On January 20, 2020, the first US case of a novel virus was detected [1], and it was later named SARS-COV-2 [2,3]. The coronavirus is spread primarily via exposure to oral and nasal secretions when a person is in close contact with someone who has COVID-19 [4], and it is known to cause critical illness and substantial mortality in a subset of the infected population [5]. As of August 27, 2020, a total of 24,234,340 confirmed cases and 827,110 deaths due to COVID-19 were reported worldwide [6], of which over 5,752,653 cases and 177,759 deaths were reported in the United States alone [7]. These high numbers are in part because SARS-COV-2 is highly contagious [8], and about 44% (95% CI 30%-57%) of the confirmed cases are due to presymptomatic transmission [9-11].

Without a vaccine or an effective treatment, the COVID-19 pandemic could easily overwhelm hospitals. Actions undertaken at the individual level, such as washing hands, social distancing [12], and wearing face masks [13], can slow the spread of the disease [14]. Government measures to curtail the spread started with international travel restrictions [15]. California was the first to issue state-wide stay-at-home orders [16], followed by most, but not all (8 states did not), states [17]. The states with stay-at-home orders successfully reduced the contagion compared to states that did not enforce these orders [18]. Stay-at-home policies have significant economic and social consequences [19]; federal, state, and local officials now struggle to protect American lives while also recovering the economy by enabling people to go back to work [20].

Multiple factors influence COVID-19 precautionary and return-to-activity behaviors. For example, knowledge about COVID-19 and its risks are associated with a high-risk behavior, such as attending large gatherings and not wearing masks [21]. Additionally, the risk of getting severely ill from COVID-19 increases with age and coexisting conditions [22], and the risk is higher in men than in women [23,24]. Among some racial and ethnic groups in specific contexts, evidence points to higher rates of hospitalization and death due to COVID-19, and this is especially true in vulnerable populations such as migrants and undocumented individuals [25-27]. Political orientation and environment also are associated with COVID-19 response recommendations [21,28]. Finally, income disparities can result in situations that pit physical distancing against meeting basic needs [29].

With conflicting statements in the media from medical and political leaders, the general public lives with considerable uncertainty about the disease and the impact of their behaviors on their health and the health of the community. Understanding the factors affecting adults’ willingness to engage in precautionary behavior or to return to normal activities could improve messaging among those with trusted voices and potentially aid economic recovery [30]. Using cross-sectional, national, population-based surveys conducted across time, this exploratory study examines major factors associated with COVID-19 precautionary behaviors, willingness to return to typical activities when told it is safe to do so by public health officials, and the levels of concern about the virus in order to inform preventive efforts and determine key populations that may benefit from reinforced messaging from health care providers. Our hypothesis was that the identification of political party affiliation would have as large an effect as other traditional covariates such as age, gender, race or ethnicity, health (ie, number of prescriptions), education, information, income, COVID-19 status, and religion with regard to three key outcomes: (1) COVID-19–related concerns, (2) precautionary behaviors, and (3) willingness to return to activity.

The data included responses from 125,508 interviews conducted between March 19 and August 5, 2020, approved by the UCLA Institutional Review Board for analyses. Unless otherwise noted, all ORs presented were significant at P<.001, with 95% CIs presented.

The data from our analyses provide considerable evidence that the majority of Americans have rapidly adopted new preventive behaviors in the face of the deadly COVID-19 pandemic. On average, more than 8 in 10 report wearing a mask outside (unweighted: 70,802/80,624), and most have avoided meeting family and cancelled travel plans. In addition, these data shed light on the challenges that cities and states face as society reopens. Even after public health officials declare activities to be safe to engage in, more than half the survey respondents reported that they will not send a child to school or travel by air, and only 61.9% will visit a dentist (unweighted: 36,540 /58,206). It is unclear whether projected caution is related to the inconsistent messaging or the source of information requires greater exploration than we can provide here and needs to be further evaluated. This may also be related to public uncertainty and trust in the messenger or the message itself [34]. There is significant politicization that casts doubt on public health warnings and in the accuracy of statements from public officials in the recommendations associated with preventive behaviors and how to ramp-up the economy [35,36]. Politicization of COVID-19 preventive behaviors is not limited to the United States, but it is also observed in other countries such as the United Kingdom and Brazil [37,38]. Confusion and mixed messaging (alongside variations in protocols implemented by 50 state governors) calls on the physician to provide guidance that is based on science and perceived as trustworthy by patients [39,40].

