Morbidity and Mortality Weekly Report
MMWR / October 16, 2020 / Vol. 69 / No. 41 1497
US Department of Health and Human Services/Centers for Disease Control and Prevention
Factors Influencing Risk for COVID-19 Exposure Among Young Adults
Aged 18–23 Years — Winnebago County, Wisconsin, March–July 2020
Rebecca F. Wilson, PhD
1
; Andrea J. Sharma, PhD
1
; Sarahjean Schluechtermann, MPH
2
; Dustin W. Currie, PhD
1,3
; Joan Mangan, PhD
1
;
Brian Kaplan, MS, MA
1
; Kimberly Goffard, MBA
2
; Julia Salomon, MS
2
; Sue Casteel, MS
1
; Ashley Mukasa
2
; Niki Euhardy, MPH
2
;
Andrew Ruiz, MSPH
1
; Gregory Bautista, MPH
1
; Erika Bailey
4
; Ryan Westergaard, MD, PhD
4
; Douglas Gieryn
2
On October 9, 2020, this report was posted as an MMWR Early
Release on the MMWR website (https://www.cdc.gov/mmwr).
On May 13, 2020, the Wisconsin Supreme Court declared
the state’s Safer at Home Emergency Order (https://evers.
wi.gov/Documents/COVID19/EMO28-SaferAtHome.pdf)
“unlawful, invalid, and unenforceable,”* thereby increasing
opportunities for social and business interactions. By mid-June,
Winnebago County,
†
Wisconsin experienced an increase in
the number of infections with SARS-CoV-2, the virus that
causes coronavirus disease 2019 (COVID-19), with the larg-
est increase among persons aged 18–23 years (young adults)
(1). This age group
§
accounts for 12.5% of the population
in the county. To identify factors that influence exposure
to COVID-19 among young adults in Winnebago County,
characteristics of COVID-19 cases and drivers of behaviors
in this age group were examined. During March 1–July 18,
2020, 240 young adults received positive SARS-CoV-2 test
results, accounting for 32% of all Winnebago County cases.
In 30 key informant interviews, most interviewees reported
exposure to misinformation, conflicting messages, or opposing
views about the need for and effectiveness of masks. Thirteen
young adults described social or peer pressure to not wear a
mask and perceived severity of disease outcome for themselves
as low but high for loved ones at risk. Having low perceived
severity of disease outcome might partly explain why, when not
in physical contact with loved ones at risk, young adults might
attend social gatherings or not wear a mask (2). Exposure to
misinformation and unclear messages has been identified as
a driver of behavior during an outbreak (3,4), underscoring
the importance of providing clear and consistent messages
* https://www.wicourts.gov/sc/opinion/DisplayDocument.
pdf?content=pdf&seqNo=260868.
†
The COVID-19 data provided in this report are specific to the Winnebago
County Health Department (WCHD) jurisdiction. Data for the portions of
the City of Menasha or City of Appleton that fall within Winnebago County
are not included. Data provided on the Wisconsin Department of Health
Services website might be different than the information provided by WCHD
because the state reports data for the entire county, which includes those portions
of Menasha and Appleton.
§
Percentage of population includes persons aged 18–24 years in Winnebago County,
Wisconsin, and were obtained using the U.S. Census 2018 American Community
Survey data. Population data for young adults aged 18–23 years were not available
for this report. https://data.census.gov/cedsci/table?g%20=%20
0500000US55139.060000&y%20=%202018&d%20=%20ACS%205-Year%20
Estimates%20Detailed%20Tables&tid%20=%20ACSDT5Y2018.B01001.
about the need for and effectiveness of masks. In addition,
framing communication messages that amplify young adults’
responsibility to protect others and target perceived social or
peer pressure to not adhere to public health guidance might
persuade young adults to adhere to public health guidelines
that prevent the spread of COVID-19.
SARS-CoV-2 spreads easily through person-to-person
contact; certain behavioral factors (e.g., wearing masks, social
distancing, and avoiding large gatherings) are effective in pre-
venting COVID-19.
