Experiences with Public Health Recommendations for COVID-19: A Qualitative Study of Diverse Mothers with Young Children in the United States

Abstract

Background:

Despite the increased availability of vaccines, masking and social distancing remain important strategies to mitigate COVID-19 transmission. This qualitative study aimed to better understand experiences navigating public health recommendations to slow the spread of COVID-19 among economically and ethnically diverse mothers with young children.

Methods:

Mothers of preschoolers (n=25) were recruited from Project EAT 2010–2018 (Eating and Activity over Time) longitudinal cohort. Participants completed a virtual semi-structured interview about their experiences during COVID-19. Interview transcripts were coded using deductive and inductive content analysis and analyzed using thematic analysis to identify themes.

Results:

The first identified theme, “Selective adherence to recommendations” included subthemes highlighting how social distancing was more challenging than mask wearing, family and children were primary reasons for reduced adherence, and concern for the wellbeing of others influenced adherence. The second theme, “Personal experiences and relationships were important determinants of perceived severity of the virus and critical aspects of desired support,” included subthemes on feelings of uncertainty, personal experiences with the virus, and desired community supports. Participants felt stressed and confused about what information to trust. Personal experiences with COVID-19 influenced perceptions of its seriousness, and mothers were more confident about following recommendations when they them from trusted medical professionals and desired for communities to work together.

Conclusions:

How findings among this diverse population of mothers can help inform future public health messaging and policies throughout the remainder of this pandemic, its aftermath, and future public health emergencies, in which masking and social distancing will be needed, are discussed.

Introduction

Reducing the transmission of COVID-19 is a key priority to prevent health care systems from becoming overburdened and to reduce the disease impact of the virus (1). A variety of strategies have been used worldwide to reduce disease transmission including masking, social distancing recommendations, stay at home orders, and vaccinations. While the efficacy and practicality of masking and social distancing are sometimes debated (2), these remain two key public health recommendations to prevent the spread of the virus that are widely recommended (3). Current guidance in the United States includes masking and social distancing recommendations even among individuals who are vaccinated, which make these particular recommendations bound to remain important throughout the remainder of the pandemic and in its aftermath (4).

Research aimed at quantifying adherence to mask and social distancing recommendations indicates that adherence is highly variable and dependent on a number of facilitating and preventative factors (5–8). Given the wide variety of barriers and facilitators, as well as the likelihood that these factors co-exist, qualitative research can help to better understand the nuanced experience of adhering to COVID related recommendations (9). Importantly, the collection of such nuanced information can contribute to a better understanding of upstream factors that can be used to inform health communication and policies aimed at improving adherence to public health guidance to reduce virus transmission. Unfortunately, little formal qualitative research exists on the lived experience of mothers following public health recommendations regarding COVID-19 in the United States.

The purpose of this qualitative study was to examine the experiences that an economically and racially/ethnically diverse sample of young mothers have had with public health guidance to reduce the transmission of COVID-19. Findings from this formative research are intended to inform efforts to support the ability of economically and racially/ethnically diverse mothers to engage in recommendations as the pandemic continues. This particular population is important to study because mothers with young children are likely to be vulnerable to negative economic consequences of the pandemic. Women typically carry more of the burden for domestic and childcare labor which was exacerbated during the pandemic (e.g., navigating changing childcare demands, distance learning, etc.), and disproportionately more women than men left the labor market over the course of the pandemic (10, 11). Although masking and social distancing practices are recommended irrespective of vaccination, recommendations for these practices are particularly emphasized among unvaccinated populations (12). Accordingly, such recommendations are likely to disproportionately impact families with young children as children will be one of the last populations to be eligible for vaccination. Understanding mothers’ experiences with recommendations is also needed because mothers play important roles in shaping the daily routines of their families, which makes them key targets for public health intervention.

Methods

Participants

During August and September of 2020, all Kids EAT! participants (N=75) were approached to participate in study to understand their experiences during COVID-19. Kids EAT! is an existing cohort of racially/ethnically diverse families with children aged 2–5 who participated in the EAT 2010–2018 study cohort (13, 14). A rolling recruitment approach was used and sample extensiveness was judged to be adequate when recruitment of new participants provided few additional insights and theoretical saturation was reached. Recruitment was conducted primarily via e-mail; e-mails indicated that the study goal was to deepen our understanding of how families with young children had been impacted by the COVID-19 pandemic. Interested participants were scheduled to complete a semi-structured interview via phone. This procedure resulted in a total of 25 mothers participating in the present study. Participating mothers were 26.12 ± 1.27 years old on average. The majority of participants resided in the greater Twin Cities metropolitan area (76%) and had an annual household income of <$35,000 (68%). Table 1 provides detailed demographic characteristics of the study sample.