Despite the generally high rates of reported precautionary behaviors, the 10%-20% nonadherence rate may exceed the thresholds needed to quell the virus spread [13,41-43]. It is also noteworthy that these rates are likely high estimates because our survey questions asked about whether the behavior was practiced at all, but not how often or how consistently. It should alarm health care providers that small, but possibly substantial, groups of patients are not following public health rules (which may have limited evidence-based data), suggesting that behavioral intention concerning the contagion should be explored with patients. Several studies have shown that level of concern and risk perception is linked to adoption of precautionary behaviors [44-46], which is augmented by varying infection fatality rates [47]. Reinforcing preventive messages is particularly needed for patients who have recovered from COVID-19 infection. Such individuals are less likely to engage in precautionary behaviors, which may be the reason they contracted the virus. It is likely, however, that recovered patients also have developed some immunity against reinfection. This demonstrates the risk of inadequate testing, false-positive serological testing, and assumptions around T-cell immunity in creating a false sense of security that in turn encourages permissive behavior [48-50].

The analyses identified clear patterns in the levels of concern, precautionary behaviors, and willingness to resume activities after the restrictions are lifted. Despite controlling for all other factors, party affiliation was a significant factor for being very concerned about COVID-19, engaging in preventive measures, and returning to activities, to an extent not observed in other major disease outbreaks or prior pandemics [51-55]. The group most likely to be concerned about COVID-19 (ie, older adults, female participants, and Democrats) was also more likely to engage in preventive behaviors and less willing to resume activities. A second group (ie, younger adults, male participants, less well-educated participants, and Republicans) reported lower levels of concern about COVID-19, were less likely to report precautionary behaviors, and more willing to return to activities. Previous studies have suggested that people trust medical experts more than political leaders [56,57]. However, it would be short-sighted to neglect how the lens of political party affiliation informs attitudes and how patients process information given the prior evidence that political party influences health domains such as obesity, end-of-life management, and vaccine adoption [58]. Our findings are consistent with those of other studies that highlight the political polarization of preventive health behavior with regard to COVID-19 and in general [21,28,59,60].

This study’s limitations deserve mention. First, this study focused primarily on readily observable factors. However, such factors (eg, gender) are not explanatory by themselves. Relatedly, most health behaviors involve multiple determinants, and the determinants evince substantial interindividual variability. Reliable mask-wearing might result from concern for others’ health, risk aversion, respect for the relevant science, high motivation to comply with rules, among other factors. Evidence for the malleability of risk perceptions, prosocial motivation, and other contributors to health-promoting behaviors point toward promising targets for change [61-64]. Our research group and others [65] are working to identify such malleable targets. The present survey did not collect data on occupation and work-related subsidies. Second, the cross-sectional nature of the data does not allow for definitive interpretation of findings regarding across-time stability and change; however, the sampling strategy and large sample lend confidence to the findings. Third, measures of precautionary behaviors were author-constructed in a way that may overestimate their extent. Fourth, the questions about COVID-19 status did not differentiate between those individuals who had symptoms versus a confirmed laboratory test, yet the construct of believing that one has had COVID-19 is clinically relevant. Finally, in this study, we could not compare the sample population to an international sample to analyze the effect of the prosperity of a country or differences in national health care insurance plans [66,67].

Health care providers have a significant role to play both in managing the pandemic and ensuring adherence to prevention and recovery behaviors. This implies not only making masks mandatory in clinical settings but also strongly counseling patients to wear face coverings [68] in high-risk environments and avoiding high-risk activities. For providers and public health officials to serve as facilitators, they need to understand the attitudes and perceptions of their patients and tailor messages to move them toward both prevention and recovery. This is critical because recovery represents a set of behaviors that impact not just economic health but also the personal health of patients, many of whom have also been deferring the care of their chronic medical illnesses as well as routine but important health maintenance and prevention. Future studies need to develop and test targeted messaging approaches, including those with respect to political party, to encourage preventative behaviors and willingness to return to activities.