The global battle against the spread of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), henceforth Coronavirus, and Coronavirus Disease (COVID-19) requires extensive public cooperation and compliance with public health policies to be effective. Politicians and public health authorities in many countries have communicated to citizens about the urgency to comply with non-pharmaceutical (non-medical) requirements to slow the spread of the virus. A common approach globally has been social distancing to ensure physical distance between people. The rationale behind social distancing is that the virus spread will slow down by measures such as staying home, avoiding crowds, and refraining from touching one another to diminish transmission of virus . Social distancing policies have become a crucial part of mitigating pandemic influenza globally .
This project analyzes and compares social distancing policies implemented in Denmark and Sweden in 2020 to curb the spread of Coronavirus. Both Nordic countries developed and implemented numerous policies for social distancing. Governments in both countries worked with medical and epidemiologic experts in public health authorities nationally and internationally to select policy measures to achieve the policy objectives regarding social distancing. The two neighboring countries share many cultural, historical, political, and economic characteristics. Both countries have a publicly funded health and welfare system and both have a constitutional monarchy, with limited power for the ruler; power is exercised through governments and ministers. Sweden has nearly twice the population of Denmark (10 million versus 5.8 million) but is more sparsely populated (24 inhabitants/km2 versus 132 inhabitants/km2) . However, despite many similarities in the two countries, their response to the Coronavirus crisis differed markedly. Whereas authorities in Denmark initiated mandatory regulations and many severe restrictions, Swedish authorities predominantly promoted voluntary recommendations.
Denmark implemented regulations that mandated a lockdown of the country's borders and the closing of schools, restaurants, and shopping malls . Compared with many other European countries, Denmark was an early mover. A number of restrictions were in place early on in the pandemic, including limiting gatherings to ten people, recommending the workforce to stay home and closing the borders . Denmark’s response was broadly similar to many other European countries, but the lockdown was less restrictive than those in France or the United Kingdom, for example. Thus, there was no stay-at-home order and many shops remained open although bars, gyms, and hairdressers were closed . Internationally, Denmark was referred to as something of a “test case” in its swift early response of mandatory measures .
In contrast, Sweden’s response to tackling the Coronavirus focused on voluntary recommendations . This approach was justified with reference to the lack of evidence for many of the regulatory measures undertaken elsewhere, e.g., school closures . Media and academic scholars attributed the Swedish approach to the citizens’ high trust in public institutions, because this was argued to create favorable conditions for voluntary state-led recommendations . Further, voluntary measures for improved public health have a long tradition in Sweden . The Swedish response took into account the broader societal and economic consequences of social distancing measures. For example, it was stressed how closing down schools would mean losing an estimated 25% of the workforce (i.e., parents would need to stay home with their children), including many health care workers . The ability to continue with the measures over a longer time period was also emphasized as an important factor .
Internationally, Sweden’s response attracted a considerable amount of media attention, being labeled a “relaxed” or “light touch” approach. The high COVID-19 death rate per capita in an international perspective (despite the challenges of comparing figures between countries) raised concern about the effectiveness of the approach .
Social distancing: definition, effectiveness, costs, and acceptance
Previous pandemics provide clues about what forms of social distancing might be relevant for slowing down the spread of COVID-19. Most evidence comes from other viral respiratory illnesses that can spread by particles remaining in the air after an infected individual coughs or sneezes, such as influenza, which has caused a number of pandemics in the 20th and 21st centuries, including the Spanish flu in 1918–1920 and the less extensive but more recent H1N1flu pandemic in 2009–2010. Unlike COVID-19, Ebola is not transmitted through the air but through direct physical contact, although the Ebola outbreak in West Africa in 2014–2015 also offered lessons on social distancing. In general, research on pandemics has shown that it is difficult to contain influenza geographically in the location where they emerge, and international spread is difficult to avoid for more than a short period .
Social distancing is usually defined as the practice of maintaining a greater than usual physical distance from other people or avoiding direct contact with people or objects in public places to minimize exposure and reduce the transmission of an infection [7, 8, 14]. The Centers for Disease Control and Prevention (CDC) define social distancing as practices for reducing the frequency and closeness of contact between people in order to decrease the risk of transmission of disease . Although the term social distancing continues to be used, the World Health Organization initiated the use of “physical distancing” in spring 2020 because it more accurately reflects the practices involved given that digital technology has enabled people to be socially connected without being physically in the same room or space with other people .
We have identified three systematic reviews that provide information on the effectiveness of social distancing measures to reduce virus transmission, the social and economic costs of such measures, and acceptance of the measures among the general public: Fong et al. ; Mahtani et al. ; Rashid et al. . Knowledge on social distancing has been obtained from clinical and epidemiologic studies, studies based on mathematical modeling of virus spread, as well as through personal clinical experiences about the impact of social distancing measures.