Table 1.

Demographic characteristics of mothers with pre-school age children, Twin Cities metropolitan area, MN, 2020, N=25

Characteristic	Number (%)
Race/Ethnicity
Asian	1 (4.0)
Black	13 (52.0)
Hispanic	5 (20.0)
Mixed Race/Other	3 (12.0)
Native American	2 (8.0)
White	1 (4.0)
Education
Partial high school or less	1 (4.0)
High school graduate or GED	7 (28.0)
Partial college or specialized training	9 (36.0)
College graduate	6 (24.0)
Graduate degree	2 (8.0)
Spouse Education
Partial high school or less	5 (20.0)
High school graduate or GED	7 (28.0)
Partial college or specialized training	2 ( 8.0)
College graduate	2 ( 8.0)
Graduate degree	9 (36.0)
Household Income
$0–$4,999	3 (12.0)
$5,000–$9,999	1 (4.0)
$10,000–$14,999	2 (8.0)
$15,000–$24,999	3 (12.0)
$25,000–$34,999	8 (32.0)
$35,000–$49,999	3 (12.0)
$50,000–$74,999	4 (16.0)
$75,000–$99,999	1 (4.0)

GED = general equivalency diploma

Procedures and analyses

Two researchers conducted semi-structured interviews with mothers (n = 25) using a semi-structured interview guide that asked mothers open-ended questions about how their family had been impacted by the COVID-19 pandemic, including changes to employment status; household responsibilities; childcare access; food security; approaches to eating and feeding, physical activity and screen time; and their thoughts on social distancing recommendations, readiness for a COVID-19 vaccine, and ability to withstand another “shelter in place” mandate. Parents were also asked to reflect on resources that had been helpful to them during the pandemic, as well as resources that would be welcomed. Table 2 includes all of the semi-structured interview questions relevant to the current analysis (represents about 10% of the qualitative protocol).

Table 2.

Interview questions assessing mothers’ experiences with public health recommendations to minimize the spread of COVID-19, Twin Cities metropolitan area, MN, 2020

Questions
1. The CDC has recommended that everyone engage in social distancing as much as they can during this time, and more recently has recommended that people wear face coverings when they are unable to socially distance. To what degree has your family chosen to follow these recommendations?
a. Has this changed throughout the course of the pandemic?
b. What has prompted any changes in adherence to these guidelines?
c. What factors have played a role in your family’s choice to follow these recommendations (or not)?
2. Do you feel like your family will be able to continue to socially distance per current recommendations moving forward? Why or why not?
a. If we experience another wave of illness in Minnesota do you feel like your family would struggle if we had to go back to stricter stay-at-home orders?
b. What are things we could do as a community to help families better prepare for this possibility?
3. Currently we are about 3–4 months into the COVID 19 pandemic. How has your level of concern or worry about COVID 19 changed over the course of the pandemic?
a. What are the primary things that have changed your mind about your level of concern over this time period?

Open ended questions were followed by probes, such as “tell me more about that”. Both interviewers were trained according to the protocols of Krueger and Casey (15); none had a prior relationship with the study participants. Interviews ranged in length from 30 to 60 minutes and were all conducted via Zoom. Interviews were audio-recorded and verbal consent was obtained before commencing the interview. All participants received a $40 gift card honorarium for their participation. This study was approved by the University of Minnesota Institutional Review Board and electronic informed consent was obtained.

Audio-recorded interviews were transcribed verbatim and coded using a deductive and inductive content analysis approach (16–18). This hybrid approach allowed the researchers to use broad prior categories such as types of recommendations for mitigating the spread of COVID-19 (e.g., masking, social distancing, stay-at home orders [deductive analysis]) to guide the analysis while allowing for unique themes to emerge naturally from the data (inductive analysis). For example, each interview transcript was read with the specific goal of understanding how families navigated and were impacted by COVID-19 recommendations, but themes and concepts emerged inductively from within this guiding template. With broad a priori interview questions as an organizational template, the researchers read through each interview line-by-line to establish initial codes and capture key thoughts and concepts. Next, the researchers coded to reduce broad categories into subcategories and identified major concepts. The major concepts were further defined, developed, and refined into main themes. Two members of the research team independently read and coded the interviews using NVivo software (version 10, QSR International Pty Ltd, Burlington, MA, 2014). All parent transcripts were analyzed and coded to ensure that saturation of themes had occurred. To improve trustworthiness of the data and reduce bias, all transcripts were coded independently by both coders and then discussed to reach consensus; both coders discussed questions in person regarding quotations or placement of quotations in theme categories until 100% agreement was reached.

