To Prof. Amir H. Pakpour, Ph.D.
Academic Editor
PLOS ONE
Ijuí, November 24th, 2020.
Dear Prof. Pakpour,
While we are grateful for the opportunity of presenting a revised version of our manuscript
entitled “Insufficient social distancing may be related to COVID-19 outbreak: the
case of Ijuí city in Brazil”, ID PONE-D-20-19438. We hereby would like to present
our responses to the reviewers’ comments. All the alterations to the text are now
red-marked to facilitate reviewers’ analyses. We are also uploading a clean version
of the manuscript.
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Answer 1. Thank you for the comment and sorry for the mistakes in the first version
of the manuscript. We revised the manuscript in terms of PLOS ONE’s style requirements.
The revised version has now the correct formatting of the head titles levels. Also,
we changed “Figure 1” by “Fig 1” as recommended, as well as we corrected the information
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Answer 2. Thank you for the comment and sorry for some English mistakes in the first
version of the manuscript. We sent the manuscript to Cambridge Proofreading service
(https://proofreading.org/). Now, we have a revised version of the manuscript, that we believe reached language
quality after it was revised by English native speaker and professional proof-read
service in the field. Thus, we modified the title from “Insufficient social distancing
may be related to COVID-19 outbreak: the case of Ijuí city in Brazil” to “Insufficient
social distancing may contribute to COVID-19 outbreak: the case of Ijuí city in Brazil”.
Also, the marked English revision was attached to the online submission system. The
certificate of English revision is attached below:
Q3. Please include additional information regarding the survey or questionnaire used
in the study and ensure that you have provided sufficient details that others could
replicate the analyses. For instance, if you developed a questionnaire as part of
this study and it is not under a copyright more restrictive than CC-BY, please include
a copy, in both the original language and English, as Supporting Information.
Answer 3. Thank you for the recommendation. We included a description of the questions
related to social distancing behavior to provide a better comprehension for readers
and to provide an opportunity for replication of the study in other cities. Also,
we included in the supplementary material the questionary in English and Portuguese.
Thank you for the suggestion. Also, we provide a link for data availability as now
mentioned at the end of manuscript. These information were described as follows:
Page 6, line 163:
“Additionally, at each study wave participants answered short questionnaires, including
sociodemographic information (sex, age, medical history, schooling, and race), COVID-19-related
symptoms, use of health services, compliance with social distancing measures, and
use of face masks. The questions on social distancing were as follows: 1) “To what
extent are you managing to follow the social distancing guidance from the health authorities,
i.e., staying at home and avoiding contact with others?” This was scored on a five-point
scale, with the following alternatives read aloud to the respondent: “very little,”
“little,” “some,” “quite,” and “practically isolated from everyone;” 2) “What have
your routine activities been?” The alternatives were: “staying home all the time,”
“only leaving home only for essentials, such as groceries,” “leaving home from time
to time to run errands and stretch legs,” “going out every day for regular activities,”
and “out of the house all day, every day, either for work or for other regular activities.”
This questionnaire passed an internal validation before it was applied in this study.
After this, the questionnaire was applied in 133 cities covering all regions of Brazil
[6,24–26]. The dataset used to produce the analyses presented in this study is freely
available at http://www.rs.epicovid19brasil.org/banco-de-dados/ and from the corresponding author upon request. The questionnaire is available in
the supplementary material.”
Q4. In the Methods, please discuss whether and how the questionnaire was validated
and/or pre-tested. If this did not occur, please provide the rationale for not doing
so.
Answer 4. The questionary was elaborated by experts from Epidemiology research group
from the Federal University of Pelotas, coordinated by the researcher Prof. Pedro
Hallal. The questionary passed by an internal validation before initiates the field
steps. The field work in Ijuí was carried out by Instituto de Pesquisas de Opinião,
a contract research organization, with the aid of UNIJUI university. The interviewers
were selected among students of health graduate and undergraduate programs from UNIJUI.
All were trained in administering the questionnaire. The questionnaire was included
in the supplementary material. After the first rounds of study in the RS, this questionary
was used in 133 Brazilian cities to evaluate the COVID-19 scenario in the country.
Due to the emergency to know about the community transmission rates, the survey was
applied in the population just after an internal validation of the questionary.
Page 6, line 163:
“Additionally, at each study wave participants answered short questionnaires, including
sociodemographic information (sex, age, medical history, schooling, and race), COVID-19-related
symptoms, use of health services, compliance with social distancing measures, and
use of face masks. The questions on social distancing were as follows: 1) “To what
extent are you managing to follow the social distancing guidance from the health authorities,
i.e., staying at home and avoiding contact with others?” This was scored on a five-point
scale, with the following alternatives read aloud to the respondent: “very little,”
“little,” “some,” “quite,” and “practically isolated from everyone;” 2) “What have
your routine activities been?” The alternatives were: “staying home all the time,”
“only leaving home only for essentials, such as groceries,” “leaving home from time
to time to run errands and stretch legs,” “going out every day for regular activities,”
and “out of the house all day, every day, either for work or for other regular activities.”
