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Introduction
COVID-19 struck various countries around the world in December 20191. The U.S. began to see its first cases of the virus in January 20202. Despite being 50 united entities, different states adopted very disparate approaches to managing the spread of the infectious disease. In an effort to more fully understand and identify systematic patterns in state-level responses, this study explored the influence of a regional variable known as the Culture of Honor3. The way that elected officials decide to frame public health messaging as well as the way citizens both interpret and respond to such recommendations could differ widely based on social norms including Culture of Honor status. This study was designed to determine whether Culture of Honor status could reliably explain the observed differences among states in their management of messaging surrounding the COVID-19 global pandemic.

What is Culture of Honor?
Culture of Honor is a term used to describe a society that is marked by specific characteristics that lead to a strong emphasis on a person’s reputation4-5. Cultures of Honor tend to arise in relatively resource-scarce, lawless locales where citizens are often relegated to defending their livelihood through the reputation of being tough, fiercely independent, and willing to use aggression if necessary. Indeed, early examples of such cultures sprang up in the lowlands of Scotland where harsh terrain prevented much else than herding as a means to provide and obtain resources3. These territories were often under siege from both the northern and southern angles. Herdsmen quickly learned the importance of establishing and protecting a reputation as someone others did not want to cross. Otherwise, there would be violent consequences. Eventually, these individuals were displaced by natural circumstances of drought and famine. The ideals they had developed that served them in the harsh climates they originally faced stayed with them as they populated various parts of the world. Today, countries around the world can be identified as espousing the values and belief systems of honor to varying degrees6-7. Latin America and Middle Eastern nations represent some of the modern examples of strong honor influence8-9. The United States of America as a whole can be identified as a Culture of Honor, but it is often divided by state status10. In general, states classified as in the US South and West are labeled as Culture of Honor states, whereas those in the North are classified as “Non-Culture of Honor” states11. There are, however, several exceptions, as shown in Figure 1.

Researchers have identified links between Culture of Honor and various forms of violence including homicide7,9, rape12, domestic terrorism13, domestic violence12,14, and suicide15. Importantly, results patterns consistently indicate that those endorsing honor norms do not condone violence for its own sake16,17, but to serve an instrumental purpose such as restoring one’s thwarted reputation (whether a real or perceived affront has occurred)18. Drawing upon these previous findings, this study sought to identify whether responses to a public health crisis as occurred during the COVID-19 pandemic might also be driven by honor norms.

Lawlessness is one key component of a Culture of Honor. This can take a variety of forms including complete lack of laws, inconsistency or refusal to enforce laws, lack of repercussions or failure to carry out stated punitive measures, or lack of trust in those charged with enforcing laws. Previous explorations of the written laws protecting victims of violent crimes such as rape and sexual assault at the state level have indicated no meaningful differences regardless of honor status. However, there have been important differences noted in the rates of violent crimes occurring in honor states and non-honor states12. These findings suggest that even when harsh laws and punishments exist for offenders of violent crimes, they are not serving as an effective deterrent to minimizing those acts of violence.

The Current Study
As the COVID-19 pandemic swept across the US in 2020, news stories highlighted the drastic differences among states in terms of overall impact. In light of the previous work emphasizing the role Culture of Honor status plays in responses to perceived threat, this project was designed to explore the role Culture of Honor has in explaining some of these observed differences. One variable of interest was sparked by headlines indicating that citizens were blatantly (and sometimes aggressively) ignoring signage limiting access to public locations. Several coastal states consistently offered scenes of people crossing barriers intended to close beaches, businesses, and other high-traffic facilities.

Differences in COVID-19’s impact abounded at the state level. Some states adopted a rigid approach with messaging including terms such as “lockdown” and “quarantine19.” Some states imposed curfews of exact times at night citizens needed to be back to their private homes20. Other states chose a proactive approach in an effort to mitigate the spread of the virus before it got to their state. Mandates varied by state and around the world21. Some citizens were encouraged to wear an N-95 mask to protect themselves or others; some people began making or purchasing cloth masks as another accessory to their clothing; disposable masks were urged in some business establishments or required in others. It was both the choice of wording by public health officials as well as how citizens responded to the messaging that sparked interest for this study. It was also important to evaluate the real impact in terms of number of cases and deaths for each state.

