Understanding adherence to self-isolation in the first phase of COVID-19 response

ObjectiveTo gain a better understanding of decisions around adherence to self-isolation advice during the first phase of the COVID-19 response in England. DesignA mixed-methods cross sectional study. Setting: EnglandParticipants COVID-19 cases and contacts who were contacted by Public Health England (PHE) during the first phase of the response in England (January-March 2020). ResultsOf 250 respondents who were advised to self-isolate, 63% reported not leaving home at all during their isolation period, 20% reported leaving only for lower risk activities (dog walking or exercise) and 16% reported leaving for potentially higher risk, reasons (shopping, medical appointments, childcare, meeting family or friends). Factors associated with adherence to never going out included: the belief that following isolation advice would save lives, experiencing COVID-19 symptoms, being advised to stay in their room (rather than just "inside"), having help from outside and having regular contact by text message from PHE. Factors associated with non-adherence included being angry about the advice to isolate, being unable to get groceries delivered and concerns about losing touch with friends and family. Interviews highlighted that a sense of duty motivated people to adhere to isolation guidance and where people did leave their homes, these decisions were based on rational calculations of the risk of transmission - people would only leave their homes when they thought they were unlikely to come into contact with others. ConclusionsMeasures of adherence should be nuanced to allow for the adaptations people make to their behaviour during isolation. Understanding adherence to isolation and associated reasoning during the early stages of the pandemic is an essential part of pandemic preparedness for future emerging infectious diseases. Strengths and limitations of this studyO_LIOur participants were contacted directly by Public Health England during the first three months of the pandemic - the only cohort of cases and contacts who experienced self-isolation during this early phase of the pandemic. C_LIO_LIResults may not be directly generalisable to wider populations or later phases of pandemic response. C_LIO_LIWe classified reasons for leaving the home as higher or lower contact, as a proxy for potential risk of transmission, however further research published since we conducted our research as refined our understanding of transmission risk, highlighting the need for more in-depth research on adherence behaviour and transmission risk. C_LIO_LIThe mixed methods approach combined quantitative measures of adherence with an exploration of how and why these decisions were being made in the same people. C_LIO_LIOur study provides unique insights into self-isolation during the earliest stages of the pandemic, against a background of uncertainty and lack of information that will recur, inevitably, in the face of future pandemic and similar threats. C_LI

Exploring the impact of shielding advice on the health and wellbeing of individuals identified as extremely vulnerable and advised to shield in Southwest England amid the COVID-19 pandemic: A mixed-methods evaluation

ObjectiveExplore the impact and responses to public health advice on the health and wellbeing of individuals identified as clinically extremely vulnerable (CEV) and advised to shield (not leave home for 12 weeks at start of the pandemic) in Southwest England during the first COVID-19 lockdown. DesignMixed-methods study; structured survey and follow-up semi-structured interviews. SettingCommunities served by Bristol, North Somerset & South Gloucestershire Clinical Commissioning Group. Participants204 people (57% female, 54% >69 years, 94% White British, 64% retired) in Southwest England identified as CEV and were advised to shield completed the survey. Thirteen survey respondents participated in follow-up interviews (53% female, 40% >69years, 100% White British, 61% retired). ResultsReceipt of official communication from NHS England or General Practitioner (GP) was considered by participants as the legitimate start of shielding. 80% of survey responders felt they received all relevant advice needed to shield, yet interviewees criticised the timing of advice and often sought supplementary information. Shielding behaviours were nuanced, adapted to suit personal circumstances, and waned over time. Few interviewees received community support, although food boxes and informal social support were obtained by some. Worrying about COVID-19 was common for survey responders (90%). Since shielding had begun, physical and mental health reportedly worsened for 35% and 42% of survey responders respectively. 21% of survey responders scored [≥]10 on the PHQ-9 questionnaire indicating possible depression and 15% scored [≥]10 on the GAD-7 questionnaire indicating possible anxiety. ConclusionsThis research highlights the difficulties in providing generic messaging that is applicable and appropriate given the diversity of individuals identified as CEV and the importance of sharing tailored and timely advice to inform shielding decisions. Providing messages that reinforce self-determined action and assistance from support services could reduce the negative impact of shielding on mental health and feelings of social isolation. O_TEXTBOXStrengths and limitations of this study O_LIThe mixed-methods study examines the experiences of clinically extremely vulnerable (CEV) people at the height of the COVID-19 crisis, immediately after the first lockdown in England. C_LIO_LIThe use of an existing list of individuals identified as needing to "shield" from Bristol, North Somerset & South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) allowed for access to key patient groups at the height of the crisis. C_LIO_LIFindings may not be applicable to wider CEV populations due to demographic bias. C_LI C_TEXTBOX

Learning about COVID-19 across borders: Public health information and adherence among international travellers to the UK