This questionnaire passed an internal validation before it was applied in this study.
After this, the questionnaire was applied in 133 cities covering all regions of Brazil
[6,24–26]. The dataset used to produce the analyses presented in this study is freely
available at http://www.rs.epicovid19brasil.org/banco-de-dados/ and from the corresponding author upon request. The questionnaire is available in
the supplementary material.”
Q5. Thank you for stating the following in the Acknowledgments Section of your manuscript:
[This work was supported by the 371 Regional University of Northwestern Rio Grande
do Sul State (UNIJUI), Federal University of Pelotas 372 (UFPEL), and Government of
Rio Grande do Sul State, as well as by the Coordination for the Improvement 373 of
Higher Education Personnel (CAPES).]
We note that you have provided funding information that is not currently declared
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present in the Funding Statement section of the online submission form. Please remove
any funding-related text from the manuscript and let us know how you would like to
update your Funding Statement. Currently, your Funding Statement reads as follows:
[The author(s) received no specific funding for this work.]
Answer 5. Thank you for the recommendation. We deleted the funding information in
the Acknowledgments Section. Now, we have this text:
Page 17 line 460
Acknowledgments
We would like to thank all volunteers who participated in the population-based survey.
We would also like to thank Professor Airam Sausen for her courses on COVID-19 prediction
math.
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ANSWERS TO THE REVIEWERS
Review Comments to the Author
Reviewer #1:
Comments and suggestions:
The study seems to me to be well written, with the data well summarized and presenting
and discussing a set of data can be interesting to understand the role of social distance
in the management, mitigation, of the pandemic outbreak, particularly in the case
of the city of Ijuí, a of the most populous in the state of Rio Grande do Sul, Brazil.
However, I would like to point out some specific and general aspects and comments,
which I understand, could enrich and clarify the content of the study.
Specific comments:
Q8. In the introductory part of the manuscript, starting at line 54, it would be interesting
for the authors to update the data by comparing some indicators of cases and deaths,
especially with other Brazilian states. Perhaps, with the States of São Paulo, Rio
de Janeiro and Ceará for which various indicators have always been the highest in
Brazil. Perhaps, an illustrative table or figure can be used showing a relative comparative
configuration of the varied incidence indicators (free choice by the authors);
Answer 8. Thank you for your suggestion. In fact, since our first version of the manuscript
(august) for nowadays, we have more clear data regarding COVID-19 transmission in
different States and cities in Brazil. We included a short description in the introduction
to provide an overview of Brazil situation.
Page 3 line 54
“The first case of COVID-19 in Brazil was reported on February 27, 2020 in the city
of São Paulo. Based on published events, eight of the 27 federated units of Brazil
present cumulative mortality rates above 10 per 100,000 inhabitants: four in the north,
two in the northeast, and two in the southeast region (including Rio de Janeiro and
São Paulo) [6]. Until November 2020, Brazil officially recorded 5,468,270 cases of
COVID-19 (2,602 per 100,000 inhabitants) and 158,456 COVID-19 deaths (75 per 100,000
inhabitants). The five federative units with the highest mortality counts are São
Paulo (39,007 deaths), Rio de Janeiro (20,376 deaths), Ceará (9,325 deaths), Minas
Gerais (8,872 deaths), and Pernambuco (8,587 deaths). The highest cumulative mortality
rates above 10 per 100,000 inhabitants are found in Ceará, with 102 deaths per 100,000
inhabitants[7]. In the state of Rio Grande do Sul (RS), the southernmost state in
Brazil with 11.3 million people, the first case of COVID-19 was diagnosed on February
29, 2020. As of August 6, 2020, 76,563 confirmed cases (673 per 100,000 inhabitants)
and 2,163 deaths (19 per 100,000 inhabitants, 2.8% of confirmed cases) have been reported
[8,9]. As of November 2020, RS recorded 240,694 COVID-19 cases (2,116 per 100,000
inhabitants) and 5,699 deaths (50 per 100,000 inhabitants)[8].”
Q9. It would also be interesting to describe and characterize Brazil, as a whole 3.
It is also interesting to show how the indicators of social distance, control and
measurement, varied weekly (choose the unit of analysis), or over weekends when compared
to working days. I recommend, see Prof. Steven Taylor, Psychology of Pandemics, ....