¶
Young adults represent an increasingly
large proportion of U.S. COVID-19 cases (5). A recent survey
found that persons aged 18–24 years reported lower agreement
with and adherence to public health guidance (e.g., wearing
masks) compared with those aged ≥25 years (2). Identifying fac-
tors (e.g., perceived severity of disease outcome) that influence
risk for exposure to COVID-19 and framing communication
messages to target those factors might persuade young adults to
engage in behaviors that are effective in preventing the spread
of COVID-19 (6,7).
This study used a quantitative and qualitative approach to
identify drivers of behavior that influence risk for exposure
to COVID-19 among young adults. Characteristics (e.g.,
social gathering attendance, occupation, and age) of young
adults with COVID-19 during March 1–July 18, 2020, and
within Winnebago County, were obtained from Wisconsin’s
Electronic Disease Surveillance System.** In addition, key
informant interviews were conducted during July 9–22 with
30 persons, including 13 young adults, nine owners of business
establishments employing and frequented by young adults (e.g.,
restaurants and bars), and eight community leaders
††
(persons
¶
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-
spreads.html.
** In Wisconsin’s Electronic Disease Surveillance System, information for occupation
and social gathering is systematically collected in various formats (e.g., text field
and drop-down menu options); thus, abstraction of free text fields was completed
to enhance data completeness and accuracy of these variables.
††
Community leaders were interviewed to gain an understanding of broader
concerns related to COVID-19 and its impact within the community, but
because of their diverse roles within the community, results from those
interviews were not analyzed for themes but presented as salient concerns
raised by community leaders. Thus, NVivo software was not used to analyze
interviews for community leaders. Broader concerns expressed by community
leaders that paralleled those of business owners and young adults were
presented along with themes that emerged from interviews with business
owners and or young adults.
Morbidity and Mortality Weekly Report
1498 MMWR / October 16, 2020 / Vol. 69 / No. 41 US Department of Health and Human Services/Centers for Disease Control and Prevention
in various leadership roles) within Winnebago County using
semistructured interview guides. Interviews did not knowingly
include anyone who had received positive SARS-CoV-2 test
results before the interview. Interview guides included ques-
tions to assess various factors (e.g., attitudes and perceptions).
§§
Participants were recruited using snowball sampling, a method
whereby enrolled participants refer other potential participants
(8). Local health officials provided initial participant referrals.
In-person interviews, lasting 30–75 minutes, were digitally
recorded, transcribed, and analyzed using NVivo software
(version 12; QSR International).
¶¶
Analysis involved summa-
rizing patterns of information shared by participants regarding
their subjective experiences of the pandemic. All participants
consented to being interviewed and received a gift card for
participating.*** Interviews were conducted until thematic
saturation was achieved and no new themes emerged.
†††
By mid-June, after the Safer at Home Emergency Order
was invalidated, Winnebago County experienced an increase
in COVID-19 cases, with the largest increase among young
adults (Figure). During March 1–July 18, 2020, young adults
accounted for 240 (32%) of 757 cumulative COVID-19 cases
in Winnebago County (Table 1). The majority of young adults
were non-Hispanic White (72%); followed by other/unknown
race/ethnicity (14%); Hispanic (7%); and non-Hispanic Black
(4%). Over half were female (54%), and 72% reported being
employed. Among those employed, 83% reported working
outside of the home during their exposure period
§§§
; over half
(58%) reported working outside of the home 2 days before
symptom onset or positive specimen collection (i.e., during
§§
The interview guide for young adults included a range of questions and were
abbreviated for this report to include questions regarding social interactions
with peers, adherence to and attitudes about public health guidance, perceived
severity of disease outcome, perceived responsibility to others, and social or
peer pressure. The interview guide for business owners included a range of
questions and were abbreviated for this report to include questions regarding
trusted sources of COVID-19 information, main concerns regarding the
pandemic, and barriers to implementing public health guidance within their
establishments. The interview guide for community leaders included
questions regarding participants’ appraisal of the pandemic, main concerns
regarding the pandemic, and trusted sources of COVID-19 information.
¶¶
https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home.
*** Providing incentives to participants have been found to increase participation
in studies (https://link.springer.com/article/10.1023/A:1025023600517). Thus,
in this study, a gift card in the sum of $25 was provided to participants, and the
amount was based on the need to balance motivating interviewees to participate
without offering a coercive sum (i.e., a sum that a low-income individual would
find difficult to refuse). Two interviewees declined the offer of a gift card.
