Intentions and Behavioural Determinants in the Face of covid-19 Pandemic: A Theory of Planned Behaviour and Risk Perception model

The containment of covid-19 implied challenges for governments and health authorities to motivate citizens to adopt several prevention behaviours (i.e., wearing a face mask and washing hands frequently). This paper aims to identify the factors that encourage people to adopt these behaviours. Our analysis was conducted over data collected by ascofapsi and the Universidad Autonoma de Barcelona about attitudes and beliefs related to the pandemic from 919 people from Colombia. The data was collected using an online snowball sampling between May and June 2020. We found that each prevention behaviour is motivated by a different set of factors. Specifically, based on the theory of planned behaviour, our results suggest that the intention to adopt a preventive behaviour is pre-dicted by a group of variables about subjective norms and attitudes as independent variables and another one linked to perceived control as mediator variables. This suggests that the motivation for prevention behaviours from authorities should be particular to each behaviour and consider the associated particular pattern of motivations and the sociodemographic characteristics and possibilities of action.

Unintended consequences of communicating rapid COVID-19 vaccine policy changes- a qualitative study of health policy communication in Ontario, Canada.

BACKGROUND: The success of the COVID-19 vaccination roll-out depended on clear policy communication and guidance to promote and facilitate vaccine uptake. The rapidly evolving pandemic circumstances led to many vaccine policy amendments. The impact of changing policy on effective vaccine communication and its influence in terms of societal response to vaccine promotion are underexplored; this qualitative research addresses that gap within the extant literature. METHODS: Policy communicators and community leaders from urban and rural Ontario participated in semi-structured interviews (N = 29) to explore their experiences of COVID-19 vaccine policy communication. Thematic analysis was used to produce representative themes. RESULTS: Analysis showed rapidly changing policy was a barrier to smooth communication and COVID-19 vaccine roll-out. Continual amendments had unintended consequences, stimulating confusion, disrupting community outreach efforts and interrupting vaccine implementation. Policy changes were most disruptive to logistical planning and community engagement work, including community outreach, communicating eligibility criteria, and providing translated vaccine information to diverse communities. CONCLUSIONS: Vaccine policy changes that allow for prioritized access can have the unintended consequence of limiting communities' access to information that supports decision making. Rapidly evolving circumstances require a balance between adjusting policy and maintaining simple, consistent public health messages that can readily be translated into action. Information access is a factor in health inequality that needs addressing alongside access to vaccines.

When Right-Wing Populism Becomes Distorted Public Health Communication: Tracing the Roots of Jair Bolsonaro's Epidemiological Denialism

This article delineates key links between right-wing populism and epidemiological denialism. Building on a comparative analysis of central tropes from Brazilian president Jair Bolsonaro's 2018 campaign and his public-facing response to the COVID-19 pandemic, we argue that his engagement during both periods employs two key elements of right-wing populism: Antielitism, or the view that the political establishment is irredeemably disconnected from the citizenry, and anti-pluralism, or the blaming of political and social problems on scapegoat populations. During the COVID-19 outbreak, this denigration of public trust fuels denialism or the systemic attempt to downplay severity to minimize public response. Developing a thematic analysis around Bolsonaro's speeches, interviews, and personal social media, we address how anti-elitist and anti-pluralist strategies from the 2018 campaign inform the pandemic response. These include the discrediting of governmental bodies, the villainization of progressive activists, and the assignation of blame on foreign actors. Our goal is to provide an in-depth case study of how communication bolstering epidemiological denialism is propagated-an increasingly vital conversation as right-wing populism and health misinformation proliferate.

Reporting on the shadow pandemic in Nigeria: An analysis of five media organizations' coverage of gender-based violence during the COVID-19 pandemic

This study fills a gap in research by examining how the COVID-19 pandemic laid bare structural and systemic gender inequities in Nigeria. In particular, women and girls are at increased risk of gender-based violence (GBV). We analysed a corpus of 361 articles on GBV published between 1 January 2019 and 31 December 2020 by Daily Trust, The Guardian, Leadership, The Punch and Vanguard, to determine how effectively Nigerian media reported on GBV during the pandemic. Analysis centred on five phases of reporting during those 24 months: (1) pre-lock-down;(2) early lockdown period, 29 March–26 May;(3) response to a rise in GBV, 26 May–30 July;(4) easing of lockdown and (5) sixteen days of activism against GBV, 25 November–10 December 2020. Key themes emerging in the media coverage include the shadow pandemic of GBV in Nigeria, response to the rise in GBV, NGOs combating GBV and calls for improved legislation. © 2023 Intellect Ltd.