2020);
Answer 9. Thank you for your recommendation and suggestion. We modified different
parts of our manuscript to attend your good suggestions. Also, thank you so much by
the recommendation of the Taylor’s book. We included information from that book and
other related references in different parts of our manuscript. This is a very interesting
material for more than support our study. Also, we described in details in the results,
the descriptive data about social distancing including mean, standard deviation, minimum
and maximum and we compared data from working days vs weekend. We found a difference
between these days. Thank you for your suggestion. We included a short description
about Brazil differences in the discussion section as follows:
Introduction, Page 3 line 67
“Although a significant investment has been made worldwide to provide antiviral prophylaxis
for COVID-19, to test different drugs for prevention or treatment COVID-19 cases,
and to develop vaccines [10], current recommendations to reduce the spread of COVID-19
include physical distancing [11], quarantining, and large-scale lockdowns of entire
populations [12][13]. Evidence indicates that the implementation of social distancing
can suppress COVID-19 transmission rates to prevent the disease from overwhelming
the healthcare system. In an analysis of 49 countries, Atalan [14] showed that the
COVID-19 pandemic can be suppressed by lockdown measures. In another study including
data from 131 countries [15], a decrease in the transmission rate of COVID-19 was
observed within 1-3 weeks following the introduction of school closures, workplace
closures, public events bans, stay-at-home orders, and limits on internal movement.
However, the reduction of transmission ranged from 3% to 24% approximately one month
following the introduction of the recommendations, and the effect was only statistically
significant for public events bans [15]. Similarly, in New Zealand (a country of 4.886
million inhabitants), the estimated COVID-19 case infection rate decreased from 8.5
to 3.2 per one million people after the implementation of a nationwide the lockdown,
resulting in a low relative burden of disease [16]; until now New Zealand has accumulated
only 1,973 COVID-19 cases and 25 deaths. Although social distancing and lockdown
measures appear to be successful, there is “social fatigue” associated with following
these recommendations, leading many societies to return to a usual lifes, increasing
COVID-19 transmission [17,18].”
Results, Page 9 line 225
“…For a fair comparison, percentages pointed above the open circles in Figure 1A
correspond to MSDI on weekends, whereas the closed circles correspond to MSDI on working
days. We observed an increase in distancing on the weekends, indicating that more
people tended to stay home on weekends vs. weekdays. Specifically, on weekends MDSI
was ~12% higher than on working days (44.87 ± 9.70 [95% CI: 41.99 - 47.75] vs. 36.07
± 7.45 [95% CI: 34.66 - 37.48], p < 0.0001, Student’s t-test). However, a decrease
in overall MSDI (weekends and weekdays) was registered between March 22, 2020 (70.2%)
and June 21, 2020 (48.2%). From a macro point of view, it is evident that the population
of Ijuí is loosening social distancing and increasing social interaction up to the
end of June.”
Discussion, page 13 line 359
“Social distancing measures appear effective, mainly when implemented in conjunction
with the isolation of people who test positive for COVID-19 and quarantining of anyone
who has been in contact with them [31,37]. Our data indicates that that preventive
behavior among the population of Ijuí, related to the SDA recommendation and DPR,
did not reach 70% participation in social distancing in any of the five waves of the
survey. We mentioned the threshold of 70% since it was proposed early that maintaining
social distancing at a maximum of 76% could prevent 90,000 COVID-19-related deaths
and keep intensive care units in São Paulo from being overwhelmed [38]. As of November
23, 2020, São Paulo has registered more than 394,000 COVID-19 cases and 14,000 deaths
[7], suggesting that maintaining and strengthening current social distancing measures,
isolating COVID cases, and quarantining people who have been in contact with others
who have tested positive, is absolutely vital to avoid serious stress to Brazil’s
healthcare system. Furthermore, it has been suggested that more restrictive recommendations
can be more effective in reducing the number of infected subjects [1,38–41], and it
is necessary to apply such recommendations immediately and rigorously, especially
to control the spread of COVID-19 in schools, since children and teenagers may have
a disproportional contribution to an increase in the transmission rates [18]. However,
as reported by WHO, many countries have reported an increase in “pandemic fatigue”
among the population, characterized by lack of motivation to follow the recommended
social distancing behaviors to protect themselves and others from the virus (WHO)
[42]. On March 13, 2020 the United Stated issued a national proclamation that almost
immediately resulted in a large number of people sheltering at home and reducing their
daily movements, in line with the MSDI trends we observed in Ijuí in March. From early
April to mid-April, the MSDI reached an upper limit followed by a plateau, indicating
“social distancing inertia” in Ijuí. After that, a reduction in social distancing
measures occurred even in the states that maintained the recommendation of mobility
restriction, an example of “quarantine fatigue” [17].”
Q10. From line 71, I believe that the description of the distance is insufficient.