†††
Thematic saturation, which is often used to determine sample size in
qualitative data collection (e.g., key informant interviews), is achieved when
no new information or salient themes arise from data collection. Probing,
in-depth responses provided by interviewees, and the number of salient issues
being discussed are some factors that influence when thematic saturation is
reached. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6010234/.
§§§
Exposure period is defined as the 14 days preceding symptom onset or
receiving positive test results.
their contagious period
¶¶¶
). In addition, 38% reported attend-
ing a social gathering**** during their exposure period, and
84% reported clinical symptoms consistent with COVID-19.
Among the 13 young adults interviewed, nine were women,
all were employed, and all were either enrolled in college or had
graduated from college within the last year. Common themes
that emerged during interviews as drivers of behavior were
social or peer pressure, social interactions, attitudes regarding
public health guidance, perceived severity of disease outcome,
perceived responsibility to others, workplace COVID-19 miti-
gation measures, absence of countywide measures, identifying
a trusted source for COVID-19 information, and exposure
to misinformation, conflicting messages, or opposing views
regarding masks (Table 2). In the analysis of interviews, young
adults described feeling social or peer pressure to not wear a
mask, reportedly receiving “negative reactions” or “odd looks”
from others when wearing a mask, or feeling “weird” about
wearing a mask. Young adults reported limiting social inter-
actions; however, many reported engaging in social activities
(e.g., attending a bonfire or bar) that exposed them to multiple
persons. Young adults reported wearing masks when shopping,
most held favorable views of public health guidance (e.g.,
wearing masks), and a few had negative or questioning views
of masks and social distancing. Most young adults indicated
they would likely be asymptomatic or have mild or flu-like
symptoms if they were to receive a positive test result or “had
peers who had tested positive and those peers hardly even had
symptoms.” Young adults reported having loved ones at risk
for severe COVID-19–associated outcomes and expressed a
sense of responsibility to those loved ones and the broader
community. Moreover, most young adults voiced concerns
about exposure to SARS-CoV-2 within their workplaces and
reported exposure to misinformation, conflicting messages, or
opposing views regarding the need for or effectiveness of masks.
Among interviewed business owners (nine) and community
leaders (eight), all business owners identified local health offi-
cials as trusted sources for COVID-19 information, yet a few
community leaders did not. Further, many business owners
¶¶¶
Contagious period is defined as working outside of the home the 2 days
before symptom onset or positive specimen collection. Information for
worked during contagious period was determined by examining information
contained in the Facility Intervention section and the date of onset of
symptoms, which are both systematically collected in Wisconsin’s Electronic
Disease Surveillance System. Abstraction of free text fields was completed
to enhance data completeness and accuracy of data collected on patients
reporting working outside of the home in the 2 days before symptom onset
or positive specimen collection contagious period.
**** Social gathering refers to the COVID-19 patient reporting attending a
gathering, party, or meeting with people from outside of their household
in the 14 days before symptom onset or receiving positive test results.
Wisconsin’s Electronic Disease Surveillance System does not provide a
minimum number of participants to qualify as a social gathering.
Morbidity and Mortality Weekly Report
MMWR / October 16, 2020 / Vol. 69 / No. 41 1499
US Department of Health and Human Services/Centers for Disease Control and Prevention
FIGURE. Cumulative number of confirmed COVID-19 cases, by age group (N = 757) — Winnebago County, Wisconsin, March 1–July 18, 2020
0
50
100
150
200
250
Cumulative no. of cases
Test result date
Mar 1–
Mar 7
Mar 8–
Mar14
Mar 15–
Mar 21
Mar 29–
Apr 4
Apr 12–
Apr 18
Apr 26–
May 2
May 10–
May16
May 24–
May 30
Jun 7–
Jun 13
Jun 21–
Jun 27
Jul 5–
Ju l 11
Mar22–
Mar28
Apr 5–
Ap r 11
Apr 19 –
Apr 25
May 3–
May 9
May 17–
May23
May 31–
Jun 6
June 14–
June 20
Jun 28–
Jul 4
Jul 12–
Jul 18
Wisconsin’s Safer at
Home Emergency
Order invalidated
(May 13)
<18 yrs
18–23 yrs
24–29 yrs
30–39 yrs
40–49 yrs
50–59 yrs
≥60 yrs
Abbreviation: COVID-19 = coronavirus disease 2019.