An NLP analysis of health advice giving in the medical research literature

Health advice - clinical and policy recommendations - plays a vital role in guiding medical practices and public health policies. Whether or not authors should give health advice in medical research publications is a controversial issue. The proponents of "actionable research" advocate for the more efficient and effective transmission of science evidence into practice. The opponents are concerned about the quality of health advice in individual research papers, especially that in observational studies. Arguments both for and against giving advice in individual studies indicate a strong need for identifying and accessing health advice, for either practical use or quality evaluation purposes. However, current information services do not support the direct retrieval of health advice. Compared to other natural language processing (NLP) applications, health advice has not been computationally modeled as a language construct either. A new information service for directly accessing health advice should be able to reduce information barriers and to provide external assessment in science communication.This dissertation work built an annotated corpus of scientific claims that distinguishes health advice according to its occurrence and strength. The study developed NLP-based prediction models to identify health advice in the PubMed literature. Using the annotated corpus and prediction models, the study answered research questions regarding the practice of advice giving in medical research literature. To test and demonstrate the potential use of the prediction model, it was used to retrieve health advice regarding the use of hydroxychloroquine (HCQ) as a treatment for COVID-19 from LitCovid, a large COVID-19 research literature database curated by the National Institutes of Health. An evaluation of sentences extracted from both s and discussions showed that BERT-based pre-trained language models performed well at detecting health advice. The health advice prediction model may be combined with existing health information service systems to provide more convenient navigation of a large volume of health literature. Findings from the study also show researchers are careful not to give advice solely in s. They also tend to give weaker and non-specific advice in s than in discussions. In addition, the study found that health advice has appeared consistently in the s of observational studies over the past 25 years. In the sample, 41.2% of the studies offered health advice in their conclusions, which is lower than earlier estimations based on analyses of much smaller samples processed manually. In the s of observational studies, journals with a lower impact are more likely to give health advice than those with a higher impact, suggesting the significance of the role of journals as gatekeepers of science communication.For the communities of natural language processing, information science, and public health, this work advances knowledge of the automated recognition of health advice in scientific literature. The corpus and code developed for the study have been made publicly available to facilitate future efforts in health advice retrieval and analysis. Furthermore, this study discusses the ways in which researchers give health advice in medical research articles, knowledge of which could be an essential step towards curbing potential exaggeration in the current global science communication. It also contributes to ongoing discussions of the integrity of scientific output.This study calls for caution in advice-giving in medical research literature, especially in s alone. It also calls for open access to medical research publications, so that health researchers and practitioners can fully review the advice in scientific outputs and its implications. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

It's like being hit by a tsunami: The use of the NATURAL FORCE metaphor for conceptualising the COVID-19 pandemic in English and Serbian

Many different metaphors have been used so far in public health communication to capture different aspects of the COVID-19 pandemic since they serve as an apt instrument in crisis discourse of conveying important messages to various audiences in a simple and easily understandable manner. Within the theoretical framework of Critical Metaphor Analysis (Charteris-Black, 2004, 2005, 2019;Musolff, 2004, 2006, 2016) and drawing on the data gathered during the period 2020-2021 from various British/American and Serbian online news media (The Financial Times, The Guardian, CNN, The Economist, Blic, NovaS, Novosti), we explore the strategic and arguably deliberate use of the NATURAL FORCE metaphor as an effective instrument in public health communication discourse concerning the COVID-19 pandemic. Our main aim is to demonstrate the universal power of this metaphor in channeling the general public's perceptions and behaviour into a desired direction in crisis communication, independent of the language or culture in which the crisis discourse is produced. This power is attested in this metaphor's strong emotional and evaluative contents – it serves both to communicate a sense of danger, uncertainty and threat coming from the virus, as well as to legitimise the wanted course of action and conceal the responsibility of government officials and health experts by shifting all the blame for possible inefficiencies of anti-epidemic measures solely on the allegedly uncontrollable nature of the COVID-19 pandemic. © 2022 FOKUS â€" Forum za interkulturnu komunikaciju. All rights reserved.