I recommend doing a brief review of the literature (there are several papers on this
topic) about the role of social detachment, social isolation and other behavioral
measures (the only ones that are effective while the vaccine or other collective immunization
process is absent). The literature and the importance highlighted between lines 71
to 78 are quite limited in view of the large number of studies (papers) hitherto published
on the role of isolation and social distance in controlling the spread of Covid-19;
Answer 10. Thank you for the recommendation. We improved the introduction and the
discussion in this version of the manuscript, as follows:
Introduction, Page 3 line 67
“Although a significant investment has been made worldwide to provide antiviral prophylaxis
for COVID-19, to test different drugs for prevention or treatment COVID-19 cases,
and to develop vaccines [10], current recommendations to reduce the spread of COVID-19
include physical distancing [11], quarantining, and large-scale lockdowns of entire
populations [12][13]. Evidence indicates that the implementation of social distancing
can suppress COVID-19 transmission rates to prevent the disease from overwhelming
the healthcare system. In an analysis of 49 countries, Atalan [14] showed that the
COVID-19 pandemic can be suppressed by lockdown measures. In another study including
data from 131 countries [15], a decrease in the transmission rate of COVID-19 was
observed within 1-3 weeks following the introduction of school closures, workplace
closures, public events bans, stay-at-home orders, and limits on internal movement.
However, the reduction of transmission ranged from 3% to 24% approximately one month
following the introduction of the recommendations, and the effect was only statistically
significant for public events bans [15]. Similarly, in New Zealand (a country of 4.886
million inhabitants), the estimated COVID-19 case infection rate decreased from 8.5
to 3.2 per one million people after the implementation of a nationwide the lockdown,
resulting in a low relative burden of disease [16]; until now New Zealand has accumulated
only 1,973 COVID-19 cases and 25 deaths. Although social distancing and lockdown
measures appear to be successful, there is “social fatigue” associated with following
these recommendations, leading many societies to return to a usual lifes, increasing
COVID-19 transmission [17,18].”
Discussion, Page 11 Line 298
“Although there are currently many studies about social distancing behavior and COVID-19
cases in Brazil, it is imperative to study local data separately. Brazil is a vast
country comprised of 26 federative states and the Federal District, and there are
many cultural, economic, educational, and geographic differences between states and
between different cities in the same state. Given these differences, trends in the
number of cases and deaths differs between states and cities, and municipalities have
the autonomy to determine which measures to adopt in order to best mitigate COVID-19
according to their respective scenarios [33]. All of Brazil’s states implemented distancing
measures, mostly after March 15, 2020. Partial economic lockdown was implemented before
the tenth confirmed case of COVID-19 by 18 (67%) states and before the first death
from COVID-19 by 24 (89%) of the states [33]. In April 2020, of nine major cities
in Rio Grande do Sul, the biggest cities (Porto Alegre and Santa Maria) exhibited
the highest degree of social distancing, while Ijuí had a less favorable pattern,
with a strikingly higher percentage reported being “out of the house all day” [25].”
Discussion, Page 11 Line 369
“Furthermore, it has been suggested that more restrictive recommendations can be more
effective in reducing the number of infected subjects [1,38–41], and it is necessary
to apply such recommendations immediately and rigorously, especially to control the
spread of COVID-19 in schools, since children and teenagers may have a disproportional
contribution to an increase in the transmission rates [18]. However, as reported by
WHO, many countries have reported an increase in “pandemic fatigue” among the population,
characterized by lack of motivation to follow the recommended social distancing behaviors
to protect themselves and others from the virus (WHO) [42]. On March 13, 2020 the
United Stated issued a national proclamation that almost immediately resulted in a
large number of people sheltering at home and reducing their daily movements, in line
with the MSDI trends we observed in Ijuí in March. From early April to mid-April,
the MSDI reached an upper limit followed by a plateau, indicating “social distancing
inertia” in Ijuí. After that, a reduction in social distancing measures occurred even
in the states that maintained the recommendation of mobility restriction, an example
of “quarantine fatigue” [17].
Alongside this, considering data from Middle East respiratory syndrome (MERS) in Saudi
Arabia in 2014 and SARS caused by SARS-CoV-1 in China in 2003, the psychological effects
of a new pandemic tend to be more pronounced, widespread, and longer-lasting than
the pure somatic effects of the infection, and the “epidemic of the fear” may be worse
than the disease itself. It has been estimated anxiety about the possibility of infection
ranges from 24% to 83% at the beginning of an epidemic, while the long-term epidemic
period may trigger or exacerbate stress-related mental disorders such as mood disorders,
anxiety disorders, and post-traumatic stress disorder [18].
An intrinsic limitation of our study is the variability of self-perception about COVID-19
risk and what it means to socially distance. People see and act in different ways,
depending on whether those things are perceived as psychologically relatable [43].
Thus, people respond to social distancing recommendations according to their empirical
constructs. The construal level theory (CLT) of psychological distance has been recognized
as a way to discuss the judgment and decision-making related to distance perception,
which comprehends a mutual meaning of distance dimensions: temporal distance, social
distance, spatial distance, and hypotheticality (i.e., distance from actuality) [44].