Results

Two primary themes were identified regarding participants’ experiences with wearing masks and practicing social distancing during COVID-19. The first theme was “selective adherence to recommendations.” This theme included three subthemes: social distancing was more challenging to sustain than mask wearing; family and children were primary reasons for reduced or selective adherence to recommendations; and concern for the wellbeing of others prompted both increased and reduced adherence to recommendations. The second theme was labeled “Personal experiences and relationships were important determinants of perceived severity of the virus and critical aspects of desired support” It included three subthemes: Feelings of uncertainty, confusion, and stress; personal experiences shaped perceptions of seriousness of virus; and community support was desired.

Theme 1. Selective adherence to recommendations

Table 3 provides examples of participant quotes related to selective adherence to recommendations. Participants expressed uncertainty and confusion about how to best balance the risk of the virus with the challenges of following recommendations. As a result adherence to recommendations was selective. Specifically, adherence seemed to change over time, differed across the various recommendations (i.e., handwashing, mask wearing, social distancing) and depended on families’ situations. Three subthemes emerged regarding these contexts in which participants were selective in their adherence to recommendations: Social distancing was more challenging to sustain than mask wearing; family and children were primary reasons for reduced or selective adherence to recommendations; and concern for the wellbeing of others prompted both increased and reduced adherence to recommendations.

Table 3.

Additional examples of participant quotes for the theme “Selective adherence to recommendations,” organized by the subtheme, Twin Cities metropolitan area, MN, 2020

Subtheme	Example Quotes
Social distancing was more challenging to sustain than mask wearing	“We have kids and everything’s so unknown, so, I mean, wearing a face mask won’t really hurt you. it’s annoying at points, depending on — if you have to wear it, I guess, to work, that would be annoying, but to the grocery store, it wasn’t a big deal for us.” (Hispanic, High School Graduate)
	“I can be honest that I haven’t been social distancing, but my mom is always on me about wearing face coverings and having my son wear a face covering.” (Black, Associates Degree)
	“Out in public we always keep a mask on and everything, but at home or when we’re at a relative’s house and everything, it’s pretty much just—I would say like all the rules kind of fly out the window.” (Mixed Race, Vocational Degree)
Family and children were primary reasons for reduced or selective adherence to recommendations	“[My kids] know when they get out of the car to put their mask on right away. They know it’s just the new thing. But it’s like after a while, they’re pulling their mask down or things like that.” (Black, Some College Completed)
	“Before, we would wear them [masks] even around like immediate family, and now we do it a little bit less, just because she can’t really breathe when she’s like running with her cousins. Yeah. So, yeah, definitely a little less with just immediate family that we trust.” (Mixed Race, Some College Completed)
	“it’s kind of hard telling your little kids who just want to run around and play and doesn’t really — still is learning self — like their own personal space — to stay back. So as much as I could — or if I seen them get too close to anybody, I was pulling them back away.” (Black, Some College Completed)
	“[My kids] go to a sitter if I have to go to the grocery store, and it’s typically with family, not with just any random people. It’s always with family. And I don’t mind them being around family, because I know the majority of my family isn’t essential” (Mixed Race, Some College Completed)
	“I think every family is different, and I think I have more a family that needs each other…I think for our family, it’s really hard to socially distance, because there usually is some type of crisis.” (Black, Some College Completed)
	“It’s just kind of hard to keep ourselves away from family, especially my son away from his grandparents.” (Black, High School Graduate)
	“I don’t think within the family we should still do the social distancing thing or wear a mask, but definitely in public and going into buildings and stuff.” (Mixed Race, Vocational Degree)
Concern for the wellbeing of others influenced adherence to recommendations	“I just know how easily it can spread, and I just wouldn’t want to take the risk for my household or other households. I just want to, I mean, be one more person to make a difference.” (Mixed Race, Some College Completed)
	“So just not wanting to spread it to the people that I love and not wanting to get it ourselves, but also we don’t want to live in fear and go back to completely isolating. So social distancing, it’s not realistic.” (Hispanic, Partial College )
	I feel like the social contact and ability to be social is wearing on a lot of us. And my son, like I said, is going to preschool…so there won’t be any social distancing…I mean, they’re little kids, and I think that that’s what they need. (Black, Graduate Degree)
	I’m pretty sure that I’ll be able to return to work in the next few months, so I definitely will wear a mask, because he’s [family member] immunocompromised, so I wouldn’t want to get him sick. I wouldn’t take any risks with my work and COVID risks. (Mixed Race, Some College Completed)

