government communications around physical distancing. Non-directive prompts were used to elicit further detail as needed. Participants were also asked if they wanted to say anything else they felt was relevant that the topic guide did not address. The topic guide was developed by the research team and a panel of seven members of the public (the contribution of the public and patient involvement [PPI] panel is described in detail below) from an initial review of existing literature and personal experience of engaging in physical distancing behaviours. The topic guide underwent several stages of refinement with input from the PPI panel. Informed consent was sought and obtained via audio recording from all participants prior to the interview. The interviews were conducted over four weeks from the 28^th of September 2020 to 22^nd of October 2020 and lasted between 30–45 minutes. Interviews were audio-recorded; interview recordings were stored in a separate secure location from the audio-recorded statements of informed consent to ensure participants could not be easily identified. Interviews were conducted and transcribed verbatim by a member of the research team who had practical skills and experience in conducting qualitative research (KF; Patton, 1990). Field notes were taken to record the researcher’s initial observations about the interview data and to aid in future analyses. In the interest of time, given the urgency of COVID-19 research, transcripts were not returned to participants for comment or correction.

Context

From September 28^th to October 22^nd the national cumulative incidence of confirmed cases per 100,000 of the population rose from 734.73 to 1,121.62 (see daily infographic of the Epidemiology of COVID-19 in Ireland from the Health Protection Surveillance Centre (HPSC) website). At this time, restrictions in Ireland were between Level 2 (all counties except Dublin and Donegal until 6^th October), Level 3 (Dublin and Donegal) and Level 4 (Cavan, Monaghan and Donegal) with a move to Level 5 (lockdown 2.0) for the whole country on 21^st of October 2020, when the number of confirmed cases reached the highest recorded to that of the first wave in April 2020. An explanation of the restrictions in place in Ireland at each Level (1– 5) can be viewed in the Government of Ireland's plan for living with COVID-19.

Patient and public involvement

A PPI group was involved in the design, recruitment, topic guide development, and analysis stages of the study. PPI panel members were recruited through PPI Ignite at NUI Galway, through existing PPI groups, and through advertisements to NUI Galway Students’ Union, and NUI Galway University of Sanctuary. Two to three members of the research team (OM, HD, and KF) met on four occasions with PPI partners online via the Zoom video communications platform. The purpose of these meetings was firstly to review the interview topic guide for its clarity and relevance and to give advice on strategies to recruit a diverse sample. PPI members also contributed to the qualitative analysis in a three-step process: Step 1: Contributors were given a brief introduction to qualitative research and coding. We then sought their assistance in inductively coding a sample of passages from the interview transcripts. This was done to ensure the team had not missed any important barriers/facilitators and to feed into the development of the thematic map. Step 2: PPI members were involved in validating the themes identified, by reviewing the list of themes and corresponding quotes and commenting on whether the themes made sense in relation to the research question, and if they felt the codes provided compelling evidence for each theme. Step 3: This meeting was to discuss contributor’s feedback on the draft analysis section. The PPI contributors also gave additional time between formal meetings to review the thematic map and analysis section of this article. Panel members played a fundamental role in the research process by helping to shape the design and analysis, enhancing the quality and appropriateness of this research.

Data analysis

Reflexive thematic analysis was used to analyse interview transcripts under the guidelines described by Braun & Clarke (2006). This analytic approach was chosen as it is highly flexible and provides a rich and detailed, yet suitably complex account of qualitative data (Braun & Clarke, 2019; King, 2004). The data was managed using NVivo 12 Software (QSR International, 1999). An inductive approach to qualitative data analysis was taken, such that themes were identified solely from the data. Each transcript was read independently, and initial codes were assigned to the data by KF. These codes were shared with a member of the research team (HD) and refined through discussion. Initial candidate themes were identified from the codes and discussed with other members of the research team (KF, HD, OM, JMS, GJM). All team members had a background in psychology and interest in health behaviour. These themes were further developed and refined in a virtual reflexive group session. PPI members also contributed to the qualitative analysis as described above.

Maintaining and negotiating close relationships

This was a central theme identified in the analysis with all participants describing maintaining and negotiating close relationships as the most difficult behaviour and a barrier to physical distancing. Two subthemes identified within this theme were: (1) Difficulties of physical distancing and sacrificing human contact and (2) Having to negotiate distancing with others.

Difficulties of physical distancing and sacrificing human contact

Many participants described the difficulty of being unable to see or having to maintain distance with family members and close friends outside of their household, and how challenging and abnormal this felt.

“I think because our normal actions and our normal interactions with other people like previous to this for however long we're on this planet, would have been social, would have involved touching, and hugging, and also being close to somebody not just speaking with them or having a good time with them, you just don't forget that. It's almost like a motor reaction, where you're kind of putting yourself into a situation where you're not necessarily physically distancing with each other,” (Male, 28, professional/managerial).