As a consequence, individual constructs about distance may influence evaluation, prediction,
and behavior. In the same way, individuals may have different conceptions about risk,
even if we consider risk directly as the chance of injury, damage, or loss [45]. As
for the concept of temporal distance, Li and colleagues [46] suggested that people
answering the survey could be influenced by the immediate pandemic-related context
and details. Furthermore, because COVID-19 is primarily transmitted through close
contact, people are more sensitive to implement social distancing with strangers and
tend to believe that their behavior is in accordance with municipal social distancing
regulations [46].
In this scenario, perceptions of risk play a key role in a process called “social
amplification of risk.” Social amplification of risk is triggered by the occurrence
of an adverse event (whether major or minor) and reflects the fact that the adverse
impacts of such an event sometimes extend far beyond the direct damages to victims
and may result in massive indirect impacts [45]. Also, extensive media coverage of
an event can contribute to heightened perceptions of risk and may have influenced
the answers in our survey. Recent studies have shown that factors such as gender,
race, political views, affiliations, emotional affect, and trust are strongly correlated
with risk perception. Equally important is that these factors can influence the judgments
of experts as well as laypeople [18,45]. Our study is limited in its ability to investigate
psychological influences during COVID-19 pandemic period, and further studies regarding
the “feelings of subjects” about social distancing are recommended to better understand
the phenomenon of “fatigue quarantine behavior” worldwide.”
Q11. Between lines 112 to 121, one could (if not inserted before) a table comparing
the weekly variation or Regina comparison within the State of RS of the social distancing
indicator (MSDI), as well as on its validity and reliability ( accuracy, reliability,
as a behavioral indicator);
Answer 11. Thank you for the recommendation. We discussed our data in connection of
the study of Oliveira and colleagues that provided interesting data with higher sample
size than ours study. This study used a mobile phone isolation indexes in the biggest
population states in Brazil, and described the validity of MSDI as a behavior indicator
and its relation with covid19 transmission rates. The new paragraph is showed below:
Discussion, Page 12, line 316
“On March 19, 2020 the city administration issued its most restrictive decree in the
analyzed period, The decree restricted public transport, closed stores, suspended
classes at schools and universities, and established special protocols for restaurants
and other services for one week [19]. Accordingly, on March 22, 2020 the MSDI reached
its highest value: 70.2%. Other subsequent decrees were issued in Ijuí, but with
more relaxed restrictions. In parallel, the Federal Government of Brazil has been
minimizing this pandemic and, in most cases, encouraging people to keep their regular
routines [34]. Thus, we observe a continuous reduction of the social distancing, to
the point that at the end of June, MSDI fell to the same levels seen at the beginning
of the analyzed period, when there were no cases of COVID-19 in Ijuí or even in Brazil
as a whole [7,35]. Our results were similar to those reported by Oliveira and colleagues
[36], presenting a mean isolation index from February 1, 2020 to April 10, 2020 of
40.2%, ranging from 18.5% to 69.4%. Specifically, this study analyzed mean isolation
index in the states of São Paulo (13.5% to 67.9%) and Rio de Janeiro (16.6% to 69.4%)
and found that social isolation indexes of 46.7% have the highest accuracy (93.9%)
to predict R(t) <1 [36], which means that the epidemic is slowing. These data reinforce
the validity and reliability of MSDI as a behavioral indicator of social distancing.”
Q12. Somewhere in the description and characterization of the sample, population studied,
it could be, in my best consideration, insert a table describing the population characteristics
of those considered in the studies in some of its phases, especially responding to
surveys, questionnaires and other sociodemographic information. Brazil and its 27
states are very unequal considering any indicator of inequality, for example, the
GINI index or even HDI-regional or state, municipal;
Answer 12. Thank you for the recommendation. We included more details about Ijuí HDI
score in the methods. Also, we moved to the manuscript the results from tables 1 and
2, which was presented as supplementary material in the first version of the manuscript.
These tables are about sociodemographic information and other characteristics of the
sample involved in the survey as follows:
Page 4 Line 106
“Ijuí (28°23'16 S and 53°54'53" W) is the most populous city in the northwest region
of Rio Grande do Sul. With 83,475 residents, it is considered a city of students (“university
city”) and a center of hospital and university resources. Furthermore, it is the largest
and most important population center in the region, with a population rounding 150,000
people. Ijuí has a high Human Development Index (HDI) score of 0.781, above the overall
HDI of Brazil (0.761). Ijuí has a high score for all three parameters measured for
HDI calculation: education (HDI-E = 0.707), with 98.9% of children aged 6-14 in school;
longevity (HDI-L = 0.858), with an average life expectancy of 76.48 years; and per
capita income (HDI-R = 0.786), with R$ 38,341.14 (approximately $7,119.33 per capita/year
[23].”
Page 9 Line 245
“In each round of the population-based survey, >400 adults were surveyed and tested
for the presence of SARS-CoV-2 antibodies, for a total of 2,222 study participants.