Education and COVID-19 excess mortality.

We study the role of education during the COVID-19 epidemic in Italy. We compare excess mortality in 2020 and 2021 compared to the pre-pandemic mortality between municipalities with different shares of educated residents. We find that education initially played a strong protective role, which however quickly faded out. After pondering several alternative explanations, we tentatively interpret this finding as the outcome of the interplay between education, information and public health communication, whose availability and coherence varied along the epidemic.

The Roles of Information Valence, Media Literacy and Perceived Information Quality on the Association Between Frequent Social Media Exposure and COVID-19 Vaccination Intention.

PURPOSE: This study aimed to examine the associations between frequent exposure to positive/negative information about vaccine efficacy/safety on social media and intention of COVID-19 vaccination, and to test if media literacy and perceived information quality would moderate such associations. DESIGN: A multi-city cross-sectional survey. SETTING: At five universities in different regions of China. SUBJECTS: 6922 university students (a response rate of 72.3%). MEASURES: frequency of exposure to social media information about COVID-19 vaccination, media literacy, perceived information quality, intention of COVID-19 vaccination, and sociodemographic characteristics. ANALYSIS: Logistic regression analysis was conducted to test main and interaction effects. RESULTS: Higher exposure to positive information about vaccine efficacy (adjusted odds ratio [AOR] = 1.30, P < .001) and vaccine safety (AOR = 1.27, P < .001) were positively associated with vaccination intention. No significant associations were shown between exposure to negative information about vaccine efficacy/safety and vaccination intention. Higher net exposure to negative vs positive information was negatively associated with vaccination intention (AOR = .82, P < .001). High media literacy was further found to attenuate the effect of negative information exposure and strengthen that of positive information exposure. Perceived information quality was not a significant moderator. CONCLUSION: The valence of social media information regarding the efficacy and safety of COVID-19 vaccines and individuals' media literacy jointly shaped COVID-19 vaccination intention. The findings can inform the development of effective health promotion strategies for enhancing COVID-19 vaccination.

Media Reports on COVID-19 Vaccinations: A Study of Topic Modeling in South Korea.

Early successes in controlling the COVID-19 pandemic have prevented Republic of Korea from implementing a prompt, large-scale vaccine rollout to the public. The influence of traditional media on public opinion remains critical and substantial in Republic of Korea, and there have been heated debates about vaccination in traditional media reports in Korea. Effective and efficient public health communication is integral in managing public health challenges. This study explored media reports on the COVID-19 vaccines during the pandemic in Republic of Korea. 12,399 media news reports from May 2020 to September 2021 were collected. An LDA topic model was applied in order to analyze and compare the topics drawn from each study phase using words from the unstructured text data. Although media reports from before the national vaccination implementation focused on the development and rollout of COVID-19 vaccines, diverse topics were reported without any overlap. After the vaccination rollout, the biggest concern was the side effects of the COVID-19 vaccine. In sum, Republic of Korea's major media outlets reported on diverse topics rather than generating a common discourse about topics related to COVID-19 vaccination.

When good messages go wrong: Perspectives on COVID-19 vaccines and vaccine communication from generally vaccine accepting individuals in Canada.

Vaccines are one of the most important and successful public health interventions to reduce the spread of infectious diseases. However, unlike childhood diseases and routine vaccines, COVID-19 is a novel threat, and COVID-19 vaccines may elicit specific anxieties. Through focus groups, we examine the concerns and attitudes toward the COVID-19 vaccine expressed by individuals who accept routine vaccinations in Canada. We also conducted a pre-focus group survey to document participant attitudes towards vaccines in general. While most participants had received at least one dose of the COVID-19 vaccine or had the intention to get it, many had concerns. First, participants felt anxious about the quick development and approval of the vaccines, even if they recognized that the vaccines have undergone clinical trials. Second, participants felt confused about shifting public health guidelines regarding vaccine safety, changing the interval between doses, and mixing different vaccine brands. Finally, participants said they felt abandoned when deciding whether to get vaccinated or not. People who generally accept vaccines expressed concerns about COVID-19 vaccines, mostly related to the inevitable uncertainties of a new vaccine (i.e. novelty, safety, mandates, etc.). COVID-19 vaccine hesitancy, understood as concerns about the novelty of a vaccine and the rapid implementation of it, could be useful for understanding questioning attitudes towards COVID-19 vaccines from people who accept routine vaccinations. Understanding COVID-19 vaccine hesitancy can also provide valuable insights as booster doses are periodically needed and people may not be as accepting of these additional doses.