Using publicly available data found on websites hosted by each US state, this archival study predicted that there would be meaningful differences observed of the overall COVID-19 pandemic impact on US states based on their Culture of Honor status. Specifically, US states in the South and West including Texas, Florida, Alabama, and Virginia were expected to demonstrate 1) higher overall numbers of COVID-19 cases and deaths, 2) strict messaging aimed at curbing the spread of the virus, and 3) higher levels of outright disregard for laws or restrictions imposed by public officials than non-Culture of Honor states in US North such as Indiana, Ohio, Connecticut, and Iowa.

Methods
This project was initially designed as an archival study utilizing publicly-available information on state websites. However, while gathering these state-level data, another researcher who had received IRB approval for individual-level data collection as part of a different study generously provided access to the variables in that study related to the hypotheses of this project. Thus, this project includes data analyzed at the state-level with an n of 50 as well as 978 individuals across the US who participated in the other online study gathered through MTurk22.

For each of the US states, the following information was gathered by accessing their unique COVID-19 website: official action taken by elected officials (such as the governor), framing of the messaging communicated to residents (such as “Shelter in Place,” “Healthy at Home,” “Strict Lockdown”), total number of positive cases, total deaths, and adherence to orders (general patterns of citizens following recommendations to limit public exposure and any examples of violations of orders). In addition, from the larger individual-level dataset, there were 3 variables of interest: support for government (state-level) to take action to mitigate the spread of COVID-19, level of reported anger experienced due to government mitigation efforts, and level of trust in information shared by the government (state-level) related to the pandemic.

The archival data were entered into SPSS by state and coded for Culture of Honor status. For the other 3 variables, participants responded to questions via Qualtrics with higher values indicating more support for government action, more anger over government action, and more distrust in information shared by the government respectively. Participants indicated their level of agreement on a variety of scales of government including federal, state, and city as part of this larger study22. However, for the current study, results are reported using only participants’ state-level responses.

Results
First, using state-level data available at this publicly available website23 as of 6-7-2023, total cases of COVID-19 were calculated for the 27 Culture of Honor states and the 23 Non-Culture of Honor states. The total number of cases in the US was 121,563,790. 82,871,869 of these cases (or 68.2%) were in honor states while the remaining 38,691,921 (or 31.8%) came from non-honor states. Next, death tolls were also calculated for all honor states and non-honor states. To date, 1,100,379 people in the US have died from COVID-19. 657,730 (59.8%) of these deaths have come from honor states while the remaining 442,649 (40.2%) have come from non-honor states. These results are in line with predictions that Culture of Honor states would see higher total cases of COVID-19 and related deaths than non-honor states.

In order to assess the hypothesis that government officials would be strict in their public health messaging, frequencies were analyzed for the framing variable. There were 16 Culture of Honor and 14 Non-Culture of Honor states whose official messaging included “lockdown” and “shelter in place.” The remaining 20 states (11 Culture of Honor and 9 non-culture of honor) emphasized wording such as “healthy at home” and “safer at home.” Overall, this analysis indicates that more states adopted strict messaging than more positive framing when attempting to manage the pandemic.

Next, an independent samples t-test was conducted assessing the difference in level of support for government action mitigating the spread of COVID-19 by Culture of Honor status. There were 399 individuals who completed this study living in Non-Culture of Honor states and 579 living in Culture of Honor states. This analysis revealed that those individuals living in Non-Culture of Honor states reported significantly stronger support for government action (M = 5.88, SD = 1.26) than those living in Culture of Honor states (M = 5.65, SD = 1.36), t(976) = 2.72, p = 0.007. This result fits the hypothesis that citizens living in Culture of Honor states would demonstrate outright disregard for any action taken by their government to stop the spread of the virus.

Additionally, an analysis probing for regional differences in feelings toward government action to stop the spread of COVID-19 was conducted. An independent samples t-test revealed no significant difference in level of anger among those living in honor states (M = 2.64, SD = 1.70) compared to those living in non-honor states (M = 2.48, SD = 1.62), t(976) = -1.46, p = 0.14. Though there was no specific hypothesis regarding this analysis, it does not fit the general pattern of other observed findings.