Loneliness and feelings of missing out on the college experience made physical distancing particularly challenging for students.

“I definitely think it's a lot harder being back in college because obviously you want to see your friends, it's my last year as well so it's a bit sad. So it's definitely harder I think with people my own age, yeah just friends and stuff that you miss,” (Female, 23, student)

Having to negotiate distancing with others

Negotiating distancing with friends and family members was a barrier to physical distancing where participants felt unable to refuse physical affection or closeness from loved ones. There was a sense of worry prior to interacting with friends and family that they would not be as cautious or choose to maintain distance. A female participant explains the difficulty of maintaining distance from an elderly family member when they came to visit after the first lockdown.

“…when he [grandad] came down like I had my mask on, I was still very, very scared of everything at that point. He just had cancer last year, so I was very worried about him, and as soon as I opened my house door he just came and hugged me immediately there was no social distancing and you just can't say no, you know? I couldn't stay "You can't do that grandad", and then the rest of the trip I kind of just thought oh well f**k it, it's too late now like we've already hugged. So yeah, the rest of the trip we didn't socially distance with each other,” (Female, 26, unemployed).

The worry and anxiety of having to negotiate distancing with friends, being nervous to ask friends to keep a two-metre space when meeting up in social settings, in fear that it will instigate feelings of awkwardness and embarrassment and they will not feel the same obligation or concern to maintain physical distancing made it difficult for participants to continue distancing.

“…there's kind of two, maybe three [friends] that I'd meet up with on a regular basis, and I do find social distancing with them quite difficult, because I always worry like if I said ‘oh can you keep your two metres’ that there just going to kind of laugh at me and be like what are you doing that for, don't be ridiculous,” (Interview 20, female, 26, unemployed).

Public environments support or discourage physical distancing

The physical environment and safety measures in place in retail and recreational settings was an important barrier/facilitator to physical distancing. Many participants discussed how comfortable/uncomfortable they felt when in retail and recreational environments such as supermarkets, restaurants and gastro pubs. There were mixed opinions on the safety measures taken in these settings, where participants felt adherence to physical distancing was made easier or harder based on the set up of different restaurants or shops.

One participant explained how they felt so uncomfortable in their local shop that they decided to leave due to the lack of preventative health measures taken by management and staff to protect customers when grocery shopping. They described witnessing other customers in the shop not wearing a mask when masks were mandatory at that time and failing to physically distance from each other, or practice appropriate coughing and sneezing etiquette.

“I did leave a shop in my hometown. There were no controls in place, people weren't wearing masks. I remember just having this kind of you know feeling of god I've never felt so uncomfortable in my local shop. I think within two minutes I said, ‘right, we're just leaving right now I'm not staying here.’ It was just there was no physical distancing, people were standing up right beside you and just super, super uncomfortable,” (Male, 25, student).

Positive experiences were also encountered, for example, going to a restaurant for a friend’s birthday. A female participant explained how she felt quite nervous before attending, wondering what measures the establishment would have in place, but described feeling safe and comfortable as a result of the guidelines enforced by management and staff to facilitate physical distancing.

“I remember the first time we went out and it was my friend's birthday, and we just went to a local enough place, and we were kind of a bit nervous going in and it was just really well done everything. It was a big place so there was lots of space, the staff were excellent, like they were not intrusive. But you know you were very clear that you were safe, and they were being safe, and it just felt comfortable and safe,” (Female, 59, professional/managerial).

On the other hand, the opposite is observed in a hotel restaurant where outdoor seating and tables were so close together customers at different tables were brushing against each other while they had their meal.

“Last Sunday for instance, I saw a particular hotel and they had tables outside, and there were people sitting at those tables having drinks and food. And I mean, the tables were so close to each other, that one person's back one table was literally touching the back of the person at the other table,” (Female, 67, retired)

Habituation to threat

Living with and adhering to physical distancing measures since March of 2020 meant that the anxiety and worry of the virus has diminished over-time.

“I just find I’m not as stressed out about it anymore, I just accept it, (the virus) okay like it's probably going to be fine,” (Female, 26, unemployed).

There is a sense of desensitisation to the threat of the virus, and so reducing physical distancing.

“I suppose we know more about the virus and in some ways, the urgency has gone out of it, the panic,” (Male, 25, student).

Participants also described the potential to “let our guard slip” and not adhere to physical distancing guidelines when meeting up with friends.

“I do meet up with certain friends that I would see often enough and my bandmates to be included in that, like we do kind of let our guard slip the odd time and I think that's almost like human nature as well,” (Male, 28, professional/managerial).