and community leaders reported exposure to misinformation,
conflicting messages, or opposing views regarding the need
for or effectiveness of masks. Business owners indicated they
had implemented some control measures (e.g., hand-hygiene
stations and mask-wearing); however, many reported discon-
tinuing mask-wearing requirements for reasons such as not
wanting to offend customers or perceived competition with
similar establishments. Business owners perceived the absence
of a countywide mask ordinance as a barrier to reimplementing
mask-wearing requirements within their establishments and
some spontaneously indicated that if a mask ordinance was
implemented, they would comply.
Discussion
Wisconsin’s Electronic Disease Surveillance System data
indicated social interactions and workplace and community
transmission likely contributed to the spread of COVID-19
among young adults in Winnebago County. Nearly three quarters
(72%) of young adults with COVID-19 were employed, and over
one half (58%) worked outside of the home while contagious,
increasing the risk for transmitting SARS-CoV-2 to the broader
community. Among young adult interviewees with jobs that
entailed interaction with the public, many voiced concerns about
workplace exposure, underscoring the importance of businesses
implementing control measures (e.g., requiring masks) consistent
with published guidance,
††††
especially when physical distancing is
difficult. These concerns, coupled with the fact that most business
owners identified the absence of a countywide mask ordinance as
a barrier to reimplementing mask-wearing requirements within
their establishments, highlight the benefits that might come from
implementing a countywide mask ordinance (9). Given that
business owners and most community leaders trusted local health
officials for COVID-19 information, businesses could collabo-
rate with local health officials in implementing control measures
tailored to their needs. Among the few community leaders who
distrusted COVID-19 information shared by local health officials,
that distrust appeared to stem from exposure to misinformation
††††
https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/
business-employers/bars-restaurants.html#anchor_1589927161215.
Morbidity and Mortality Weekly Report
1500 MMWR / October 16, 2020 / Vol. 69 / No. 41 US Department of Health and Human Services/Centers for Disease Control and Prevention
TABLE 1. Characteristics of confirmed cumulative COVID-19 cases
among persons aged 18–23 years (N = 240), Wisconsin’s Electronic
Disease Surveillance System — Winnebago County, Wisconsin,*
March 1–July 18, 2020
Characteristic No. (%
†
)
Age, yrs
18 8 (3.3)
19 22 (9.2)
20 28 (11.7)
21 63 (26.3)
22 67 (27.9)
23 52 (21.7)
Sex
Men 111 (46.3)
Women 129 (53.8)
Race/Ethnicity
White, non-Hispanic 173 (72.1)
Hispanic 17 (7.1)
Black, non-Hispanic 10 (4.2)
Asian 3 (1.3)
American Indian 3 (1.3)
Other/Unknown 34 (14.2)
Employment status/Occupation
§
Employed 173 (72.1)
Restaurant/Bar 47 (19.6)
Health care 35 (14.6)
Other 91 (37.9)
Unemployed 41 (17.1)
Unknown 26 (10.8)
Among employed (n = 173), worked 14 days before symptom onset or
receiving positive test results (exposure period)
Yes 143 (82.7)
No 15 (8.7)
Unknown 15 (8.7)
Among employed (n = 173), worked in the 2 days before symptom onset
or positive specimen collection (contagious period)
Yes 101 (58.4)
No 37 (21.4)
Unknown 35 (20.2)
Attended social gathering in the 14 days before symptom onset receiving
positive test results
¶
Yes 91 (37.9)
No 109 (45.4)
Unknown 40 (16.7)
Among those who reported attending a social gathering (n = 91),
locations reported**
House party 32 (35.2)
Domestic travel
††
31 (34.1)
Restaurant or bar 30 (33.0)
Unknown location
§§
14 (15.4)
Symptoms
Symptomatic 202 (84.2)
Asymptomatic 38 (15.8)
Symptoms reported by respondents (n = 202)**
Headache 117 (48.8)
Cough 106 (44.2)
Loss of taste or loss of smell 96 (40.0)
Fevers, chills, or night sweats 87 (36.3)
Sore throat or hoarseness 76 (31.7)
Runny nose, congestion, allergy, or sinus symptoms 73 (30.4)
Muscle aches 63 (26.3)
Fatigue, weakness, or dizziness 61 (25.4)
Nausea, vomiting, diarrhea, or abdominal pain 42 (17.5)
Shortness of breath, chest tightness, or chest pain 37 (15.4)
TABLE 1. (Continued) Characteristics of confirmed cumulative
COVID-19 cases among persons aged 18–23 years (N = 240),
Wisconsin’s Electronic Disease Surveillance System — Winnebago
County, Wisconsin,* March 1–July 18, 2020
Abbreviation: COVID-19=coronavirus disease 2019.