Subtheme 1.1. Social distancing was more challenging to sustain than mask wearing

Compared to social distancing, hand washing/sanitizing and mask wearing were generally reported as more prevalent and were described frequently as behaviors that mothers felt confident they could continue doing. For example, one mother described taking those precautions so that they could spend time with extended family members:

“So when we have to [go out to the store], we do wear masks, gloves, and we have hand sanitizer. Family-wise, we do still get together and meet up, but we make sure everybody’s clean…So we would still do gatherings, but everybody would go straight to the kitchen, wash your hands…I guess we’re just making sure everybody’s washing their hands, sneezing into their elbow, just pretty much typical politeness, manners, and stuff like that.” (Mixed Race, Vocational Degree)

Even participants who disliked masks or who were particularly adherent to social distancing reported wearing them in public spaces. This adherence may have been partly due to mask mandates, which were acknowledged by some mothers as the reason for their adherence to mask wearing. For example, one mother reported wearing a mask only once it became mandated:

“I wasn’t wearing a mask at all until it was like enforced, and then I started wearing it. Now I wear it, obviously, when I go out in public…I’m still uncomfortable with it… I feel a little claustrophobic wearing it…I’m following the guidelines, but I’m just unhappy about it.” (Asian, Some College Completed)

Generally the language used to describe mask wearing behaviors differed from that used to describe social distancing. Mothers reported wearing masks whereas they reported trying to be socially distant. Similarly there was ambiguity in how participants defined social distancing. Some participants described social distancing in terms of the amount of physical space they tried to give individuals when they were in public areas. For example, one mother explained having difficulties being social distancing in stores:

“I think in some places [social distancing] may be easier than others because of [the amount of] space…What we have seen when we went out to a restaurant, the social distance, the way they set up things are great...It worked pretty well. Going into the stores, sometimes it can be a little more crowded, and even though they have the arrows telling you go down this lane, everybody don’t always follow that, so you can have more than four or five people in one lane going opposite directions.” (Black, College Graduate)

Others used staying at home as a strategy to remain socially distant. For example one mother explained, “We don’t go out like to family and friends. We stay at home. I consider that social distancing.”(Black, Some College Completed) These varying ways of talking about or defining social distancing practices indicates that recommendations being made to social distance were not interpreted the same way by everyone. In contrast to consistent adherence to mask wearing in public, mothers often reported loosening up on social distancing practices over time. For example, “Wearing the mask, washing our hands, that hasn’t changed, but we’ve been interacting with more people since the start of it.” (Hispanic, Some College Completed).

Subtheme 1.2. Family and children were primary reasons for reduced or selective adherence to recommendations

Family, and children in particular, were often identified as the reason for reduced adherence to recommendation. This observation held across both mask wearing and social distancing. Parents reported masking being normalized but proper wearing of masks was challenging for children. They also described social distancing being particularly challenging to explain to their children and had trouble getting them to be distanced from others in public. See Table 3 for example quotations.

In addition to children, many participants had trouble remaining distanced from their family members. Mothers described the desire to be with family during this challenging time was more pressing than the risk of spreading the virus to one another. For example one mother reported:

“I think we all have this idea or feeling like this is my family, and if you get it, then I’ll get it, or something to that affect. Like I’m not afraid to get it like if you did have it, because I love you and I still want to see you.” (Asian, Some College Completed)

Subtheme 1.3. Concern for the wellbeing of others prompted both increased and reduced adherence to recommendations.

