The U.S. is the epicenter of the coronavirus disease 2019 (COVID-19) pandemic. In response, governments have implemented measures to slow transmission through "social distancing." However, the practice of social distancing may depend on prevailing socioeconomic conditions and beliefs. Using 15-17 million anonymized cell phone records, we find that lower per capita income and greater Republican orientation were associated with significantly reduced social distancing among U.S. counties. These associations persisted after adjusting for county-level sociodemographic and labor market characteristics as well as state fixed effects. These results may help policymakers and health professionals identify communities that are most vulnerable to transmission and direct resources and communications accordingly.
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The U.S. is the epicenter of the coronavirus disease 2019 (COVID-19) pandemic. 1 Modeling studies suggest that, without mitigation efforts, rising numbers of COVID-19 cases may overwhelm the health system's capacity and result in millions of deaths. 2 As a result, federal, state, and local governments have implemented a patchwork of public health measures to slow transmission through "social distancing." These measures include orders to stay home and close schools and non-essential businesses. The effectiveness of social distancing policies requires significant engagement from communities. However, communities may face barriers to successfully adhere to these policies depending on prevailing socioeconomic conditions and political beliefs. 3 This study examines the socioeconomic and political determinants of engagement in social distancing among U.S. counties.
We obtained data on social distancing from Unacast, who measure county-level averages of distance traveled per person, based on 15-17 million anonymous cell phone users per day. Adherence to social distancing was conceptualized as changes in average distance traveled for March 19-28, 2020 (most recent data available), relative to matched days of a pre-COVID-19 reference week. The validity of this distancing measure is confirmed by the sharp decrease after declaration of a national emergency for COVID-19 ( Figure 1A) . . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055632 doi: medRxiv preprint 4 We estimated associations between the degree of social distancing and socioeconomic and political factors using cross-sectional ordinary least squares regressions, adjusting for sociodemographic covariates, state fixed effects (to account for state-level differences in timing and degree of COVID-19 mitigation measures), and rurality (from the 2010 Census).
In bivariate analyses, lower per capita income and a higher share of voters supporting President Trump were associated with reduced social distancing (Figures 1B, 1C) . In multivariable models adjusting for sociodemographic and labor market characteristics as well as state fixed effects ( Table 1) residents without college degrees were also associated with less distancing. There were no significant associations by population share of gender or age.
Lower socioeconomic status and greater Republican political orientation were associated with reduced social distancing among U.S. counties. These results suggest that income-related barriers (e.g. the need to continue working) and political beliefs may lead to significant socioeconomic gradients in COVID-19, just as they do for other health conditions. [4] [5] Limitations of this study include the potential for omitted-variable and ecological biases due to aggregate, cross-sectional data. Social distancing may also be measured with error, given that the data do not sample all cell-phone users and do not reflect non-users.
Regardless, our findings underscore the heterogeneity of communities' engagement in public health responses to COVID-19. These patterns may help policymakers and health . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055632 doi: medRxiv preprint 5 professionals identify communities that are most vulnerable to transmission and direct resources and communications accordingly. Additional research as new data become available is necessary to correlate these findings with infection rates and mortality.
We thank Unacast for providing us their social distancing dataset for research use.
. CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055632 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
is the (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.04.06.20055632 doi: medRxiv preprint