* COVID-19 cases in this report are specific to the Winnebago County Health
Department jurisdiction and do not include COVID-19 cases that fall within
the City of Menasha Health Department jurisdiction and the City of Appleton
Health Department jurisdictions.
†
Percentages might not sum to 100% because of rounding.
§
Five young adults reported employment at more than one employer but
were counted only once under restaurant/bar (two) or health care (three).
Young adults who reported their employment status as employed and
student are counted under employed. Young adults who reported their
occupation as student and did not include any additional information about
occupation type are counted under unemployed.
¶
Social gathering refers to the COVID-19 patient reporting attending a
gathering, party, or meeting with people from outside of their household in
the 14 days before symptom onset or receiving positive test results.
Wisconsin’s Electronic Disease Surveillance System does not provide a
minimum number of participants to qualify as a social gathering.
** Characteristic is not mutually exclusive.
††
Domestic travel is categorized as a social gathering if the COVID-19 patient
reported making a journey, out of town, to attend a gathering, party, or
meeting with people from outside of their household in the 14 days before
symptom onset or receiving positive test results.
§§
Unknown location reflects COVID-19 positive patients who reported
attending a social gathering in the 14 days before symptom onset or receiving
positive test results but did not report the location of the social gathering.
and conflicting messages regarding the severity of the pandemic,
which in turn seemed to influence their views about the extreme-
ness of broader community mitigation measures (e.g., the Safer
at Home Order). Lack of trust can influence adherence to public
health guidance.
§§§§
Some young adults admitted to not wearing a mask when
socializing with friends, which might indicate a sense of security
when interacting with friends. Moreover, the expectation that they
would likely be fine if they contracted COVID-19, coupled with
social or peer pressure, might help explain transmission patterns
among young adults. Although young adults perceived a low sever-
ity of disease outcome for themselves, many expressed concerns
about transmitting SARS-CoV-2 to loved ones at risk and to the
broader community. Having a sense of responsibility to others
might explain why young adults reported wearing masks when
shopping and why most held positive views of masks. However,
when not in physical contact with loved ones at risk, young adults
might choose to not wear a mask or to attend larger gatherings
with peers who might also perceive a low severity of disease out-
come for themselves. Exposure to misinformation and conflicting
messages regarding masks might make it difficult to know what
information to trust, underscoring the importance of providing
clear and consistent messages during an outbreak (3,4). Among
the few young adults who expressed negative attitudes about masks
and social distancing or who had questions about the effectiveness
§§§§
https://www.cdc.gov/eis/field-epi-manual/chapters/Communicating-
Investigation.html.
Morbidity and Mortality Weekly Report
MMWR / October 16, 2020 / Vol. 69 / No. 41 1501
US Department of Health and Human Services/Centers for Disease Control and Prevention
TABLE 2. Themes from key informant interviews with young adults aged 18–23 years (n = 13), business owners* (n = 9), and community leaders
†
(n = 8) — Winnebago County, Wisconsin, July 9–22, 2020
Theme Example quotes
Young adults
Social or peer pressure “I felt like everybody else in here is not going to wear a mask, I might as well just go in there and not wear a mask as well. I don’t
want to be seen as different.”