Some participants described the desire overall to do the “right thing” to protect others generally. For these participants social distancing and wearing a mask were the “right” things to do and they did “everything they were supposed to do.” This sense of responsibility to keep others safe was particularly prevalent among those with a loved one or family member who was at increased health risk. For example one participant described,

“With my brother being high risk and diabetic, we wanted to make sure that like if he came up with anything, God forbid, it did not come from us, because we did our part.” (Black, Some High School Completed)

Notably, these feelings were not held by all participants. Some participants indicated that even when a family member was at increased health risk, the decision to engage in social distancing practices was complex and included an assessment of the risks of the virus compared to the potential mental health consequences of social distancing. In particular families became less adherent to social distancing as they saw consequences of it for their children or family members. For example one mother reported:

“After [son] had, I guess, those anxiety attacks about bugs, we loosened up our quarantine restrictions. We had like a barbeque with the family right after, and it helped a lot. And we ended up staying over at my mom’s, and he started to do a lot better.” (Hispanic, Some College Completed)

Theme 2. Personal experiences and relationships were important determinants of perceived severity of the virus and critical aspects of desired support

Mothers expressed being confused with changing recommendations and understanding the virus. Similar to the personal reasons participants reported leading to selective adherence (i.e., loved ones’ wellbeing, desire to be with family), participants’ prior experiences with the virus impacted their perception of its severity. They leaned on their own experiences and the experiences and advice of people they trusted. This desire for personal, community-based support was expressed in two different ways. Mothers highly valued advice from medical professionals with whom had an existing, trusting relationship. They also identified that financial and material needs could be better met if communities worked together. Three subthemes emerged within this overall theme of the importance of personal connections and support: Feelings of uncertainty, confusion, and stress; personal experiences shaped perceptions of seriousness of virus; and community support was desired. Table 4 provides example participant quotations for each subtheme.

Table 4.

Additional examples of participant quotes for the theme “Personal experiences and relationships were important determinants of perceived severity of the virus and critical aspects of desired support,” organized by subtheme, Twin Cities metropolitan area, MN, 2020

Subtheme	Quote
Feelings of uncertainty, confusion, and stress	“The news and stuff like that, that’s the main information that I’m getting, like watching the news. And when they come around the neighborhood, the local clinic, and they tell us about everything that we should be doing, that really helps, I think.” (Hispanic, High School Graduate)
	“I felt like, “Is like the Hunger Games, or what is going on here?”… I don’t want to use the word “hopelessness,” but that is kind of how it feels…The control has completely left the human race, I feel like, and I think it can be a scary place to be in if I dwell on it too long.” (Black, Graduate Degree)
	“Everybody’s home all the time, which you would think it would be so great, but then when there’s all this uncertainty and inability to go out in the community and like go out and do things, I think it really put a lot of stress and negative energy into our home…we were pretty much like fighting the whole quarantine. I think a lot of people can relate, I’m sure. It’s hard. So hard.” (Asian, Some College Completed)
	“It’s just like the numbers have fluctuated so much, and the CDC says one thing, and then there’s another thing. The President doesn’t wear a mask, and then it’s just — there’s just so much pros and cons…it was freaky at first, but then it was like — there was a thing about the mask not even protecting anyone, and then it became mandatory that we do wear the mask, and then they released — nobody has to wear masks, it’s not mandatory anymore, and now just like a week ago or two weeks ago, it’s mandatory again in all public areas. So just like I don’t know what to do anymore.” (Mixed Race, Vocational Degree)
Personal experiences shaped perceptions of seriousness of virus	“Unfortunately, we had an uncle that passed away from COVID. We’ve had a total of three other family members that were hospitalized and were in for like almost a month...even though they were doing the same thing as we were, somehow they got exposed, somehow they got — so it’s like we just try our best to like keep [social distancing], even though we never know where we’re going to get it or we’re never going to know where it comes from.” (Hispanic, High School Graduate)
	“And then once my dad got sick, it got a little more serious, so everybody started wearing face masks.” (Hispanic, Some College Completed)
	“You look at everything that’s happened in Minnesota with the riots and the gatherings and the protests, and you think about why weren’t — you know, the numbers didn’t just skyrocket right after that, and so you’re like, “Well, what is the truth in all of this?” I don’t know. You could say masks help, or whatever you can say, but, I mean, like bars — when Wisconsin just opened up all their bars, like nobody got sick.” (Hispanic, Some College Completed)
	“After we went through it [had COVID], I felt like I was just not worried that much again. We did okay…like most of the people that I know, like family, friends, friends of friends, families of friends, whatever, like nobody has died from COVID-19 here in Minnesota. I know like a lot of people had it. Some people had more of a hard time than others, but everybody survived. So I feel like I’m not that much worried anymore because of that.” (Hispanic, Vocational Degree)
Community support was desired	“I think really just support, support each other. It’s just so much negative stuff, and everyone has their own opinion and different perspective of everything.” (Black, Some College Completed)
	“I think the stay-at-home orders and guidelines kind of left out different groups of people in kind of like the inclusiveness of it and like helping certain groups of people [single people, elderly] still feel connected to people, places and things.” (Black, Graduate Degree)
	“I think that we can just not take more than we need, honestly…we can just all go to the store and just take what we need, not over-take, because that’s how people can start panicking, when there’s stuff not available” (Mixed Race, Some College Completed)