Characteristics of the study population are described in Tables 1 and 2. The majority
of the subjects interviewed were women (~60%) and white (~80%), with a roughly equal
distribution across age and education categories (Table 1). Between 32% and 39% of
participants reported having hypertension and ~13% and ~10% had diabetes and asthma,
respectively.”
Table 1. Sociodemographic characteristics of Ijuí subjects by date of population-based
survey
Table 2. Comorbidities characteristics of Ijuí subjects by date of population-based
survey
General comments:
Q13. I think that the authors should consider some other variables that may be underlying
the effects of social detachment, or social isolation, such as the personality variables
of individuals and the social psychological variables that affect, overly, the attitudes
and behaviors related to hygienic practices, cognitive assessment of risk factors,
social distance and social isolation, as well as when to implement, if this occurs,
mass, collective vaccination.
Answer 13. We included in the manuscript a brief discussion about psychological influence
in the meaning of the understanding about social distancing and risk. Since we considered
that our studies had limitations in terms of deeper investigation of psychological
variables, we inserted in the manuscript a recommendation to this type of study as
follows:
Page 14 Line 388
“An intrinsic limitation of our study is the variability of self-perception about
COVID-19 risk and what it means to socially distance. People see and act in different
ways, depending on whether those things are perceived as psychologically relatable
[43]. Thus, people respond to social distancing recommendations according to their
empirical constructs. The construal level theory (CLT) of psychological distance has
been recognized as a way to discuss the judgment and decision-making related to distance
perception, which comprehends a mutual meaning of distance dimensions: temporal distance,
social distance, spatial distance, and hypotheticality (i.e., distance from actuality)
[44]. As a consequence, individual constructs about distance may influence evaluation,
prediction, and behavior. In the same way, individuals may have different conceptions
about risk, even if we consider risk directly as the chance of injury, damage, or
loss [45]. As for the concept of temporal distance, Li and colleagues [46] suggested
that people answering the survey could be influenced by the immediate pandemic-related
context and details. Furthermore, because COVID-19 is primarily transmitted through
close contact, people are more sensitive to implement social distancing with strangers
and tend to believe that their behavior is in accordance with municipal social distancing
regulations [46].
In this scenario, perceptions of risk play a key role in a process called “social
amplification of risk.” Social amplification of risk is triggered by the occurrence
of an adverse event (whether major or minor) and reflects the fact that the adverse
impacts of such an event sometimes extend far beyond the direct damages to victims
and may result in massive indirect impacts [45]. Also, extensive media coverage of
an event can contribute to heightened perceptions of risk and may have influenced
the answers in our survey. Recent studies have shown that factors such as gender,
race, political views, affiliations, emotional affect, and trust are strongly correlated
with risk perception. Equally important is that these factors can influence the judgments
of experts as well as laypeople [18,45]. Our study is limited in its ability to investigate
psychological influences during COVID-19 pandemic period, and further studies regarding
the “feelings of subjects” about social distancing are recommended to better understand
the phenomenon of “fatigue quarantine behavior” worldwide.”
Q14. Spatial distance, temporal distance, social distance and probability distance
(heuristic availability) could be considered in passing in the analysis of the results,
especially in the discussion. There is an immense literature showing that these psychological
distances affect the perceived risk and affect the cognitive assessment of the importance
of the immediate introduction of distance and social isolation;
Answer 14. Thank you for the recommendation. We included in the discussion section
two paragraphs discussing concepts about distance and risk perception applying in
the context of pandemic period as follows:
Page 14 Line 388
“An intrinsic limitation of our study is the variability of self-perception about
COVID-19 risk and what it means to socially distance. People see and act in different
ways, depending on whether those things are perceived as psychologically relatable
[43]. Thus, people respond to social distancing recommendations according to their
empirical constructs. The construal level theory (CLT) of psychological distance has
been recognized as a way to discuss the judgment and decision-making related to distance
perception, which comprehends a mutual meaning of distance dimensions: temporal distance,
social distance, spatial distance, and hypotheticality (i.e., distance from actuality)
[44]. As a consequence, individual constructs about distance may influence evaluation,
prediction, and behavior. In the same way, individuals may have different conceptions
about risk, even if we consider risk directly as the chance of injury, damage, or
loss [45]. As for the concept of temporal distance, Li and colleagues [46] suggested
that people answering the survey could be influenced by the immediate pandemic-related
context and details. Furthermore, because COVID-19 is primarily transmitted through
close contact, people are more sensitive to implement social distancing with strangers
and tend to believe that their behavior is in accordance with municipal social distancing
regulations [46].
