key: cord-1000414-k83zt387
authors: Jimenez, Tyler; Restar, Arjee; Helm, Peter J.; Cross, Rebekah Israel; Barath, Deanna; Arndt, Jamie
title: Fatalism in the context of COVID-19: Perceiving coronavirus as a death sentence predicts reluctance to perform recommended preventative behaviors()
date: 2020-06-08
journal: SSM Popul Health
DOI: 10.1016/j.ssmph.2020.100615
sha: b9abb25c38229bd2f5b9f418e3d83c51a9441e14
doc_id: 1000414
cord_uid: k83zt387

To manage the spread of coronavirus, health entities have urged the public to take preventative measures such as social distancing and handwashing. Yet, many appear reluctant to take these measures. Research is needed to understand factors underlying such reluctance, with the aim of developing targeted health interventions. We identify associating coronavirus with death as one such factor. 590 participants completed surveys in mid-March 2020, which included attitudes toward coronavirus, preventative behavioral intentions, and sociodemographic factors. Associating coronavirus with death negatively predicted intentions to perform preventative behaviors. Further, associating coronavirus with death was not evenly distributed throughout the sample and was related with a number of sociodemographic factors including age, race, and availability of sick leave. Following recommended preventative measures to slow the spread of coronavirus appears to relate to the degree to which people associate coronavirus with death. These findings can be used by public health researchers and practitioners to identify those for whom targeted health communication and interventions would be most beneficial, as well as to frame health messaging in ways that combat fatalism.

On March 11, 2020, the World Health Organization classified COVID- 19, commonly 22 referred to as coronavirus, as a global pandemic 1 . Since its first report in December 2019, 23 coronavirus has spread to over 180 countries, taking thousands of lives 2 . In the US, day-to-day 24 life has been interrupted to an unprecedented degree as a result of precautionary measures given 25 the widespread nature of coronavirus transmission: businesses and schools have closed, jobs 26 have been lost, people have begun working from home, community gatherings have been 27 cancelled, travel has been restricted, and some areas have experienced food and toiletry 28

shortages. Worryingly, the U.S. health care system is unprepared to handle the number of 29 coronavirus cases projected to be seen in the near future. As one stark example of this, a 30 moderate projection in which 40% of the U.S. population contracts coronavirus during 2020 31 would see a shortage of hospital beds by half 3 . 32

To avoid such scenarios, the U.S. Centers for Disease Control and Prevention (CDC) 33 along with state and local governmental entities have urged the public to adopt preventative 34 behaviors. At this time, the known major transmission mode for coronavirus is through the 35 exchange of respiratory fluid, often through aerosols via coughs and sneezes but also on common 36 surfaces 4 . Its spread can be slowed by preventative practices such as social distancing (i.e., 37 deliberately increasing the physical space between individuals and avoiding social gatherings) 38 and handwashing 5,6 . Indeed, the Imperial College COVID-19 Response Team projects that such 39 practices, in concert with mitigation policies such as quarantining positive cases, could reduce 40 deaths by half 7 . 41

Yet, despite increasing awareness about these recommendations, polling data suggests a 43 reluctance to perform recommended preventative behaviors. For instance, in a March 2020 poll, 44 while 70% of U.S. adults reported concern about coronavirus spreading to their community, less 45 than half have taken preventative measures 8 . This discrepancy between concern about 46 coronavirus and uptake of the recommended preventative behaviors is of great public health 47 significance. Such data points to the need to identify factors that inhibit coronavirus-relevant 48 preventative behaviors to generate behavioral and social public health interventions that can help 49 optimally contain the spread of coronavirus. 50

To be sure, there are many likely influences at play; one factor that could potentially 51 contribute to this discrepancy between being concerned about coronavirus and inhibition of the 52 recommended preventative behaviors is associating coronavirus with death. Why, given that 53 coronavirus is not automatically deadly, would people associate it with death? First, health 54 scenarios often elicit death-related cognitions, which in turn can influence health-relevant 55 decisions 9 . Second, the vast amount of coronavirus information and misinformation circulated on 56 social media, cable news, and other sources may make people feel overloaded and, as a result, 57 fatalistic. Consistent with this line of reasoning, prior research has shown that cancer information 58 overload -that is, feeling overwhelmed by the amount of cancer information in the environment 59 -is related to fatalistic perceptions 10 . Finally, given that coronavirus is often paired with death 60 when portrayed in the media, it seems likely that people will internalize this association, 61 particularly if they belong to groups portrayed as vulnerable. 62