Subtheme 2.1: Feelings of uncertainty, confusion, and stress

Participants described feeling confused about what they should do about the virus and feeling stressed (see Table 4). These feelings appeared to be particularly exacerbated when participants relied on information from popular media or the news. Conversely, participants who had close, trusting relationships with medical professionals felt reassured about what to do. For example one mother described:

“When you’re just like looking at everything from the outside, in your head, you want to just be like, “It will pass. It’s just like the flu.” The flu, it comes and goes. But having like more of a professional opinion and then [family members in the medical field] being so close to me was convincing.” (Mixed Race, Associates Degree)

Subtheme 2.2: Personal experiences shaped perceptions of seriousness of virus

Interviews revealed that perceptions of and, ultimately adherence to, guidelines were shaped by individuals’ prior experiences with the virus. Individuals who had negative experiences with the virus reported greater concern and adherence to public health recommendations (see Table 4). Conversely, those who had not directly experienced negative consequences of the virus expressed less concern about the seriousness of the virus and adherence to recommendations and often relied on more indirect reports of others’ experience with the virus or stories they heard in the news. For example one mother explained:

“Now I feel like I’m less worried about it, just because I don’t know anyone that has been affected personally and anyone that — where it’s like someone that told me they knew someone, they made it seem like it was like a cold and something they got over really quickly.” (Black, Some College Completed)

Subtheme 2.3: Community support was desired

In response to the question asking participants what supports would be helpful, participants indicated that working together to prevent anyone from going without during a stay-at-home order would be important. For example a participant reported, “First thing’s first, when you go into the stores, don’t over-buy things…Be there for each other. See what people need. Someone may have more or less than you have. Help each other out.” (Black, High School Graduate) Participants also indicated an understanding that the situation wasn’t going to get better unless communities worked together. One mother explained: “I feel like as a community, I just want everybody to take it a little bit more serious, because if people start taking it a little bit more serious, or serious at all, then I feel like the numbers and stuff can go down.” (Mixed Race, Associates Degree) Additional example quotations are provided in Table 4.

Discussion

This qualitative study examined economically and racially/ethnically diverse mothers’ experiences with public health recommendations to prevent the transmission of COVID-19, with the goal of using this nuanced information to inform efforts that aim to support the ability of mothers to engage in recommendations as the pandemic continues and in future pandemics. Consistent with prior research (5–8), this study found adherence to recommendations to vary based on the specific recommendation with some becoming normalized (i.e., mask wearing in public spaces), but other recommendations less so. In particular social distancing was less normalized and adherence appeared to be highly impacted by family factors and concern for loved ones’ wellbeing. Similarly, personal experiences and relationships were important determinants of perceived severity of the virus and critical aspects of desired support. These key findings will be discussed through the lens of self-determination theory to explore how the information learned in this study can inform interventions to improve health messaging to promote greater, long-term adherence to recommendations to wear masks and social distance.

Self-determination theory is a behavioral theory that distinguishes between external and intrinsic motivation, with intrinsic motivation needed to sustain behavioral changes. An example of external motivation is the use of mask mandates to improve adherence to wearing masks. While this worked in public spaces and masks were normalized in these spaces, it is unlikely to promote the normalization of mask wearing in other spaces. For example one mother in this study remarked, “I go to the store, come back, and hurry up and take it [mask] off.” For intrinsic motivation to sustain a behavior change, self-determination theory postulates that three innate psychological needs need to be satisfied: autonomy (feeling in control of one’s own behaviors), competence (feeling that one has the skills needed), and relatedness (feeling connected to others and a sense of belonging) (19, 20). Given the long-term persistence of the pandemic, it will be important that health communication efforts consider autonomy, competence, and relatedness to promote intrinsic motivation for adherence to recommendations to mitigate the spread of COVID-19.