In this scenario, perceptions of risk play a key role in a process called “social
amplification of risk.” Social amplification of risk is triggered by the occurrence
of an adverse event (whether major or minor) and reflects the fact that the adverse
impacts of such an event sometimes extend far beyond the direct damages to victims
and may result in massive indirect impacts [45]. Also, extensive media coverage of
an event can contribute to heightened perceptions of risk and may have influenced
the answers in our survey. Recent studies have shown that factors such as gender,
race, political views, affiliations, emotional affect, and trust are strongly correlated
with risk perception. Equally important is that these factors can influence the judgments
of experts as well as laypeople [18,45]. Our study is limited in its ability to investigate
psychological influences during COVID-19 pandemic period, and further studies regarding
the “feelings of subjects” about social distancing are recommended to better understand
the phenomenon of “fatigue quarantine behavior” worldwide.”
Q15. Data analysis is clearly described and summarized in figures that are very revealing;
Answer 15. Thank very much for this comment. We hope that it can be useful for readers.
Q16. Could the authors discuss the downward trend in the social distancing indicators
that are becoming evident as the pandemic outbreak has lengthened? Was there a psychological
accommodation, or a pandemic fatigue?
Answer 16. Thank very much for this recommendation. We included the concepts and evidence
about social distancing inertia and quarantine fatigue in the discussion as follows.
Page 13 Line 359
“Social distancing measures appear effective, mainly when implemented in conjunction
with the isolation of people who test positive for COVID-19 and quarantining of anyone
who has been in contact with them [31,37]. Our data indicates that that preventive
behavior among the population of Ijuí, related to the SDA recommendation and DPR,
did not reach 70% participation in social distancing in any of the five waves of the
survey. We mentioned the threshold of 70% since it was proposed early that maintaining
social distancing at a maximum of 76% could prevent 90,000 COVID-19-related deaths
and keep intensive care units in São Paulo from being overwhelmed [38]. As of November
23, 2020, São Paulo has registered more than 394,000 COVID-19 cases and 14,000 deaths
[7], suggesting that maintaining and strengthening current social distancing measures,
isolating COVID cases, and quarantining people who have been in contact with others
who have tested positive, is absolutely vital to avoid serious stress to Brazil’s
healthcare system. Furthermore, it has been suggested that more restrictive recommendations
can be more effective in reducing the number of infected subjects [1,38–41], and it
is necessary to apply such recommendations immediately and rigorously, especially
to control the spread of COVID-19 in schools, since children and teenagers may have
a disproportional contribution to an increase in the transmission rates [18]. However,
as reported by WHO, many countries have reported an increase in “pandemic fatigue”
among the population, characterized by lack of motivation to follow the recommended
social distancing behaviors to protect themselves and others from the virus (WHO)
[42]. On March 13, 2020 the United Stated issued a national proclamation that almost
immediately resulted in a large number of people sheltering at home and reducing their
daily movements, in line with the MSDI trends we observed in Ijuí in March. From early
April to mid-April, the MSDI reached an upper limit followed by a plateau, indicating
“social distancing inertia” in Ijuí. After that, a reduction in social distancing
measures occurred even in the states that maintained the recommendation of mobility
restriction, an example of “quarantine fatigue” [17].
Alongside this, considering data from Middle East respiratory syndrome (MERS) in Saudi
Arabia in 2014 and SARS caused by SARS-CoV-1 in China in 2003, the psychological effects
of a new pandemic tend to be more pronounced, widespread, and longer-lasting than
the pure somatic effects of the infection, and the “epidemic of the fear” may be worse
than the disease itself. It has been estimated anxiety about the possibility of infection
ranges from 24% to 83% at the beginning of an epidemic, while the long-term epidemic
period may trigger or exacerbate stress-related mental disorders such as mood disorders,
anxiety disorders, and post-traumatic stress disorder [18].”
Q17. I understand that the role of social detachment should at least be discussed
in the important light of psychological factors of personality and psychological social
factors. Behaviors are the genuine tools we have to manage and mitigate the pandemic
outbreak;
Answer 17. Thank you for the recommendation. We included in the end of the discussion
about the quarantine fatigue some psychological effects that may be a result of a
pandemic period.