“When you’re at your friend’s, you don’t want to be ‘that’ person that wears the mask, because then you look like a weirdo, you
k now.”
“So, like for me seeing everyone not wearing masks and me being the only one, I’m like yeah, I feel pressured to take it off, and I
don’t want that, so I’ll leave.”
Social interactions “I’ve chosen to eat outside. I’ve chosen to do the things that I think are good that I also like to do. I felt like that was a risk versus a
reward type of thing.”
“[My friends and I] don’t wear masks together, but whenever I go out with them, we always just go to an outdoors place because
we’re not in a bar or restaurant or anything like that. If you limit the amount of people you see and your friends also do the same,
I feel comfortable.”
Attitudes regarding public health guidelines (e.g.,
wearing masks and social distancing)
“I personally feel like masks are a very effective way to stop the virus spread or at least control it.”
“The isolation and the masks and everything, I just don’t know that that’s really necessary……Like I said, I’m not a scientist. I don’t
know. I’m questioning it. It’s a little scary to me. Because if this is something that they’re mandating, like what else is going to
come next?” “But I just–like, that gets into personal beliefs.”
Perceived severity of disease outcome “I know like five people that have had COVID, and they’re all fine. I don’t know anybody that’s died and some of them have hardly
even had symptoms.”
“I hear most of it, you’re probably like asymptomatic. I don’t want to speak on it and jinx myself. So, I probably wouldn’t show
many signs [if I tested positive for COVID-19].”
Perceived responsibility to others “For me it’s more of who am I affecting the most. When it comes to, like, my grandparents or people at the grocery store, I don’t
want–even if do have it, and if I don’t have any symptoms, why spread it to other people?”
“I’m most worried about giving it to my dad. He’s not in great health.”
Workplace COVID-19 mitigation measures “I feel like if I went to my manager and asked him if we could do more, he would not take anything well, or he wouldn’t implement
anything. So, that’s frustrating.”
“We are actually not [required to wear masks at work], which is weird, in my personal opinion, but we are being very safe about it.”
Exposure to misinformation, conflicting messages, or
opposing views regarding public health guidance
§
“I think it’s just hard, because nobody has the same message, and I feel like since it’s a pandemic, and since it’s a health issue, it
shouldn’t be about confusing messages. I think because it’s confusing, that’s makes me not really want to listen to anything.”
“Some people are saying we need to wear masks for public health. Some people are saying they don’t work… So, it’s super hard
to trust…”
“I think definitely looking at [local and national leaders] and just seeing them not wear a mask. I think that has a really big effect
on people and their own perception of the virus.”
Business owners*
Lack of countywide measures “They should mandate masks right this second. They should have done it two weeks ago, and the pushback was terrible.”
“I would say the main thing is, that without a [county-wide] mandate for [masks] and knowing that many of my competitors are
just not going to [require masks], that is my biggest barrier to [requiring masks].”
“If I said, ‘you guys have to wear a mask,’ they’d walk down to the next bar that’s not requiring a mask. I can guarantee that. It’s
competition, and it’s a competition.”
Trusted source for COVID-19 information “My main thing is I get that email every day from the [local health department], and that’s where I go [for information on
COVID-19].”
“Within the county health department, their dashboards are great on a daily basis…..to understand daily where we are as a
snapshot.”
Exposure to misinformation, conflicting messages, or
opposing views regarding public health guidance
§
“There are people who don’t think [COVID-19] is real and that it doesn’t exist, and there are people who think that wearing a mask
impedes in their freedom and telling people where to sit [6 ft apart] impedes on their freedom as well, and they will not follow it
regardless.”
“We don’t have any leadership from the top. You get these mixed signals. Who do I trust?”
Community leaders
†
Exposure to misinformation, conflicting messages, or
opposing views regarding public health guidance
§
“And it’s, it’s just been a disaster from a PR perspective for getting good information, accurate information out……. In the
meantime, we’re all bad people you know because we’re not adhering to whatever they want us to adhere to.”
“When you have [professionals] that don’t think it’s a good idea to self-quarantine, an ordinary person is going to sit there and say
“well, [they] must know better.”
Perceived severity of the pandemic “They [federal, state, and local public health agencies] have all done a crappy job of selling why this is bad, and that’s why nobody
believes it.”