Finally, the variable of distrust in information shared by the government about the pandemic was explored. An independent samples t-test revealed that those living in honor states reported significantly greater distrust in information provided by their government (M = 3.26, SD = 1.52) than those living in non-honor states (M = 2.91, SD = 1.45), t(976) = -3.55, p <.001. This finding is also in line with the general expectation that those in honor states would perceive mitigation efforts negatively, though there was no specific hypothesis regarding trust overall.

For the state-level analysis of whether citizens living in Culture of Honor states showed more disregard for mitigation measures imposed by their government officials, the adherence variable was assessed. The majority of the non-Culture of Honor states (20 out of 23) demonstrated strong levels of adherence. In contrast, only 2 out of the 27 Culture of Honor states demonstrated strong levels of adherence. This analysis is in line with predictions that citizens in Culture of Honor states would show blatant disregard for restrictions imposed by their state officials.

Discussion
Taken together, the findings of this study indicate a marked difference in the experience of the global COVID-19 pandemic for citizens living within Culture of Honor states compared to those living outside those bounds. This project is the first known attempt to locate the influence of honor norms on public health management. What began as an archival study morphed into a broader project incorporating individual-level perceptions to offer a more robust glimpse into the role Culture of Honor played in state-level responses to the COVID-19 pandemic. The pattern of findings reveals that, in line with expectations, states governed by honor norms did experience a stronger impact of the public health crisis than did those outside honor bounds. This occurred as elected officials attempted to exert their power in stopping the spread of the deadly virus. Indeed, results from this study suggest that those living in Culture of Honor states experienced more (not less) effort from government officials to protect their citizens. However, those attempts were thwarted. Ultimately, those in honor states felt a deeper impact as they experienced significantly more overall cases of COVID-19 in their states as well as a higher death toll.

At the outset of this project, there were 3 stated hypotheses about the anticipated impact of state Culture of Honor status on management of the COVID-19 pandemic. These revolved around both government handling of the public health messaging as well as how citizens responded to official restrictions. The study combined archival data with individual-level analysis in order to triangulate effects. States were assessed on several variables including total COVID-19 cases, total deaths, framing, and adherence, while individuals living within those states provided more nuanced information about their perceptions of state-level management of the outbreak of the virus.

This project reveals a previously unexplored link between Culture of Honor and public health management. Specifically, results indicate that citizens living in states ruled by honor norms were more heavily impacted in terms of total number of COVID-19 cases and associated deaths by the global pandemic than their counterparts living outside of honor states. Despite this overall impact, however, governors and other state-level officials within honor states did attempt to mitigate the spread of the virus. These efforts are demonstrated by the way such messaging appeared with citizens urged to shelter in place or lockdown. Though not explored in this study, it is possible that these phrases played upon the fear of citizens rather than their perhaps intended outcome to provide safety to everyone. In attempting to keep their constituents safe, officials in honor-driven states seem to instead have sparked distrust of the information shared about the pandemic. More honor states demonstrated blatant disregard for mitigation efforts including people showing up at public locations (such as beaches or bars) that were closed. Protests were also frequent across honor states as another indication of the publics lack of adherence to the measures put in place for their protection.

Of note, the analysis probing the emotional reactions among those living in honor states compared to those in non-honor states did not reveal a significant difference. When assessing the group means for this test, it is apparent that individuals across the US, regardless of Culture of Honor state status, generally did not report feelings of anger over government action to mitigate the growing public health crisis. This null result is curious given prior work that has shown honor-oriented men to become momentarily distressed over a perceived insult that their non-honor-oriented male counterparts did not display24. It does, however, align with other previous honor research that has explored the thin veneer known as the “paradox of politeness” that demonstrates that Southerners are polite to one another until an imaginary boundary is crossed25. Once that has been breached, violence can ensue leading to outcomes that were far from initially planned (such as bar fights that suddenly become homicides). The people who participated in this study did so early in the process of global shutdowns and often chaotic regulations. It is entirely possible that everyone, Culture of Honor status notwithstanding, was more understanding that the government was trying to keep them safe. This could have been seen as less insulting to their honor or violating their rights than it was perceived later as the pandemic raged on for years. It would be interesting to have more recent data to analyze to determine whether the null finding has remained constant across the years of the pandemic or whether there has been a shift in feelings that would capture the anticipated difference by honor status. Unfortunately, the design of the current project precludes this analysis, but future work could build upon this initial project to provide a more complete perspective.