In the present context, associating coronavirus with death -a coronavirus related 63 mortality salience so to speak -could belie a fatalistic perception of coronavirus as a death 64 sentence. Even a generalized connection between coronavirus and death may make health issues seem uncontrollable 11 , thus inhibiting the performance of preventative behaviors. Fatalistic 66 thinking (i.e., fatalism) has been widely found to undermine preventative behaviors in other 67 diseases in which vaccines are currently not available 12 . For instance, empirical evidence from an 68 analysis of the Health Information National Trends Survey (HINTS), a national study on cancer-69 related attitudes and behaviors, found that the degree to which people agreed with the statement, 70

"When I hear about cancer, I automatically think of death" predicted reported physician 71 avoidance 13 . A subsequent study found that age and subjective health status were predictive of 72 believing cancer to be a death sentence; specifically, younger (as compared to older) individuals 73

and those with poorer (as compared to fairer) health were more likely to automatically associate 74 cancer and death 14 . Similarly, in the context of the HIV epidemic, fatalistic thinking has also 75 been linked to increased HIV risk behaviors (i.e., condomless sex) 15 . 76

If associating coronavirus with death is found to predict reluctance to perform 77 preventative behaviors, then it is vital to identify characteristics of individuals most likely to 78 perceive this cognitive association. This identification will allow public health researchers and 79 practitioners to develop targeted interventions aimed at increasing preventative behaviors. Given 80 the specifics of coronavirus, it is unclear which factors would predict associating coronavirus 81 with death. To fill in this gap, the purpose of this study is to: (1) identify factors that predict 82 associating coronavirus with death; and (2) assess the relationship between associating 83 coronavirus with death and preventative behavioral intentions such as social distancing and 84 handwashing. To be eligible for this study, participants had to (1) be at least 18 years old and (2) based 99 in the United States. A number of web-based best practice measures were taken to ensure data 100 quality. First, to eliminate potential bots from completing the survey, we included a captcha in 101 the consent form. Second, following recommendations 16 , we included an attention check 102 intended to screen out inattentive participants. This consisted of an item that instructed 103 participants to select a specific response; participants who selected a different response (n = 12) 104

were excluded from analyses. It must be noted that many populations in the U.S. would not be 105 represented in the samples. For example, those who do not speak English and those without 106 internet and computer access would not be reached by the present recruitment strategy. Such a 107 strategy -recruiting participants from Mturk -affords an initial opportunity to examine the 108 proposed psychological processes as the coronavirus pandemic unfolds. to get tested for coronavirus if I have symptoms such as a fever and shortness of breath". 124

Work-related Self-Esteem. 125

To measure the tendency to derive self-esteem from work, we adapted seven items from 126 the Contingencies of Self-Worth scale 17 . Items, scored on a one (strongly disagree) to seven 127 (strongly agree) scale, included "When I do well at my job, I feel good about myself" and "I 128 could not respect myself if I did poorly at my job". Two items were removed to improve scale 129 reliability (α = .69). 130

Associating Coronavirus with Death.

An adapted item 13 , which asked, "How much do you agree or disagree with the following 132 statement? When I hear about coronavirus, I automatically think of death", was included to 133 assess perceiving associations between coronavirus and death. Participants responded to this 134 question on a scale of 1 (strongly disagree) to 7 (strongly agree). 135

At the time of data collection (March 2020), the CDC recommended a number of 137 preventative behaviors intended to slow the spread of coronavirus. These included, among 138 others, avoiding close interpersonal contact (i.e., social distancing) and thorough handwashing. 139

To assess intentions to perform these recommended preventative behaviors, we included eight 140 items measured on a 1 (strongly disagree) to 7 (strongly agree) scale. Six items focused on 141 social distancing (α = .75; e.g., "I intend to practice social distancing in the upcoming weeks") 142 and two focused on handwashing (α = .67; e.g., "I intend to wash my hands frequently in order 143 to reduce my chances of catching coronavirus"). 144