ObjectivePublic health control measures at borders have long been central to national strategies for the prevention and containment of infectious diseases. Travel was inevitably associated with the rapid global transmission of COVID-19. In the UK, public health authorities took action to reduce risks of travel-associated spread by providing public health information at ports of entry. This study aims to understand individual risk assessment processes, decision making, and adherence to official advice among international travellers; to provide evidence to inform future policy on the presentation of public health information to facilitate safer international travel. Study designThis study is a qualitative study evaluation. MethodSemi-structured interviews were conducted to investigate risk assessment processes, decision making, and adherence to official Public Health England (PHE) advice among travellers. ResultsParticipants regarded official advice as adequate at the time, despite observing differences between the intervention measures implemented in the countries of departure. Participants however also described adopting precautionary measures including self-isolation and the use of face coverings that went beyond official advice, and variability in the extent to which they adhered to guidance on contacting health authorities. Adherence to official guidance was informed by the perceived salience of specific transmission possibilities and containment measures assessed in relation to participants social and institutional environments. ConclusionAnalysis of travellers reported motivations demonstrates that responses to public health advice constitute a proactive process of risk assessment and rationalised decision-making that incorporates consideration of living situation, trust in information sources, correspondence with cultural logics, and willingness to accept potential risk to self and significant others in guiding preventive action. Our findings concerning international passengers understanding of, and compliance with, official advice and mitigation measures provide valuable evidence to inform future policy and we provide recommendations on the presentation of public health information to facilitate safer international travel. Access to a central source of regularly updated official information would help minimise confusion between different national guidelines. Greater attention to the differentiated information needs of diverse groups in creating future public-facing guidance would help to minimise the uncertainties generated by receipt of generic information.

Experiences of supported isolation in returning travellers during the early COVID-19 response: an interview study

ObjectivesTo understand the experiences of those who underwent supported isolation as part of the response to the COVID-19 pandemic, after returning to the UK from Wuhan, China. DesignWe used semi-structured interviews to capture participants experiences and perceptions of supported isolation. SettingTelephone interviews carried out within approximately one month of an individual leaving supported isolation. Participants26 people who underwent supported isolation at either Arrowe Park Hospital (n = 18) or Kents Hill Park Conference Centre (n = 8) after being repatriated from Wuhan in January - February 2020. ResultsParticipants were willing to undergo supported isolation because they understood that it would protect themselves and others. Positive treatment by staff was fundamental to participants willingness to comply with isolation procedures. Despite the high level of compliance, participants expressed some uncertainty about what the process would involve. ConclusionsAs hotel quarantine is introduced across the UK for international arrivals, our findings suggest that those in charge should: communicate effectively before, during and after quarantine, emphasising why quarantine is important and how it will protect others; avoid enforcement and focus on supporting and promoting voluntary compliance; facilitate shared social experiences for those in quarantine; and ensure all necessary supplies are provided. Doing so will increase adherence and reduce any negative effects on wellbeing.

Understanding patterns of adherence to COVID-19 mitigation measures: A qualitative interview study.

In an effort to reduce the spread of COVID-19, the UK government has introduced a series of mitigation measures. The success of these measures in preventing transmission is dependent on adherence, which is currently considered to be low. Evidence highlights the disproportionate impact of mitigation measures on individuals from Black, Asian and minority ethnic (BAME) communities, as well as among those on a low income, and an understanding of barriers to adherence in these populations is needed. In this qualitative study we examined patterns of adherence to mitigation measures and reasons underpinning these behaviors among people on low income and those from BAME communities. Semi-structured interviews were conducted with 20 participants from BAME and low-income White backgrounds. The topic guide was designed to explore how individuals are adhering to social distancing and self-isolation measures during the COVID-19 pandemic, and to explore in detail the reasons underpinning this behavior. Data were analyzed using thematic analysis following which charts were used to help compare concepts within and between participants and develop an understanding of patterns of adherence. Participants were confused by the constantly changing and seemingly contradictory rules and guidance. As a result, decisions were made about how best to protect themselves and their household from COVID-19, and from the detrimental impact of lockdown restrictions. This was not always in line with government advice. We identified three categories of adherence to lockdown measures 1) caution motivated super-adherence 2) risk-adapted partial-adherence and 3) necessity-driven partial-adherence. Decisions about adherence considered potential for exposure to the virus, ability to reduce risk through use of protective measures, and perceived importance of/need for the behavior. This research highlights a need for a more nuanced understanding of adherence to lockdown measures. Provision of practical and financial support could reduce the number of people who have to engage in necessity-driven partial-adherence. Information about viral transmission could help people assess the risk associated with partial-adherence more accurately. More evidence is required on population level risks of people adopting risk-adapted partial-adherence.

