In this survey study, we aimed to rapidly assess public concerns about the coronavirus disease 2019 (COVID-19) crisis1,2 in the United States before shelter-in-place orders were widely implemented. Specifically, we assessed concerns about COVID-19, symptoms, and individual actions in response to the pandemic.
On March 14, 2020, we posted an online cross-sectional survey3 on 3 social media platforms (Twitter, Facebook, and Nextdoor) to collect data on symptoms, concerns, and individual actions taken. Twitter and Facebook posts were shareable to facilitate snowball sampling. The institutional review board at Stanford University approved this study, and informed consent was obtained from participants. Participants were informed of the purpose, risks, and benefits; minimal personal information (eg, zip code and Qualtrics location) was collected. The survey included 21 questions (multiple choice, single choice, numeric, and open ended). A paper version of the survey was pilot tested with 41 participants, who were not included in the final results. In addition to demographic data (Table), we asked about recent cold and flulike illness. Other questions addressed participants’ concerns and lifestyle modifications. All questions were optional; thus, the number of respondents to each question varied. As of March 16, 2020, 844 of 3233 (26.1%) US counties had at least 1 respondent (range, 1-868 respondents). More details about the Methods are provided in the Supplement.
In 48 hours, from March 14 to 16, 2020, 9009 surveys were completed. The median age of participants was 44 (range, 18-85) years. Of participants who specified, 5838 of 8959 (65.2%) were women, 7304 of 8828 (82.7%) were white, and 2575 (34.7%) and 3361 (45.3%) of 7412 reported obtaining bachelor degrees and graduate degrees, respectively. Of 8982 respondents, 2874 (32.0%) reported having a cold or flulike illness in the past 4 weeks. Of 8950 respondents, 6043 (67.3%) were very or extremely concerned about COVID-19, although concern varied by age (Figure, A). Of these 8950 respondents, 8562 (95.7%) reported making changes to their lifestyle in response to COVID-19. The most common lifestyle changes were more hand washing (8336 [93.1%]), avoiding social gatherings (7963 [89.0%]), and stockpiling food and supplies (6686 [74.7%]) (Figure, B). In addition, 1725 of 8983 (19.2%) respondents were self-isolating all of the time, while 4475 (49.8%) were self-isolating most of the time and leaving the house only to buy food and essentials.
Top concerns participants reported were getting sick because of COVID-19 (6284 of 8966 [70.1%]) and not being able to get medical care (4149 of 8966 [46.3%]). The most common difficulties reported were obtaining hand sanitizer, food, and childcare. Among 6689 respondents, 981 (14.7%) reported reduced wages or work hours, and 102 (1.5%) reported having lost their jobs because of the crisis. If their physician was not available in person, 4807 of 8944 (53.7%) respondents indicated that they would choose to be seen via a remote televisit.
In this convenience sample survey distributed via 3 social media platforms in mid-March 2020, participants reported serious concerns about COVID-19 and that they were preparing by washing hands, remaining homebound, and practicing social distancing. There was variation in the levels of concern about COVID-19 in different age groups, and the most common difficulties were getting hand sanitizer or food, arranging childcare, and lost wages or reduced working hours.
We used this methodology to rapidly characterize public sentiment regarding measures taken and threats faced as the pandemic evolves while recognizing that this goal was not conducive to probability sampling. With this convenience sampling that is not representative of the public at large and lack of information on participation rates, these findings are limited and are not generalizable. Men and older individuals (who are generally known to be underrepresented on social media) were underrepresented among the respondents. Although we did not collect information on the socioeconomic status of participants, it was likely to have been high because few reported concerns about their employment. We plan additional work that will achieve greater geographic representation with focus on longitudinal trends on the health, financial, and social concerns in the United States regarding the COVID-19 pandemic.
Accepted for Publication: March 24, 2020.
Published Online: April 7, 2020. doi:10.1001/jamainternmed.2020.1369
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Nelson LM et al. JAMA Internal Medicine.
Corresponding Author: Eleni Linos, MD, MPH, DrPH, Departments of Dermatology and Epidemiology and Population Health, School of Medicine, Stanford University, 269 Campus Dr, Mail Code 5179, Ste 4235 CCSR, Palo Alto, CA 94305 (linos@stanford.edu).
Author Contributions: Dr Linos had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Nelson, Bondy, Linos.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Nelson, Oluyomi, Rosas, Linos.
Statistical analysis: Oluyomi, Nava, Bondy, Linos.
Obtained funding: Linos.
Administrative, technical, or material support: Nelson, Simard, Nava, Bondy, Linos.
Study supervision: Nelson, Linos.
Conflict of Interest Disclosures: Dr Linos reports receiving grants from the National Institutes of Health (DP2CA225433 and K24AR075060). No other disclosures are reported.
Funding/Support: This work was funded in part by the Clinical and Translational Science Award Program of the National Institutes of Health’s National Center for Advancing Translational Science (UL1 TR001085).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We thank those who helped refine survey questions and disseminate the survey on social media: Georgina Armstrong, MPH, Baylor College of Medicine; Wei-Ting Chen, PhD, Stanford University; Esther Choo, MD, MPH, Oregon Health & Science University; Roxana Daneshjou, MD, PhD, Stanford University; Ben Davenport, BSE, MS; Eric L. Ding, ScD; Steve Goodman, MD, MHS, PhD, Stanford University; Meghan Halley, PhD, Stanford University; Esther John, PhD, MSPH, Stanford University; Justin Ko, MD, MBA, Stanford University; and Adam Miner, PsyD, MS, Stanford University. We would also like to thank Lucy Zhang, BA, Stanford University, for technology and social media advice and Meghan Halley, PhD, Stanford University, for programmatic support. None of those acknowledged was compensated.