The perceived threat of visiting friends and family in different households has lessened over time, due to learning about these threats and the potential consequences to other family members but not actually encountering them in our personal lives. Invitations from others suggests they feel the risk is low and repeatedly saying no becomes tiresome.

“It's like if someone invites you over and you’re like ‘oh yeah’ but then they say, ‘oh mam or dad have an underlying health condition,’ and then it’s like well, why are you inviting me over? I don't know what to do, and then the parents are kind of like, ‘ah no it's okay,’ and then you’re kind of feeling nearly, like I could just say no, which I did initially, but like after a while your kind of like, ah I'll come in for a cup of tea,” (Male, 23, student).

Participants felt that the distancing posters and floor signs were no longer as salient as they had been in place for so long. The newness and significance of the bright yellow signs and floor arrows has worn off. The more participants are presented with these repetitive public health messages, the more we get used to them and choose not to react to them.

“It's almost like the yellow ‘X’s on the floor have gotten a bit grubby, so it must be over,” (Female, 43, working professional).

Participants spoke about their experience of distancing at work, how their thoughts about physical distancing had changed over-time, where they have allowed themselves to become more complacent because the vigilance required to practice distancing every day at work with customers and staff is mentally draining.

“Oh at the beginning it was more like stay the f**k away from me please, it was very, very odd. But now I've kind of relaxed a bit more because I'm just kind of emotionally worn down,” (Male, 24, casual worker).

Being unable to maintain a high level of vigilance over long periods of time reflected this habituation to threat.

“I think at the beginning, very beginning I was probably adhering to it a bit more (physical distancing), in that I was really making sure to stand well back. I think now I've been doing less than two metres, definitely,” (Female, 23, casual worker).

Taking risks to maintain well-being

Some participants described how they actively weighed up the risks of (not) physically distancing at times in order to support their own well-being. This need to maintain or enhance their well-being was at times a barrier to practicing physical distancing.

Despite being considered high risk this participant explains how refereeing sport is one area of her life where she was willing to take the risk to not always be in a position to physical distance from others, due to the mental and emotional contentment this brings her.

“I call this the one area of my life (refereeing sport) that I kind of give myself a little bit of an extra lead, being able to I suppose interact a bit more, and I suppose put myself in scenarios where distancing might not be as possible as other areas, but the payoffs of it for me mentally is huge,” (Female, 27, professional/managerial).

Participants described that gratification from meeting and chatting with others in a social setting, that need for connection and sense of fulfilment from social interaction was reported to be worth the risk.

“If you mean with friends it's nearly impossible, It literally doesn't [happen] like when were indoors we all sit on the couch like doing stupid sh**, like all you can kind of do is limit the amount of people there but at the end of the day it's as much as you do really,” (Male, 25, student).

The choice elderly people made to leave their homes for light exercise at quieter times to protect their mental health during the initial lockdown.

“The whole business the whole, the early lockdown, I did find it very difficult, I found it mentally difficult, and I certainly was going to get out early in the morning for a walk and late at night for a walk, walking in places where there was hardly anybody else, but I had to do that,” (Male, 78, retired).

Personal responsibility to control the “controllables”

Participants felt that taking personal responsibility for their behaviour was an important enabler of physical distancing. It was their own personal choice to choose to physically distance from others not only to protect themselves, but to protect other people around them.

“…you know you have no idea what anyone else is living with so just be kind and give them their space. If you end up in their space because of a conversation of whatever, well just measure that in terms of is this a risk for you or I? You know maybe it could be a risk for them because you know, for yourself whether it is or it isn't and decrease the space if need be and just say sorry we'll just keep the two metres and that's for you and for me,” (Female, 48, working professional).

A female participant felt once she was adhering to the public health advice by practising the proper hygiene etiquette, wearing a mask and keeping her distance she was controlling the situation for herself and her family as best she could to keep safe, being conscious and trying her best. By allowing herself to control what she could control in terms of her own behaviour this meant that she felt less anxious about the virus getting into her home and life.

“I'm very much [for] control of the controllables, and it's probably a way of controlling the situation, for me has been taking the precautions that I believe are best. In terms of using the sanitizer, wearing my mask and keeping distance, and being really conscious of not mixing with big groups of people or lots of small groups of people within a short space of time. I suppose that's reduced the worry for me, because I actually don't know what else I can be doing,” (Female, 43, working professional).

A male student explains how he felt a sense of personal responsibility to physical distance from others out of respect for his landlady’s health and concern about the virus.

“I live with the landlady like the owner of the house here, and I respect her too. Even recently, now, she's just asked me can I stay in, you know, until we just see what happens. I'd have to respect it for her to because it's her home house she wants to feel safe here,” (Male, 23, student).