Page 13 Line 359
“Social distancing measures appear effective, mainly when implemented in conjunction
with the isolation of people who test positive for COVID-19 and quarantining of anyone
who has been in contact with them [31,37]. Our data indicates that that preventive
behavior among the population of Ijuí, related to the SDA recommendation and DPR,
did not reach 70% participation in social distancing in any of the five waves of the
survey. We mentioned the threshold of 70% since it was proposed early that maintaining
social distancing at a maximum of 76% could prevent 90,000 COVID-19-related deaths
and keep intensive care units in São Paulo from being overwhelmed [38]. As of November
23, 2020, São Paulo has registered more than 394,000 COVID-19 cases and 14,000 deaths
[7], suggesting that maintaining and strengthening current social distancing measures,
isolating COVID cases, and quarantining people who have been in contact with others
who have tested positive, is absolutely vital to avoid serious stress to Brazil’s
healthcare system. Furthermore, it has been suggested that more restrictive recommendations
can be more effective in reducing the number of infected subjects [1,38–41], and it
is necessary to apply such recommendations immediately and rigorously, especially
to control the spread of COVID-19 in schools, since children and teenagers may have
a disproportional contribution to an increase in the transmission rates [18]. However,
as reported by WHO, many countries have reported an increase in “pandemic fatigue”
among the population, characterized by lack of motivation to follow the recommended
social distancing behaviors to protect themselves and others from the virus (WHO)
[42]. On March 13, 2020 the United Stated issued a national proclamation that almost
immediately resulted in a large number of people sheltering at home and reducing their
daily movements, in line with the MSDI trends we observed in Ijuí in March. From early
April to mid-April, the MSDI reached an upper limit followed by a plateau, indicating
“social distancing inertia” in Ijuí. After that, a reduction in social distancing
measures occurred even in the states that maintained the recommendation of mobility
restriction, an example of “quarantine fatigue” [17].
Q18. Statistical and epidemiological analyzes are appropriate and well described;
Answer 18. Thank very much for this comment. We hope that it can be useful for readers.
Q19. The work, in my view, constitutes an important study to understand the pandemic
spread.
Answer 19. Thank very much for this comment. We hope that it can be useful for readers.
References included in the new version of the manuscript:
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2020 [cited 6 Aug 2020]. Available: https://covid.saude.gov.br/
10. Chakraborty R, Parvez S. COVID-19: An overview of the current pharmacological
interventions, vaccines, and clinical trials. Biochemical Pharmacology. 2020. doi:10.1016/j.bcp.2020.114184
11. Ng OT, Marimuthu K, Koh V, Pang J, Linn KZ, Sun J, et al. SARS-CoV-2 seroprevalence
and transmission risk factors among high-risk close contacts: a retrospective cohort
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12. Aleta A, Martín-Corral D, Pastore y Piontti A, Ajelli M, Litvinova M, Chinazzi
M, et al. Modelling the impact of testing, contact tracing and household quarantine
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13. Block P, Hoffman M, Raabe IJ, Dowd JB, Rahal C, Kashyap R, et al. Social network-based
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Hum Behav. 2020. doi:10.1038/s41562-020-0898-6
14. Atalan A. Is the lockdown important to prevent the COVID-9 pandemic? Effects
on psychology, environment and economy-perspective. Ann Med Surg. 2020. doi:10.1016/j.amsu.2020.06.010
15. Li Y, Campbell H, Kulkarni D, Harpur A, Nundy M, Wang X, et al. The temporal
association of introducing and lifting non-pharmaceutical interventions with the time-varying
reproduction number (R) of SARS-CoV-2: a modelling study across 131 countries. Lancet
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16. Jefferies S, French N, Gilkison C, Graham G, Hope V, Marshall J, et al. COVID-19
in New Zealand and the impact of the national response: a descriptive epidemiological
study. Lancet Public Heal. 2020. doi:10.1016/S2468-2667(20)30225-5
17. Zhao J, Lee M, Ghader S, Younes H, Darzi A, Xiong C, et al. Quarantine Fatigue:
first-ever decrease in social distancing measures after the COVID-19 outbreak before
reopening United States. 2020 [cited 15 Nov 2020]. Available: https://arxiv.org/abs/2006.03716
18. Taylor S. The psychology of pandemics: Preparing for the next global outbreak
of infectious disease. Newcastle upon Tyne: Cambridge Scholars Publishing. Cambridge
Sch. 2019.
34. Ajzenman N, Cavalcanti T, Da Mata D. More Than Words: Leaders’ Speech and Risky
Behavior during a Pandemic. SSRN Electron J. 2020. doi:10.2139/ssrn.3582908
42. WHO. WHO/Europe discusses how to deal with pandemic fatigue. In: WHO/Europe discusses
how to deal with pandemic fatigue [Internet]. 2020 [cited 6 Nov 2020]. Available:
https://www.who.int/news-room/feature-stories/detail/who-europe-discusses-how-to-deal-with-pandemic-fatigue
43. Maglio SJ. An agenda for psychological distance apart from construal level. Soc
Personal Psychol Compass. 2020. doi:10.1111/spc3.12552
44. Trope Y, Liberman N. Construal-Level Theory of Psychological Distance. Psychol
Rev. 2010. doi:10.1037/a0018963
45. Slovic P. The Psychology of Risk [Psicologia do Risco]. Saude Soc Sao Paulo.
2010.
Looking forward to hearing from PlosOne soon,
Yours faithfully,
Prof. Dr. Thiago Gomes Heck
Coordinator of Post Graduate Program in Integral Attention to Health
Regional University of Northwestern Rio Grande do Sul State (UNIJUI)
Ijuí, RS, Brazil
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