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Bodas and Peleg Israel Journal of Health Policy Research (2020) 9:54 https://doi.org/10.1186/s13584-020-00418-w ORIGINAL RESEARCH ARTICLE Open Access Income assurances are a crucial factor in determining public compliance with self- isolation regulations during the COVID-19 outbreak – cohort study in Israel Moran Bodas1,2 and Kobi Peleg1,2* Abstract Background: The outbreak of a new Coronavirus disease (COVID-19) poses dramatic challenges to public health authorities worldwide. One measure put in place to contain the spread of the disease is self-quarantine of individuals who may have been exposed to the disease. While officials expect the public to comply with such regulation, studies suggest that a major obstacle to compliance for self-quarantine is concern over loss of income or employment due to the prolonged absence from work. Methods: A cohort study of the adult population of Israel was conducted in two time points during the COVID-19 outbreak, the last week of February and the third week of March 2020, in order to assess public attitudes. In particular, public compliance rates to self-quarantine with and without State-sponsored compensation for lost wages were assessed. Results: The results suggest that public attitudes changed as the threat increased, making people more compliant with regulations. In February 2020, compliance rate for self-quarantine dropped from 94% to less than 57% when monetary compensation for lost wages was removed; however, in March 2020 this drop became more moderate (from 96 to 71%). The multivariate logistic regression revealed that older, non-Jewish, worried over COVID-19, and trusting the Ministry of Health were more likely than their counterparts to comply with self-isolation, even when monetary compensation was not assumed. Conclusions: Despite the effects of threat on people’s obedience with regulations, this study demonstrates that providing people with assurances about their livelihood during absence from work remains an important component in compliance with public health regulations. Keywords: COVID-19, Compensation, Compliance, Self-quarantine, Attitudes, Cohort * Correspondence: [email protected] 1Israel National Center for Trauma & Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 5265601 Ramat-Gan, Israel 2The Department of Emergency Management & Disaster Medicine, School of Public Health, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Bodas and Peleg Israel Journal of Health Policy Research (2020) 9:54 Page 2 of 10 Background quarantine dropped from 94% to less than 57% when A novel Severe Acute Respiratory Syndrome (SARS) cor- monetary compensation for lost wages was removed. onavirus originated in December 2019 from Wuhan, Hubei, Since then, additional studies have demonstrated the im- China. The disease caused by this virus (a.k.a. COVID-19) pact of monetary compensation on compliance with has since spread throughout the globe causing major dis- self-isolation [3]. ruption to ordinary life [23, 40]. As of 19 April 2020, a total In fact, the State of Israel offered several monetary in- confirmed cases of 2,241,359 cases of COVID-19 were con- centives to prompt individuals to comply with self- firmed globally, of which 152,551 died [39]. isolation and other health regulations, including state- Health authorities struggle to contain the spread of sponsored unemployment benefits for individuals who COVID-19 by implementing a variety of measures de- lost their source of income during the COVID-19 out- signed to reduce the rate of infection. These include social break valid until June 2021, as well as financial compen- distancing, hygiene, use of gloves and masks in public sation for businesses and self-employed individuals, areas, etc. [14]. One of the main measures employed by depending on the level of loss they experienced.1 In health authorities in the effort to combat the spread of in- addition, the government issued single time grants for fectious diseases is self-quarantine [13, 18]. Several studies each citizen made payable through the National Insur- have demonstrated the applicability of self-quarantine spe- ance Institute [29]. cifically in reducing COVID-19 morbidity [12, 16, 20]or The purpose of the current study was to assess the increasing public perception of its efficacy in doing so same public attitudes toward the COVID-19 outbreak (e.g., [10]). that were assessed in February 2020 at a later stage of Accordingly, individuals who are thought to have been the outbreak (March 2020). The comparison between exposed to COVID-19 are instructed to place themselves the two time points allows the assessment of change in under household self-quarantine for a minimum of 14 public attitudes as the threat of COVID-19 increased days. Prior research suggest that during disease out- and progressed. breaks, the public views self-quarantine favorably and is willing to comply with such regulation [5]. Conse- Methods quently, officials expect the public to comply with such This cohort study was conducted in Israel during Febru- regulation; however, studies suggest that a major obs- ary–March 2020. Randomized samples of the adult tacle to compliance for self-quarantine is concern over population of Israel were engaged in a study to assess loss of income or employment due to the prolonged ab- public attitudes concerning the outbreak of COVID-19. sence from work [4, 33]. Responses were collected through the iPanel online poll- Public cooperation with regulations such as self- ing service. Since 2006, the iPanel provides an online isolation are vital for these measures to be effective in platform for a wide variety of information collection ser- slowing down the spread of diseases. Non-compliance vices, including polls and public opinion surveys. It ad- with self-isolation can lead to increased morbidity and heres to the stringent standards of the world association mortality and set back national efforts to contain the for market, social, and opinion researchers (ESOMAR). outbreak. Such behavior is dependent on numerous fac- In addition, the iPanel was evaluated by the Applied tors, including public fear [17] or concern [30], possible Statistical Laboratory of the Hebrew University in penalties for breaching regulations [36], perceived cost Jerusalem and was found to be highly accurate in asses- of protective measures ([11], attitude toward solitude sing internet-based samples of the adult Jewish popula- [37], information overload [11, 19], working conditions, tion in Israel [31]. particularly being able to work from home [25], whether A representative sample of the adult population of the the self-isolation is voluntary or mandatory [34], and State of Israel was assessed on two time points: last week general preparedness [10]. of February and third week of March 2020. On each Therefore, it is imperative to assess public attitudes to- time point, a different sample was assessed, making the ward compliance with health regulation posed during two sample mutually exclusive. The final sample for Feb- the COVID-19 outbreak, in particular self-quarantine. In ruary included 563 respondents and the final sample for an earlier publication, we reported the results of a survey March 2020 included 511 respondents, representing performed in the last week of February 2020 in Israel [6]. At that time, only five cases of COVID-19 had been 1Compensation for part or full time employees who were put on non- confirmed in Israel, and more than 5000 Israelis put in paid leave included unemployment benefits up to 80% of original sal- self-quarantine at their homes. The results of that study ary. Compensation for self-employed individuals included government – suggested a major effect of monetary compensation for grants in three stages covering 60 70% of original monthly income ac- cording to various eligibility criteria. In addition, each citizen in Israel lost wages on the intent of people to comply with self- was awarded a one-time grant, usually in the sum of 750 NIS per per- quarantine regulation. The compliance rate for self- son, including children up to the fifth child. Bodas and Peleg Israel Journal of Health Policy Research (2020) 9:54 Page 3 of 10 response rates of about 25% each, similar to other stud- explore differences between February and March sam- ies that utilized the iPanel (e.g., [2, 7, 8, 24]). Table 1 ples. Regression performed in Enter mode and 95% Con- summarizes the sociodemographic breakdown of the fidence Intervals were calculated. In all statistical studied samples. At the time responses were collected, analyses performed, a p-value of 0.05 or less was deter- the following circumstances were evident: In the last mined as statistically significant. week of February 2020 a total number of five cases of COVID-19 were confirmed in Israel and more than Results 5000 Israelis were required to self-quarantine at home.