Descriptive statistics are summarized by study sample and tested for differences between 146 the two samples. To determine internal reliability, we conducted sensitively analysis of our 147 scaled variables. Then, a series of linear and multivariate regressions were employed. For the 148 first sample, all sociodemographic factors, coronavirus knowledge, coronavirus attitudes, 149 coronavirus worry, and work-related self-esteem were simultaneously used to predict associating 150 coronavirus with death. Significant predictors were then included as control variables in a 151 multivariate regression, which simultaneously predicted social distancing and handwashing from 152 associating coronavirus with death. All statistical analyses were conducted in SPSS version 26. 153

Sample characteristics, and variable means and standard deviations are displayed in 156

Tables 1a and 1b. The majority of the sample felt they were exposed to a lot of coronavirus 157 information and had coronavirus-related worries. People generally indicated high social 158 distancing (5.7/7), handwashing (6.1/7), and screening intentions (5.6/7). Across both samples, 159 45% were cisgender women, 66% were White, with an age range of 18-74 (M age = 37.12, SD age = 160 12.03). As the number of deaths from coronavirus in the U.S. increased from 11 to 108 between 161 the two dates of data collection (March 5 th and 18 th ), it was possible that the association between .28, η² = .002). The distribution of associating coronavirus with death is displayed in Figure 1 . Overall, age, race, coronavirus-related worry, perceived ability to take sick leave, and 169 work-related self-esteem were each predictive of associating coronavirus with death (Table 2) . perceived ability to take sick leave, perceived ability to receive necessary medical treatments, 184 political conservatism, and income. 185

A multivariate regression was used to assess the relationship between associating 187 coronavirus with death and preventative behavioral intentions. The model predicted the two 188 dependent variables -social distancing and handwashing intentions -from associating 189 coronavirus with death, while controlling for coronavirus-related worry, age, race (coded as 190

Black and non-Black), perceived ability to take sick leave, and work-related self-esteem (the 191 association between each of these preventative behavioral intentions are displayed in Table 3 ) . The present findings identify one factor underlying reluctance to perform preventative 198 behaviors recommended for slowing the spread of coronavirus: associating coronavirus with 199 death. Further, we show that associating coronavirus with death is predicted by a host of 200 sociodemographic factors, including coronavirus-related worry, age, race, perceived ability to 201 take sick leave, and work-related self-esteem. These findings are broadly consistent with the 202 health fatalism literature and can inform coronavirus-related health communication strategies, 203 specifically identifying segments of the population -Black, young, and those without sick leave 204 -that would benefit most from interventions aimed at promoting preventative behaviors. 205

Given that the particular vulnerability of older adults to coronavirus morbidity and 206 mortality has received considerable media attention, it was expected that associating coronavirus 207 with death would be positively associated with age. However, an opposite pattern emerged; 208 younger adults were more likely than older adults to associate coronavirus with death. This 209 relationship did not change when controlling for political conservatism. This is interesting to 210 note given the initial partisan media coverage of coronavirus, with many conservative outlets 211 initially downplaying the seriousness of the epidemic. Although the direction of this age effect is 212 surprising, this finding is consistent with other research showing a negative relationship between 213 age and perceiving cancer as a death sentence 14 . There are a number of possible explanations for 214 why there was such an association between age and perceiving coronavirus as a death sentence, 215 which future research may explore. First, it is possible that older adults are more able than are 216 younger adults to handle threatening health information without holding fatalistic beliefs. 217

Second, younger people may tend to be more fatalistic in regard to health given the potential 218 years of life lost. Moreover, this finding suggests that public health messaging regarding 219 preventative behaviors may not be reaching or resonating with younger audiences 18 . In fact, early 220 messaging about coronavirus suggested that younger people were less likely to experience severe 221 illness and death due to the virus. Given that younger adults (age 20 to 54) currently make up 222 nearly 40% of coronavirus hospitalizations in U.S. 19 , there is a need for careful segmentation of 223 public health messaging for this age group; one that denotes their severity and vulnerability for 224 acquiring and transmitting coronavirus. 225