The three reviews have arrived at similar conclusions. Rashid et al.  stated that the overall quality of the evidence is not strong and that most social distancing measures were found to be moderately effective. Similarly, Mahtani et al.  said that “although limited, the best available evidence appears to support social distancing measures as a means of reducing transmission and delaying spread” and concluded that “staggered and cumulative implementation of these interventions may prove most effective.” They emphasized that the timing and duration of such measures were critical. Fong et al.  concluded that social distancing measures could be effective interventions to reduce transmission and mitigate the impact of an influenza pandemic, but “the evidence base for these measures was derived largely from observational studies and simulation studies; thus, the overall quality of evidence is relatively low.”
School closure has been found to be moderately effective in reducing the transmission of influenza and in delaying the peak of an epidemic [19–24]. However, this measure has been associated with very high economic costs and negative social impacts although this largely depends on the duration of the closure .
With regard to workplace-related interventions, the evidence available is rather limited. Interventions such as work closure and working from home have been found to be modestly effective, although they are usually considered to be acceptable, particularly if compensation is provided [25, 26]. Research suggests that a fairly high proportion of workplace closures are required for such a measure to have significant impact. However, workplace closures could cause considerable economic difficulties and widespread social distress [25, 27].
Working from home has been found to be potentially moderately effective in reducing the transmission of influenza . Although the social and economic costs associated with working from home are likely to be moderate compared with business closures, they would have a disproportionate effect on small businesses and self-employed people .
With regard to voluntary self-isolation of individuals, this has been found to be moderately effective. There is an increased risk of intrahousehold transmission, particularly where bathroom facilities are shared [29–31]. The costs of voluntary isolation have not been investigated in any depth, but they are thought to be moderate and relate primarily to employment loss as a result of having to stay home from work . Findings concerning the acceptability of voluntary self-isolation are somewhat variable [32–34].
The effects of cancelling mass gatherings depend on numerous factors such as event duration, degree of crowding, type of venue, and event timing in relation to the period either side of the peak of the epidemic . There is some evidence that it is possible to safely organize a mass gathering in the midst of pandemic influenza by taking rigorous control measures . The public’s acceptability of cancellation of mass gatherings is likely to vary depending on the characteristics of the gathering .
The literature review suggests that existing research findings on social distancing are inconsistent and that the quality of the accumulated evidence is not overly strong. Overall, there is rather limited evidence of the effectiveness for social distancing measures; many measures are described in the research literature as being “moderately effective.” Findings also tend to be inconsistent regarding the acceptance as well as social and economic costs of social distancing measures. Different interpretations of the social distancing research findings likely influence the development and implementation of policies and use of policy measures to prevent the spread of the Coronavirus.
The approaches used by Denmark and Sweden offer a unique opportunity to study the development, implementation, and compliance concerning social distancing policies and policy measures. Knowledge about the more typical and common approach taken by Denmark and the more unusual approach adopted by Sweden is required to understand and explain how and why different social distancing measures may work or not. We have not been able to find any studies focusing on Denmark or Sweden or comparative research concerning social distancing policy measures.
The paucity of knowledge underscores the relevance of investigating what social distancing policies and measures have been implemented and the characteristics of these as well as differences and similarities between Denmark and Sweden. It is highly relevant to investigate how governments and public health authorities argue and provide reasons for policy regulations and recommendations and the extent to which the measures are, or are proclaimed to be, based on research- or experience-based knowledge as well as the importance of political “saleability” and ideological considerations regarding what measures are taken. There is also a need to investigate how measures are perceived, accepted (or not), and acted upon and complied with by the public and by different groups of citizens in society.
Aims and research questions
The aim of this project is to generate new knowledge concerning important aspects of policies and policy measures for social distancing in Denmark and Sweden to prevent the spread of the Coronavirus. Both countries have developed and implemented numerous policies and introduced many policy measures concerning social distancing, but their responses to the crisis differ markedly.
The following research questions will be investigated with regard to Denmark and Sweden:
- What social distancing policies regarding the Coronavirus have been formulated and implemented in 2020, who are the policymakers behind the policy measures, who are expected to implement the measures, and who do the measures ultimately seek to influence?
- How have the social distancing policies and policy measures been justified and what types of knowledge form the basis for the measures concerning the Coronavirus?
- What are the differences and similarities in citizens’ perceptions of acceptability of and compliance with social distancing policy measures in relation to the Coronavirus?
Although definitions of policies are multifarious, public policies can be defined as objectives formulated and/or actions taken by a government (e.g., regarding social distancing) to address a societal problem (e.g., regarding the spread of the Coronavirus). A policy may sometimes be identifiable in terms of a decision but often involves a series of decisions or what may be seen as more of a general orientation. Moreover, policies tend to change over time . This project concerns policies that are regulatory, which means that they specify conditions and constraints for individual and collective behavior [39, 40] to achieve social distancing.