Many participants in this study expressed feeling uncertain or confused by the virus. This uncertainty is a sign of a lack of autonomy. Social distancing requires an individual to refrain from a behavior; whereas wearing a mask encourages individuals to engage in a behavior. Having actions to take rather than constraints on behavior can provide individuals a greater sense of control over their behaviors. The lesser degree of adherence to social distancing than masking is consistent with prior health messaging research in which a greater response to positive, action-oriented messaging was found than to negative, prohibitive messages (21). Prohibitive messages are restrictive and research indicates that restriction is unlikely to be sustained (22). Public health messaging can be strengthened by focusing on the actions individuals can take to social distance and provide options within the constraints of social distancing (23). For instance, recommendations could be coupled with alternative options for common social activities (e.g., instead of playing basketball, try tennis or cycling at the park) or with virtual resources to maintain social supports. Providing choices is an important component of helping individuals have autonomy and feel in control of their behaviors (despite the uncontrollable situation of the pandemic and needing to social distance).

Additional supports are important for lower income families whose feelings of constraint may be exacerbated due to limited resources. For individuals to feel competent, the second basic tenet of self-determination theory, they need to have means to achieve the behavior change. Participants in this study expressed not just financial concerns but also a lack of knowledge of who they could turn to for help. Further, the ambiguity in how social distancing was discussed by participants in this study indicates a need for recommendations regarding social distancing to be clarified. If participants are uncertain how to socially distance or what it means to be socially distant, they are unlikely to be able to adopt the behavior. Concrete examples of social distancing and how individuals can successfully achieve it may be helpful to decrease the ambiguity of social distancing (e.g. “a grocery cart is about six feet; make sure to keep a grocery cart between you and the next person at all times when shopping).

Perhaps most importantly, one of the reasons social distancing is a challenging behavior to sustain is that it interferes with the final component of self-determination theory: relatedness. Social distancing recommendations, or to stay away from loved ones during a crisis, can be viewed as counterintuitive. Perceived social support is a key factor in mitigating negative mental health consequences during COVID-19 (24, 25). However, obtaining social support in a socially distant way is challenging. As has been seen in other studies (26), mothers in this study made exceptions to social distancing for family members to help each other through the pandemic and reduced social distancing practices when children’s mental health deteriorated. In addition to recommending innovative ways to connect with family virtually or in another distanced way, it is important for social distancing recommendations to be paired with the acknowledgement that this is challenging and provide mental health strategies to remain resilient.

The lack of feeling connected to others was also evidenced by the supports participants desired and the value participants placed in advice from people they trusted. Participants clearly wanted communities to work together to get through the pandemic. Advertisements throughout the COVID pandemic have targeted and/or may have even influenced this desire for togetherness by emphasizing “we’re all in this together (27).” The importance of connection was also illustrated by how participants’ perceptions of the virus and adherence to recommendations were influenced when information came from trusted medical providers and/or other individuals they trusted and respected. Having public figures like the president saying opposing information created confusion. This finding has important implications for public health professionals and public figures to ensure recommendations made are clear, accurate, and personal.

Finally, the findings of this study are illustrative of the difficulties of prevention. People learn through conditioning such that past experiences inform future behaviors. Prevention is challenging because it inhibits an individual from the adverse experience (i.e. contracting COVID), which removes the opportunity for an individual to be conditioned through experience to understand the necessity of preventative behaviors (28, 29). This challenge was illustrated by participants’ perceptions of the virus and preventative behaviors being based on their experiences with the virus. As the pandemic continues, individuals will continue to have a variety of virus experiences, and their perceptions and behaviors are likely to fluctuate. Health professionals need to be prepared to help individuals navigate their evolving perceptions. Providing clear expectations and transparency that guidelines may change as more is learned in this unprecedented time can help people remain confident in and trust science-based recommendations. Without being transparent that recommendations are expected to evolve as more evidence is gathered people are likely to be confused and may mistrust or feel those providing recommendations are less credible if recommendations change.