Black individuals in this sample were also particularly likely to associate coronavirus 226 with death. While confidence in this finding should be tempered by the relatively small Black 227 sample (n = 119), it is broadly consistent with prior research showing that fatalism is particularly 228 experienced among Black (as compared to White) people 20 , which can be understood as a 229 reaction to historical and contemporary injustice 21 . Black people's experience with medical 230 racism in the US has been widely documented and has had significant impacts on fatalistic 231 beliefs 22 . However, the relationship between fatalism and preventative behaviors is varied. For 232 example, studies have shown that Black people who perceive racism 23 or hold HIV conspiracy 233 beliefs 24 are more likely to engage in HIV screening. 234

It is possible that those without sick leave were more likely to associate coronavirus with 235 death because they may assume that continued work leaves them susceptible to coronavirus 236 transmission and that a lack of sick leave will leave them unable to receive treatment. An 237 inability to take sick leave may contribute to limited perceived personal control over prevention 238 options 25 . Addressing such perceptions should be done through both interventions and policy. 239

For essential workers, individual-level interventions should attempt to disrupt the association 240 between coronavirus and death, perhaps by emphasizing the efficacy of preventative behaviors. 241

For non-essential workers, policies such as the newly passed guaranteed sick leave in New 242

York 26 might prove more beneficial. As suggested by other studies 27 , such measures may have 243 positive downstream effects on the practicing of preventative behaviors. 244

Interestingly, the present finding that associating coronavirus with death negatively 245 predicted preventative behavioral intentions is seemingly at odds with the Health Belief Model (HBM) 28 . According to the HBM, the perceived severity of a potential health issue should be 247 positively related to preventative behavioral intentions 29 . Thus, in the current case, the HBM 248 would predict that greater associations between coronavirus and death would predict greater 249 social distancing and handwashing intentions. As this was not the case, and other research has 250 similarly shown that associating cancer with death predicts physician avoidance 13 , it seems likely 251 that, while conceptually similar, severity and fatalism do not always predict behavioral intentions 252 in the same way. Moreover, there is considerable research derived from protection motivation 253 theory and other such perspectives that indicates the impact of perceived severity on health 254 behavior change can be moderated by perceptions of (personal and response) efficacy 30,31 . Future 255 work might seek to distinguish these fatalism and severity, perhaps by examining factors that 256 lead to, and those which follow from, perceptions of efficacy, severity, and experiences of 257

Understanding the centrality of associating coronavirus with death in relevant health 259 behaviors can benefit health researchers and practitioners alike. Researchers should continue to 260 investigate factors that influence whether people associate coronavirus with death, particularly as 261 death tolls continue to mount; the epidemic is developing at a rapid rate, which is likely to 262 influence the degree to which people associate coronavirus with death. Those in medicine and 263 public health might utilize the degree to which people associate coronavirus with death as a tool 264 to direct how best to communicate. As suggested by the present studies, those who strongly hold 265 such a perception are least likely to perform necessary preventative behaviors, and thus the most 266 likely to benefit from targeted interventions. 267

While the present studies provide preliminary evidence regarding factors that contribute 269 to coronavirus-related preventative behaviors, they are not without limitation. First, the 270 convenience sample used was not nationally representative in terms of gender, age, and race, and sources of coronavirus-related information (e.g., social media) shape the degree to which people 281 associate coronavirus with death and intentions to perform preventative behaviors. 282

As coronavirus continues to spread, research on factors that inhibit preventative 284 behaviors is urgently needed. The present study offers novel empirical evidence that associating 285 coronavirus with death predicts reluctance to perform recommended preventative behaviors such 286 as social distancing and handwashing. Further, we show that coronavirus-related worry, age, 287 race, perceived ability to take sick leave, and work-related self-esteem are predictive of 288 associating coronavirus with death. These findings can help inform our understanding of and 289 responses to the global coronavirus pandemic. 290 

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* Indicates a significant difference (p < .05) between samples. N = 590

• Age, race, and ability to take sick leave predict associating coronavirus with death • Such associations are negatively correlated with behaviors intended to prevent the spread of coronavirus such as handwashing and social distancing • The findings point to the need for targeted health communications and interventions, as well as inform factors underlying resistance to performing preventative behaviors Ethics Approval All research in this manuscript was approved by the University of Missouri Institutional Review Board.