Importantly, this study categorized states dichotomously as either “Culture of Honor” or “Non- Culture of Honor.” Although this is in line with previous practice for state-level analyses10,11, doing so leaves open the question of how strongly individuals within a given state subscribe to honor norms. The individual-level data were also analyzed based on geographic location when assessing Culture of Honor status. While it is possible that individuals living within honor states do not personally strongly abide by those values, it is reasonable to expect that they have been exposed to them by virtue of living in the state. Similarly, it is also possible that someone living in a non-honor state could nonetheless live by honor values. If anything, these unknown personal values add more error to the statistical analyses making it all the more striking that such regional differences were found in the current study.

Another limitation of the design of the current project is the inability to control phrasing and question items left to interpretation by participants when relying on data collected by others. Nevertheless, the coding scheme adopted for the framing and adherence variables in the study as well as the widely-accepted categorization at the state level for honor status minimize the need to have such control. In addition, the nature of an archival study is such that data remain consistent based on the entities and organizations that report them, so any inaccuracies in statistics would also remain in place for future studies. One strength of the way analyses were conducted in this study is that data on total cases and COVID-19 related deaths were gathered more than 3 years after the onset of the global pandemic, so any states that might have initially struggled to accurately track cases likely have implemented more reliable strategies by the time of this writing.

Public health officials should pay heed to the implications of the findings of this project. Knowing their state-level Culture of Honor status could benefit them when determining effective mitigation strategies in the midst of a public health crisis such as the COVID-19 pandemic. Given the general lack of confidence in law enforcement combined with individual results in this study that indicate an overall sense of distrust in information shared by the government among those in honor states, officials might benefit from straightforward approaches to information dissemination. Indeed, one consistent theme that emerged as the pandemic raged on was that the message was inconsistent and even the “experts” were uninformed about the true nature of the virus and its consequences. One effective approach might incorporate an admission that scientific evidence can shift views over time and is typically a lengthy process. When a new pathogen is identified as happened at the outset of the COVID-19 pandemic1, it can be the case that science is on display in real time in ways it typically is more shrouded in mystery until more confidence in findings can occur after many trials, approaches, and angles have been investigated.

Future studies should explore more fully the reasons why Culture of Honor status heavily influences government responses and citizens’ perceptions of those efforts to minimize the effects of a global pandemic. This study demonstrated that honor status matters but cannot tease apart the rationale. It is curious that among stricter regulations, citizens rebelled and thwarted those efforts, ultimately resulting in greater impact rather than smaller. Public officials would do well to probe individuals for why they might be less inclined to trust their authority, but doing so would likely require first fostering a relationship built on mutual respect. In honor cultures where confidence is notably low in any form of enforcement efforts, building such rapport could prove challenging. Perhaps most importantly, this study indicates that open communication between those in positions of authority and their constituents is paramount to effectively implement safety measures aimed at protecting citizens for them to recognize and adhere to those restrictions.

Conclusion
This study sought to determine whether mitigation measures and framing of public service messaging during the COVID-19 pandemic in the
U.S. could be reliably predicted by the regional differences in Culture of Honor status. At the outset of the pandemic, states adopted various practices, with some more lenient and others more rigid, in efforts to stop the spread of the novel pathogen. Archival data were assessed in this study, revealing that well over half of the total nationwide deaths to COVID-19 were in Culture of Honor states, despite other results that show rigid lockdowns in those same states. In other words, public health officials attempted more strongly to prevent their citizens from contracting the virus, but their efforts appear to have been in vain. Indeed, this study reveals that those efforts by public officials were thwarted by residents in addition to being perceived negatively. Combined, the results of this study suggest that health officials should bear in mind Culture of Honor status when determining the most effective course of action to keep their citizens safe during a public health crisis.

Conflicts of Interest Statement
The authors have no conflicts of interest to declare.

Acknowledgements
The author wishes to thank the undergraduate students who assisted with gathering archival data for this study: Karley Downham, Jordan Grant, Ian Keyes, Marilyn Quintero, and Quentin Vonesh. The author would also like to extend since gratitude to Luke Conway for access to his individual level dataset.

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