“I might not call it a pandemic, but until the numbers get higher than the regular flu, in my mind it’s still a nasty flu.”
Trusted source for COVID-19 information “[The local county health department] has done a good job with visibility, I believe.”
“[We’re] being asked to wear a mask and do all sorts of things, you know. And I’m saying it’s being based on wrong information,
[bad data].”
Abbreviation: COVID-19=coronavirus disease 2019.
* Business owners are owners of establishments employing and frequented by young adults (e.g., restaurants and bars).
†
Community leaders were interviewed to gain an understanding of broader concerns related to COVID-19 and its impact within the community, but because of their diverse roles within
the community, results from those interviews were not analyzed for themes but presented as salient concerns raised by community leaders.
§
Exposure to misinformation, conflicting messages, or opposing views regarding public health guidance was reported within all interviewee groups. To facilitate interpretation and analysis
of this theme, these three salient issues were reported under one theme because of their similarities.
Morbidity and Mortality Weekly Report
1502 MMWR / October 16, 2020 / Vol. 69 / No. 41 US Department of Health and Human Services/Centers for Disease Control and Prevention
of masks, those views appeared to be based on the expressed need
to make their own choices (i.e., personal agency).
The findings in this report are subject to at least four limitations.
First, interviews were conducted in Winnebago County; therefore,
findings are not widely generalizable. Second, self-reported informa-
tion collected in Wisconsin’s Electronic Disease Surveillance System
and from interviews is subject to social desirability bias and might
have led to underestimations of some characteristics and factors.
Third, interviewees identified through snowball sampling might
have similar characteristics; thus, this report might not capture rep-
resentativeness of diverse responses. Finally, missing information in
text fields could have led to underestimations of some characteristics.
Despite limitations, this report provides a framework for
tailoring communication messages that are empathetic, that
amplify personal responsibility and responsibility to protect
others, and that focus on perceived pressure to not wear a mask,
all of which might persuade young adults to adhere to public
health guidelines (e.g., wearing masks) that prevent the spread
of COVID-19. Masks are an effective tool to prevent the spread
of COVID-19 (9), and current CDC guidance recommends
universal masking to prevent SARS-CoV-2 transmission.
¶¶¶¶
This report further underscores the importance of providing
clear and consistent messages regarding need for and effective-
ness of masks, because consistent messages could help increase
widespread adoption of evidence-based guidance (3).
Acknowledgments
All interviewees; Winnebago County Public Health Department
staff members; Wisconsin Department of Health Services.
Corresponding author: Douglas Gieryn, [email protected].
1
CDC COVID-19 Response Team,
2
Winnebago County Public Health
Department, Winnebago County, Wisconsin,
3
Epidemic Intelligence Service,
CDC;
4
Bureau of Communicable Diseases, Division of Public Health,
Wisconsin Department of Health Services.
All authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.
References
1. Winnebago County Public Health Department. COVID-19 situation
update. Oshkosh, WI: Winnebago County Public Health Department;
2020. https://myemail.constantcontact.com/COVID-19-Situation-
Update-6-19-20.html?soid=1124680822228&aid=BTrjf6nMzSk
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https://www.cdc.gov/media/releases/2020/p0714-americans-to-wear-
masks.html.
Summary
What is already known about this topic?
Young adults represent an increasingly large proportion of U.S.
COVID-19 cases.
What is added by this report?
In Winnebago County, Wisconsin, perceived low severity of
disease outcome; perceived responsibility to others; peer
pressure; and exposure to misinformation, conflicting mes-
sages, or opposing views regarding masks were identified as
drivers of behaviors that might influence risk for COVID-19
exposure among young adults.
What are the implications for public health practice?
Identifying factors that influence risk for COVID-19 exposure
and framing messaging to target those factors could help
persuade young adults to adhere to public health guidelines
that prevent the spread of COVID-19. Providing clear and
consistent messages regarding the need for and effectiveness
of masks could help increase widespread adoption of evidence-
based guidance.
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Rep 2020;69:751–8. https://doi.org/10.15585/mmwr.mm6924e1
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org/10.15585/mmwr.mm6928e2