Covid-19 Sürecinde Íletişimin Kriz, Sağlık ve Siyaset Perspektiflerinden Değerlendirilmesi

Bu çalışmada Covid-19 açıkça bir kriz olarak betimlenmekte ve medya, siyasi tutum ve sağlık iletişimi bu krizin kaynakları olarak görülmektedir. Koronavirüs hastalığının diğer yaygın bilinen adıyla Covid-19’un hayatımıza girdiği günden beri televizyonlarda açıklanan vaka sayıları ve ölüm oranları, halkta yaratılan korku, panik ve endişe durumu, tıp doktorları ve konunun uzmanlarının günden güne değişen açıklamaları, yaşanan durumu krize çevirmiş ve iletişimde açıklık ve şeffaflık sağlanamamıştır. Sosyal medyada yaşanan bilgi kirliliği ile yanlış bilgi üretimi, virüsün yayılma hızından bile fazla olmuş, insanlar doğru kaynaklardan doğru bilgiye erişmede zorluklar yaşamıştır. Yaşanan halk sağlığı krizinin siyasi kişilikler tarafından politize edilmesi, virüsün yayılmasına yönelik alınan tedbirlere uyulmasını zorlaştırmıştır. Dünya üzerindeki bütün ülkelerin insan hayatını kurtarmakla ekonomiyi kurtarmak arasında bir seçim yapmak zorunda kalması, hastalık tehdidinin algılanan ciddiyetini doğrudan etkilemiştir. Bu çalışma sonucunda iletişimin merkeziyetine vurgu yapılmakta olup, dünyada yaşanan bu salgının etkin, önceden planlanan iletişim stratejileriyle yürütülmesi, bilim ile halk arasında yalın, anlaşılır ve amaca dönük iletişimin kurulması gerektiğinin altı çizilmektedir.Alternate : In this study, Covid-19 is clearly described as a crisis and media, political attitudes and health communication are seen as sources of this crisis. Since the day the coronavirus disease entered our lives, the number of cases and death rates announced on television, the fear, panic and anxiety created in the public, the daily changing statements of medical doctors and experts in the field have turned the situation into a crisis and clarity and transparency in communication has not been achieved. With the information pollution in social media, the production of false information has been even more than the spread of the virus, and people have had difficulties in accessing the right information from the right sources. The politicization of the public health crisis by political figures has made it difficult to comply with the measures taken for the spread of the virus. The fact that countries around the world have to choose between saving human lives or saving the economy has directly affected the perceived severity of the disease threat. As a result of this study, the centrality of communication is emphasized and it is underlined that this epidemic in the world should be carried out with effective and pre-planned communication strategies, and simple, understandable and purpose-oriented communication should be established between science and the public.

Use of Twitter Amplifiers by Medical Professionals to Combat Misinformation During the COVID-19 Pandemic.

Social media is an important tool for disseminating accurate medical information and combating misinformation (ie, the spreading of false or inaccurate information) and disinformation (ie, spreading misinformation with the intent to deceive). The prolific rise of inaccurate information during a global pandemic is a pressing public health concern. In response to this phenomenon, health professional amplifiers such as IMPACT (Illinois Medical Professional Action Collaborative Team) have been created as a coordinated response to enhance public communication and advocacy around the COVID-19 pandemic.

The COVID-19 Vaccination and Vaccine Inequity Worldwide: An Empirical Study Based on Global Data.