Policy characteristics refer to attributes of the formulated regulatory policy (i.e., the “implementation object”), such as the clarity of the policy objectives or the policy’s justification with regard to the perceived need it is intended to address . Policymakers are those formally responsible for setting the agenda, articulating policies, and selecting policy measures .
Policy measures are the “something” that is done to realize the objective of a policy. Thus, policy measures are the more concrete, specific actions (interventions, initiatives, etc.) carried out to implement a policy . Measures are also referred to as policy instruments or policy tools . The policy literature distinguishes between different categories of measures, e.g., enforcement, education, and engineering (modifying the environment) measures for improved traffic safety .
Implementers of public policies are typically organizations, such as governmental authorities and public and private entities. The implementers are the “link” between the policymakers and the intended targets (see below) of the policies, ensuring that the policy measures are implemented as planned. The bottom-up policy implementation perspective has emphasized the relevance of understanding the influence of the implementers . Lipsky  showed the importance of decisional latitude of street-level bureaucrats, suggesting that the influence of new knowledge must be considered alongside the implementers’ long-standing practices. Contemporary perspectives on policy research usually take a holistic view of implementers and describe complex networks of stakeholders such as individuals, organizations and inter-organizational relations, thus making it difficult to determine who the implementers are .
Targets of policies are the individuals or organizations whose behaviors a policy ultimately seeks to influence through legislation, sanctions, regulations, provision of information, and other policy measures. Targets in policy research are also referred to as clients or recipients .
The policy environment is the context in which a policy is developed and implemented, incorporating, for example, historic, political, cultural, and resource contexts . The policy environment is also referred to as the setting, conditions, and structure . This environment represents forces that are, at least partially, beyond the control of the policymakers, implementers, and targets . Bottom-up policy implementation researchers have focused a great deal of attention on the context of implementation .
Two types of results of policy implementation processes are typically distinguished: output is the impact on the implementers and outcome is the impact on the targets, e.g., citizens and organizations. Outputs are generally administrative decisions such as decisions to fund larger numbers of teachers, psychologists, or police officers, whereas comparable outcomes may include improved student assessments, reduced mental health problems, and lower crime rates in society . Outcomes can often be difficult to attribute directly to outputs . The project will not study the results quantitatively, but various aspects relating to both outputs and outcomes will be addressed in the interview and survey questionnaire studies because they likely influence the development and implementation of policies and use of various measures.
The policy cycle
The study of public policymaking has traditionally applied a policy cycle model that describes a number of activities of the policy process (Fig. 1): (1) agenda setting, i.e., identifying the objectives of a policy; (2) developing a policy to achieve those objectives; (3) selection of policy measures to realize the policy; (4) implementation of the policy and policy measures; and (5) evaluation of the policy and measures . Thus, a policy cycle divides the policy process into a series of stages, from a notional starting point at which policymakers begin to think about a policy problem to a notional end point at which policy measures have been implemented and policymakers consider how successful they have been. Although the use of the cycle model for policy studies has diminished, the activities are still relevant .
Fig. 1. The policy cycle.
In this project, the agenda setting (stage 1) is predetermined, i.e., the objectives related to preventing the spread of the Coronavirus by means of social distancing. The focus of the project is on the implementation of policies and policy measures (stage 4), but the success of this process is influenced by aspects related to the policy development (stage 2) and what policy measures have been selected (stage 3). The project applies a framework that recognizes the dynamic interdependency of these activities (see below). The project does not investigate whether or how the policies have been evaluated by the policymakers (stage 5), but the research itself may provide information of relevance for such an undertaking.
Policy implementation factors
Policy research has described numerous conditions for successfully implementing policies and policy measures. For example, the importance of clear and well communicated policy objectives has been emphasized [41, 47]. The policy must be a good solution to the problem , and the required resources must be committed to implement the policy . Further, policies need to be implemented by skillful implementers, e.g., public officials . Policy researchers have categorized various conditions into frameworks that describe different types of influences, i.e., change factors, on policy implementation results. Frameworks range from comprehensive checklists of large numbers of specific factors to frameworks describing a limited number of overarching factors of relevance for explaining policy implementation success (or failure) [41, 44].
To create a structure for addressing the three research questions, the project uses a theoretical framework informed by the policy literature (e.g., [33, 36, 38, 39, 49]) and implementation science [50, 51]. The framework consists of five interdependent domains that have an impact on policy implementation: (1) policymakers; (2) policy characteristics; (3) implementers; (4) targets; and (5) policy environment. The domains are illustrated in Fig. 2, with lines connecting all domains with each other to reflect the inherent interdependency.
Fig. 2. Influences on policy implementation.
The five domains account for aspects related to three stages of the policy cycle: the policy development (stage 2), selected policy measures (stage 3), and the implementation of these measures (stage 4). The domains are interdependent, underscoring the relevance of understanding policies in holistic terms because their success or failure depends on combinations of different factors .