Maintaining Adherence to COVID-19 Preventive Practices and Policies: A Systematic Observational Study of Masking and Distancing in the District of Columbia and Other US States

Document Type

Journal Article

Publication Date



JMIR public health and surveillance




BACKGROUND: Prior to the development of effective vaccines against SARS-CoV-2, masking and social distancing emerged as important strategies for infection control. Locations across the US required or recommended face coverings where distancing was not possible, but it is unclear to what extent people complied with these policies. OBJECTIVE: This study provides descriptive information about adherence to public health policies pertaining to mask wearing and social distancing and examines differences in adherence to these policies among different population groups in the District of Columbia and 8 other US states. METHODS: This study was part of a national systematic observation study using a validated research protocol for recording adherence to correct mask wearing and maintaining social distance (6-feet/1.83 meters) from other individuals. Data were collected from December 2020 to August 2021 by research team members who stationed themselves in outdoor areas with high pedestrian traffic, observed individuals crossing their paths, and collected data on whether individuals' masks were present (visible or not visible) and/or worn (correctly, incorrectly, not at all) and whether social distance was maintained if other individuals were present. Observational data were entered electronically into Google forms and were then exported in Excel format for analysis. All data analyses were conducted using SPSS. Information on local COVID-19 protection policies (e.g., mask wearing requirements, etc.) was obtained through examination of city and state health department websites for the locations where data were being collected. RESULTS: At the time these data were collected, most locations in our study required (57.6%) or recommended (40.8%) masking. Despite this, more than 30% of our sample were unmasked (28.5%) or masked incorrectly (6.3%). Masking policy was significantly related to correct masking with locations that required or recommended masking (66% correct masking v. 17.1% in locations that did not require masking, P<.001). articipants who maintained social distance from others were more likely to be correctly masked than those who were not (P<.001). Adherence to masking policy by location was found to be significant (P<.001), however this was driven by 100% compliance in Georgia, which did not require masks at any point during the data collection period. When the same analysis was conducted for compliance with mask requirements and recommendations, there was no significant difference by location. Overall adherence to masking policies was 66.9%. CONCLUSIONS: Despite a clear relationship between mask policies and masking behavior, a third of our sample was non-adherent to those policies and approximately 23% of our sample did not have any mask, either on or visible. This may speak to the confusion surrounding "risk" and protective behaviors, as well as pandemic fatigue. These results underscore the importance of clear public health communication, particularly given variations in public health policies across states and localities.


Prevention and Community Health