Vaccination is critical for controlling the COVID-19 pandemic. However, the progress of COVID-19 vaccination varies from different countries, and global vaccine inequity has been a worldwide public health issue. This study collected data from the Our World in Data COVID-19 vaccination data set between 13 December 2020 and 1 January 2022. The measurement reflecting the pandemic situation included New cases, New deaths, Hospital patients, ICU patients, and the Reproduction rate. Indicators for measuring the vaccination coverage included Total vaccinations per hundred and People vaccinated per hundred. The Human Development Index (HDI) measured the country's development level. Findings indicated that countries with higher HDI have more adequate vaccine resources, and global vaccine inequity exists. The study also found that vaccination significantly mitigates the pandemic, and reaching 70% immunization coverage can further control the epidemic. In addition, the emergence of Omicron variants makes the COVID-19 epidemic situation even worse, suggesting the importance and necessity of addressing vaccine inequity. The globe will face a greater challenge in controlling the pandemic if lower-vaccinated countries do not increase their vaccination coverage. Addressing the issue of vaccine inequity needs the cooperation of HIC, LMIC, public health departments, and vaccine producers. Moreover, the media has to contribute to effective public health communication by raising public perceptions of the COVID-19 pandemic, vaccination, and vaccine inequity.

Social Versus Physical Distancing: Analysis of Public Health Messages at the Start of COVID-19 Outbreak in Malaysia Using Natural Language Processing

The study presents an attempt to analyse how social media netizens in Malaysia responded to the calls for “Social Distancing” and “Physical Distancing” as the newly recommended social norm was introduced to the world as a response to the COVID-19 global pandemic. The pandemic drove a sharp increase in social media platforms’ use as a public health communication platform since the first wave of the COVID-19 outbreak in Malaysia in April 2020. We analysed thousands of tweets posted by Malaysians daily between January 2020 and August 2021 to determine public perceptions and interactions patterns. The analysis focused on positive and negative reactions and the interchanges of uses of the recommended terminologies “social distancing” and “physical distancing”. Using linguistic analysis and natural language processing, findings dominantly indicate influences from the multilingual and multicultural values held by Malaysian netizens, as they embrace the concept of distancing as a measure of global public health safety. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

Public Reaction towards the Potential Side Effects of a COVID-19 Vaccine: An Italian Cross-Sectional Study.

In March 2021, the possible link between the Oxford-AstraZeneca vaccine and some cases of blood clots lead several governments to suspend the administration of said vaccine, or to adjust their administration strategies, regardless of the fact that both EMA and WHO claimed the benefits of the vaccine to far outweigh its risks. The lack of a coordinated decision-making process between different health authorities possibly had an impact on people's trust in the health authorities themselves, and on their willingness to vaccinate against COVID-19. In this study, we assessed the impact of the Astrazeneca case on a sample of 1000 Italian participants. The results demonstrate that a large part of the population is willing to delay the vaccination to be granted a vaccine perceived as "better". We also assessed the importance of several socio-demographic and psychological factors in predicting hesitancy and discuss the implications for public communication strategies.

Prebunking messaging to inoculate against COVID-19 vaccine misinformation: an effective strategy for public health

Background Objective Method Results Conclusion Vaccination coverage needs to reach more than 80% to resolve the COVID-19 pandemic, but vaccine hesitancy, fuelled by misinformation, may jeopardize this goal. Unvaccinated older adults are not only at risk of COVID-19 complications but may also be misled by false information. Prebunking, based on inoculation theory, involves ‘forewarning people [of] and refuting information that challenges their existing belief or behavior’.To assess the effectiveness of inoculation communication strategies in countering disinformation about COVID-19 vaccines among Canadians aged 50 years and older, as measured by their COVID-19 vaccine intentions.Applying an online experiment with a mixed pre–post design and a sample size of 2500 participants, we conducted a national randomized survey among English and French-speaking Canadians aged 50 years and older in March 2021. Responses to two different disinformation messages were evaluated. Our primary outcome was the intention to receive a COVID-19 vaccine, with attitudes toward COVID-19 vaccine a secondary outcome. The McNemar test and multivariate logistic regression analysis on paired data were conducted when the outcome was dichotomized. Wilcoxon sign rank test and Kruskal–Wallis were used to test difference scores between pre- and post-tests by condition.Group comparisons between those who received only disinformation and those who received the inoculation message show that prebunking messages may safeguard intention to get vaccinated and have a protective effect against disinformation.Prebunking messages should be considered as one strategy for public health communication to combat misinformation. [ FROM AUTHOR] Copyright of Journal of Communication in Healthcare is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Attitudes toward vaccines during the COVID-19 pandemic: results from HBCU students.

