The aim of this study was to investigate factors affecting people’s compliance with stay-at-home advice during the current COVID-19 pandemic in Iran. The pandemic occurred during Nowruz (the Persian New Year) holidays, starting from March 19, 2020, and extending for two weeks. Nowruz is traditionally time to leave homes for shopping, traveling, and visiting relatives. However, COVID-19 has transformed all the traditions this year (2, 4).
The lack of vaccines or effective treatments for COVID-19 have significantly challenged control of the disease spread. Recent evidence suggests that these types of diseases can include serious social, psychological, and economic consequences. Mashhad, with a population of 3،012،090 individuals, is the second largest holy city in the world, attracting more than 20 million pilgrims and tourists annually especially during Nowruz (25). In large metropolises such as Mashhad, the importance of limiting outbreaks before their widespread transmissions is a high priority for public health policy makers and planners. Results have shown that most of the people have adopted self-isolation during recent Nowruz in Mashhad. However, nearly one-fifth of the participants had poor compliance with stay at home orders.
Clear social gradients were not found in people’s compliance with stay-at-home directives. However, those with lower subjective social class showed higher odds of non-compliance to social-isolation. People have been asked to practice social distancing as well as economic distancing. Due to numerous economic problems in Iran, general quarantine and strict social distancing include economic hardship for poor people such as those relying on informal labors with no possibilities of social distancing practices (2, 4).
In the present study, the major explanatory factor included perceived social support. The literature suggest positive effects of supportive relationships with other people on promotion of healthy behaviors, as health promotion programs often use social support to change or maintain certain behaviors (7, 10, 16, 17, 26).
Interestingly, social support was found to be both a fostering and hindering factor dependent on the source of support. Participants who perceived more support from their family members were more likely to comply with stay-at-home advices. In contrast, those who perceived more support from friends were more likely to be noncompliant. It appears that close family members may have helped to reinforce the social distancing directive and promoted adherence. Conversely, individuals who rely strongly on the support of friends may have felt greater pressure to leave their homes to socialize, a pressure that may have been amplified as a social norm by some friendship groups.
Studies have shown that different sources of support may have differential effects on health outcomes. Researchers have reported that social support from family members is strongly associated with health status and health-related behaviors. However, in some instances, social support could have negative consequences. For example, friends and family, through normative influences, may promote unhealthy behaviors and discourage healthy lifestyles (27–29).
A large and growing body of research has indicated that the family, as a supportive network, plays a significant role in shaping health behaviors (30). Family is one of the key factors that shapes and affects personal health attitudes, beliefs and behaviors. Family members may model positive health care behaviors or serve as sources of support in crises such as quitting alcohol and caffeine during pregnancy, quitting smoking, and adopting preventive measures (31).
The mechanisms; through which, various aspects of the family relationships (e.g., parental statuses, affectional closeness and obligations) affect health behaviors, have been described via social control theory (30, 31). Social control theory hypothesizes that family relationships affect health behaviors through indirect and direct control mechanisms. Indirect social control acts through the self-enforcement of norms. Individuals with positive family ties feel a greater sense of responsibility for themselves. Furthermore, families who motivate individuals to practice improve their health behaviors (32). Support from and accountability to family may directly facilitate changes in behaviors through physical interventions (e.g., preparing special meals), supportive behaviors (e.g., supporting exercise adoptions and routine contacts between the family members who are physically separated) and social sanctions (e.g., threatening to end a marriage if excessive alcohol consumption continues (31).
A limitation in this study was the use of a single-question to identify levels of compliance with stay-at-home directives during the COVID-19 outbreak. This self-report measure was used due to the lack of validated measures of voluntary social isolation(24).
Another limitation was that the use of a landline phone survey might have increased the possibility of selection bias and overrepresentation of participants with high socioeconomic status because houses with multiple landlines were more likely to be selected and those without landlines (including nearly 3% of the houses according to 2016 reports by Iran Census) were excluded.
Despite these limitations, this study provides valuable insights into some key factors influencing compliance with social distancing orders during the COVID-19 pandemic, for families, policymakers and health service managers. Specifically, results highlighted that compliance with self-isolation may be affected differently by different aspects of people's social networks.