Strengths and Limitations

The current study provides some of the first qualitative data on the young mothers’ nuanced experiences with wearing masks and social distancing in the United States. While not necessarily a high-risk population for COVID-19 complications, this population is vulnerable to negative economic and social consequences from the virus and mothers often make disproportionate sacrifices for their families during difficult times (30, 31). Further, families with young children are expected to need to remain particularly vigilant to social distancing and mask wearing practices longer than others because younger age groups either do not yet have access to a vaccine or are not yet eligible. This need has been highlighted by recent increased cases of COVID-19 among younger age groups. As seen in this study, having young children increases challenges to social distancing. Mothers play a key role in determining their family’s level of adherence to recommendations. As such, understanding their experiences is important to inform relevant health messaging.

Masking and social distancing recommendations discussed in this study have generally been recommended throughout the United States and globally, but specific mandates and recommendations vary by location. As such, some caution is warranted regarding the generalizability of this study’s findings. Further, it is not certain that experiences when participants were interviewed in August-September 2020 are necessarily reflective of their current experiences and behaviors. Future research is needed to understand how the long duration of the pandemic may have impacted mothers’ experiences with public health recommendations. Study populations from various geographic areas in which recommendations and policies differed should also be considered to better understand experiences across various contexts. Lastly, this analysis was a sub-analysis of a larger protocol aimed at understanding the impact of the pandemic on parenting around food and physical activity behaviors. While, extracting data from subsets of questions from the protocol is a common approach to be able to report in-depth data, because the primary purpose of the study was not to specifically assess mother’s experiences with recommendations to limit the spread of COVID-19 participants were not further probed with that intent in mind during interviews.

Conclusions

The high level of stress and uncertainty regarding the seriousness of the virus and how to best prevent its spread that was reported by the mothers of pre-school aged children in this study is concerning. Importantly, this study included a diverse sample of mothers. While many of the experiences reported in this study may be shared among more affluent families, social determinants of health like socioeconomic status and race/ethnicity may exacerbate people’s ability to meet their needs of autonomy, competence, and relatedness. It is crucial that clinicians reach out to families who may be struggling to provide them with support for their mental health. Health professionals can also clarify any confusion about COVID-19 to help reduce stress brought on by feelings of uncertainty. This clarification is particularly important now as recommendations may vary based on vaccination status. Families with young children are less likely to have been vaccinated and will need to adhere to more stringent social distancing and mask wearing recommendations for longer. Further inequitable vaccine distribution may mean that families of lower socioeconomic status will be less likely to be vaccinated. It was clear that mothers in this study found messages from trusted health professionals to be helpful and desired. However, such messages were infrequently reported. It is important for health professionals to provide clear and consistent prevention messaging that recognizes the difficult decisions families have had to make as they navigate the right balance of risk and benefit of recommendation adherence in a constantly evolving situation. The COVID-19 pandemic is persistent, requiring people to dial up and dial back their engagement in safety measures based on community spread and vaccine status. In this way, while this paper only discusses a snapshot in time, it can be helpful in understanding how to prepare for targeting public health messaging in upcoming waves throughout the remainder of the pandemic and in future similar situations.

Author Bios

Dr. Arlinghaus is a Registered Dietitian and an Assistant Professor in the Division of Epidemiology and Community Health at the University of Minnesota School of Public Health. Dr. Arlinghaus is committed to reducing health disparities of youth and their families with a focus on preventing chronic disease through the creation of physical and social environments that support improved physical activity and nutrition behaviors.

Mr. Hersch is a Research Services Hub Manager in the department of Family Medicine and Community Health in the University of Minnesota School of Medicine. He is focused on better understanding and addressing the complex barriers to engaging in behaviors to support health that are disproportionately faced by people of color and those from marginalized communities.

Dr. Dianne Neumark-Sztainer is a Professor and Division Head of the Division of Epidemiology and Community Health at the University of Minnesota School of Public Health. Her research is focused on the prevention and reduction of weight-related problems, including obesity, poor dietary intake, inadequate physical activity, disordered eating behaviors, and body dissatisfaction, particularly among underserved populations.

Dr. Katie Loth is a Registered Dietitian and Assistant Professor in the Department of Family Medicine and Community Health in the University of Minnesota School of Medicine. Her research explores social and environmental influences on child and adolescent weight status and disordered eating behaviors. Specifically, she is interested in identifying ways that parents can work to help their children develop and maintain a healthy weight and a healthy relationship with their bodies.