Confusion and uncertainty around government guidelines

Confusion and uncertainty about government guidelines was perceived to be a barrier of physical distancing. There were two aspects to this confusion: 1) what the guidelines actually are and 2) the rationale for different rules. There was also some concern over unclear guidance around physical distancing in certain settings, and not being able to always maintain the gold standard of two metres.

“But with the opening of barbers they were saying like it needs to be one metre. So if it's one metre or if it’s two metres, I think it's probably two metres is probably the gold standard. But I think that communication wasn't very clear at all,” (Male, 25, student)

Participants felt the uncertainty around how many households or people could visit another household at Level 3 was confusing and created challenges to abide by physical distancing guidelines. At this time government guidance was changing from week to week in early September through to October and modifications to different levels were also being introduced. For example, Dublin and Donegal moved to Level 3 mid-September, and all other counties on 6^th October 2020. Cavan, Monaghan and Donegal then moved to Level 4 on 15^th October (Government of Ireland's plan for living with COVID-19). These moves to different levels impacted the number of household visitors that were allowed, so as this participant points out, it was difficult to follow.

“So, we have the five levels and then there’s the rules on the household, and how many houses can visit and how many people? I mean, I've no idea, I have no idea we’re at Level 3 now and I don't know how many households and how many people, I think that kind of made it a bit difficult, I think that kind of confuses things an awful lot for things like socially distancing,” (Female, 26, unemployed).

Similar confusion around the rational for these rules was apparent, for example, why at Level 3 people could socialise outside in a large group, in a restaurant or bar setting that serves food but were not permitted to have anyone visit a private garden and sit outdoors. Participants were unclear of the rationale for this guideline as maintaining distance with a selected few people in a garden was seen as easier than maintaining distance when seated outdoors at a restaurant with people from many different households.

“What I couldn't understand was at level three, you couldn't meet anybody in the garden of your own house. But yet you could meet 15, was it 14/15 people outside in a restaurant, or outside in a pub. So, for me, that was crazy. I'm like, more than likely meeting people in your own garden, you’re only meeting a few you might not meet 15. But I honestly couldn't understand the logic behind that,” (Female, 67, retired).

Limitations

While our sample was diverse in terms of age, gender, and socioeconomic background, the voices of more marginalised groups in society may not have been captured. Nonetheless, our study included participants who were retired over 70 years of age, which allowed us to explore the barriers and facilitators in older people who may have been most significantly impacted by COVID-19 and who have been advised to stay at home during lockdown, unlike other studies such as Williams et al. (2020) who only included participants up to 60 years old. Including at-risk groups like those over 70 was important for our study in the Irish context. Our PPI group assisted with these recruitment efforts to ensure we reached as diverse an age cohort as possible. While some of the participants interviewed were considered high risk due to having underlying health conditions, no one we interviewed had previously tested positive for COVID-19, so we could not explore the experience of quarantine and isolation. This is an area where the psychosocial impact of physical distancing should be explored. Additionally, all participants volunteered to be part of the study which may result in selection bias, as these individuals could potentially have a vested interest in the research topic and hold different views about physical distancing compared to the general public.

Limitations notwithstanding, this study has several important strengths. The use of PPI in planning and implementing this study ensured the research was carried out appropriately, was interesting and relevant to the general public, and provided a comprehensive account of barriers and facilitators relevant to physical distancing behaviour. Involving members of the public in research, particularly from the outset of a study, can greatly improve the quality and richness of the research. Involvement of PPI partners in COVID-19 is particularly important (Murphy et al., 2020). In this case, having PPI contributors advise on how to recruit a diverse sample of participants for this research ensured we were able to recruit a sufficiently large sample remarkably quickly, which is a key advantage given the importance of producing high-quality rapid evidence to combat the effects of COVID-19 on our societies. Having PPI contributors involved in conducting the analysis is also a key strength. Involvement in the qualitative data analysis meant that PPI in this study moved from consultation, which is a relatively modest approach to PPI, towards collaboration. Future research may benefit from consistent meaningful involvement of members of the public.

Underlying data

Raw data are not publicly available as the transcripts cannot be sufficiently de-identified by redaction. Data will be made available by reasonable request to the corresponding author (email address: hannah.durand@nuigalway.ie). A request is considered reasonable where the intended use for the data is clearly outlined, and where this intended use does not violate the protection of participants, or present any other valid ethical, privacy, or security concerns.

Extended data

Open Science Framework: Identifying and addressing psychosocial determinants of adherence to physical distancing guidance during the COVID-19 pandemic.

https://doi.org/10.17605/OSF.IO/ES85A (Durand et al., 2020).

This project contains the following extended data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).