PURPOSE: To investigate the prevalence of vaccine hesitancy among black college students and to explain students' reasoning behind their vaccine hesitancy. DESIGN: online survey completed in spring and summer of 2021. Students were recruited via email. SETTING: HBCU campus, North Carolina, USA. SUBJECTS: 397 currently enrolled students. MEASURES: An original survey instrument was developed which included questions on vaccination status and plans to get vaccinated, perceived threat from the coronavirus (adopted from PEW research) exercise behaviors and demographics. Respondents were also given the chance to respond to an open-ended question about their feelings about the vaccine. ANALYSIS: Binary Logistic Regression predicting likelihood that respondent is vaccine hesitant. RESULTS: Confidence in the safety of the vaccine was the strongest predictor of vaccine hesitancy. At the time of the survey only 25% of students had received at least one dose of the vaccine. 37% of the students did not plan on ever getting vaccinated. Other considerations (living with a vulnerable person or concerns about their own vulnerability to COVID) were not associated with getting vaccinated. Students were particularly concerned about side effects from the vaccine. CONCLUSION: Racial disparities in COVID-19 infections, deaths, and vaccinations serve as a stark reminder of the urgent need to better understand the factors that could lead to mitigation of the virus. Fear about the safety of the vaccine among minority populations in particular must be unpacked in order to address valid concerns and overcome hesitancy. This study provides key insights into the contours of those fears.

Avoiding Crowded Places During COVID-19: Common Sense or a Complex Strategic Decision?

Introduction: Following a period of strict lockdowns during the COVID-19 pandemic, most countries introduced policies in which citizens were expected to avoid crowded places using common sense, as advised by the WHO. We argue that the ambiguity in the recommendation to "avoid crowded places" implicitly forces individuals to make a complex strategic decision. Methods: Using a Dutch representative sample of 1,048 participants [42% male, mean age=43.78years (SD=12.53), we examine the effect of context on the decision to visit a hypothetical recreational hotspot under the policy recommendation to "avoid crowded places." We randomize four levels of context on the crowdedness "on the streets" (no context, low, medium, and high context). Subsequently, participants are asked to estimate the percentage of others going out in the same situation. Finally, we assess the impact of a selection of personal characteristics on the likelihood of visiting a crowded place. Results: Respondents are proportionally more likely to go in a low context and high context, compared to no context (diff=0.121, p<0.000, and diff=0.034, p<0.05, respectively) and middle context (diff=0.125, p<0.000, and diff=0.037, p<0.05, respectively). Low context information also decreases the expectation of others going out (-2.63%, z=4.68, p<0.000). High context information increases the expected percentage of others going out (significant only for medium to high context; 2.94%, z=7.34, p<0.001). Furthermore, we show that education, age, and health and risk attitude are all predictive of the likelihood to visit a crowded place, notwithstanding the context. Discussion: Although there is a strong inclination to avoid crowded places during the COVID-19 pandemic (81%), we find two context-driven exceptions: when people expect to avoid crowded spots (in the "low" context, i.e., strategical decision-making) and when people expect others to go (social influence). The freedom provided by ambiguous public policy is implicitly asking more from the population than it initially seems. "Use your common sense" is often the accompanied advice, but our results show that more and better information concerning the context is essential to enable us to make an optimal decision for ourselves, and for society.

Anticipation of COVID-19 vaccines reduces willingness to socially distance.

We investigate how the anticipation of COVID-19 vaccines affects voluntary social distancing. In a large-scale preregistered survey experiment with a representative sample, we study whether providing information about the safety, effectiveness, and availability of COVID-19 vaccines affects the willingness to comply with public health guidelines. We find that vaccine information reduces peoples' voluntary social distancing, adherence to hygiene guidelines, and their willingness to stay at home. Getting positive information on COVID-19 vaccines induces people to believe in a swifter return to normal life. The results indicate an important behavioral drawback of successful vaccine development: An increased focus on vaccines can lower compliance with public health guidelines and accelerate the spread of infectious disease. The results imply that, as vaccinations roll out and the end of a pandemic feels closer, policies aimed at increasing social distancing will be less effective, and stricter policies might be required.