Public health information on COVID-19 for international travellers: Lessons learned from a rapid mixed-method evaluation in the UK containment phase

Introduction In the containment phase of the response to the COVID-19 outbreak, Public Health England (PHE) delivered advice to travellers arriving at major UK ports. We aimed to rapidly evaluate the impact and effectiveness of these communication materials for passengers in the early stages of the pandemic. Methods In stage I (Patient and Public Involvement, PPI) we interviewed seven travellers who had returned from China in January and February 2020. We used these results to develop a questionnaire and topic guides for stage II, a cross-sectional survey and follow-up interviews with passengers arriving at London Heathrow Airport on scheduled flights from China and Singapore. The survey assessed passengers' knowledge of symptoms, actions to take and attitudes towards PHE COVID-19 public health information; interviews explored their views of official public health information and self-isolation. Results In stage II, 121 passengers participated in the survey and 15 in follow-up interviews. 83% of surveyed passengers correctly identified all three COVID-19 associated symptoms listed in PHE information at that time. Most could identify the recommended actions and found the advice understandable and trustworthy. Interviews revealed that passengers shared concerns about the lack of wider official action, and that passengers' knowledge had been acquired elsewhere as much from PHE. Respondents also noted their own agency in choosing to self-isolate, partially as a self-protective measure. Conclusion PHE COVID-19 public health information was perceived as clear and acceptable, but we found that passengers acquired knowledge from various sources and they saw the provision of information alone on arrival as an insufficient official response. Our study provides fresh insights into the importance of taking greater account of diverse information sources and of the need for public assurance in creating public health information materials to address global health threats. Keywords COVID-19, public health advice, government, policy, airport, international travel

Factors associated with self-reported anxiety, depression, and general health during the UK lockdown; a cross-sectional survey

BackgroundTo investigate factors associated with anxiety, depression, and self-reported general health during "lockdown" due to COVID-19 in the UK. MethodsOnline cross-sectional survey of a nationally-representative sample of 2240 participants living in the UK aged 18 years or over (data collected 6-7 May 2020). Participants were recruited from YouGovs online research panel. OutcomesIn this sample, 21{middle dot}9% (n=458, 95% CI [20{middle dot}1% to 23{middle dot}7%]) reported probable anxiety (scored three or over on the GAD-2); while 23{middle dot}5% (n=494, 95% CI [21{middle dot}7% to 25{middle dot}3]) reported probable depression (scored three or over on the PHQ-2). Poorer mental health was associated with greater financial hardship during the lockdown, thinking that you would lose contact with friends or family if you followed Government measures, more conflict with household members during the lockdown, less sense of community with people in your neighbourhood, and lower perceived effectiveness of Government measures. Females and those who were younger were likely to report higher levels of anxiety and depression. The majority of participants reported their general health as "good" (as measured by the first item of the SF-36). Poorer self-reported general health was associated with psychological distress, greater worry about COVID-19 and markers of inequality. InterpretationRates of self-reported anxiety and depression in the UK during the lockdown were greater than population norms. Reducing financial hardship, promoting social connectedness, and increasing solidarity with neighbours and household members may help ease rifts within the community which are associated with distress, thereby improving mental health. Reducing inequality may also improve general health. RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSO_LIQuarantine is associated with adverse psychological outcomes. C_LIO_LIPsychological distress during quarantine is associated with greater financial loss, greater perceived susceptibility to and severity of the illness, and greater frustration and boredom during quarantine. C_LIO_LIMeasures put in place to prevent the spread of COVID-19 have highlighted existing inequalities in society, disproportionally affecting younger people, those in lower-income households, and Black and minority ethnic groups. C_LIO_LIResearch in the UK and other countries indicates that rates of anxiety and depression during restrictions of movement such as "lockdown" measures are higher than population norms. C_LI Added value of this studyO_LIIn this study, 22% of the sample reported anxiety, while 24% reported depression. Normative data indicate that these rates are usually approximately 5% and 7% respectively. C_LIO_LIFactors associated with psychological distress included greater financial hardship, poorer social connectedness, greater conflict within the household and the wider neighbourhood, being female and of younger age. C_LIO_LISelf-reported general health in the sample was "good" on average. Factors associated with poorer self-reported general health included markers of inequality and greater worry about COVID-19. C_LI Implications of all the available evidenceO_LIDecreasing the financial impact of measures put in place to prevent the spread of COVID-19 may help improve mental health. C_LIO_LIInterventions promoting social connectedness in isolated young people and measures that increase household and neighbourhood solidarity may help improve mental health. C_LI

Factors associated with adherence to self-isolation and lockdown measures in the UK; a cross-sectional survey

ObjectivesTo investigate factors associated with adherence to self-isolation and lockdown measures due to COVID-19 in the UK. DesignOnline cross-sectional survey. SettingData were collected between 6th and 7th May 2020. Participants2240 participants living in the UK aged 18 years or over. Participants were recruited from YouGovs online research panel. Main outcome measuresHaving gone out in the last 24 hours in those who reported symptoms of COVID-19 in their household. Having gone out shopping for items other than groceries, toiletries or medicines (non-essentials), and total number of outings, in the last week in those who reported no symptoms of COVID-19 in their household. Results217 people (9.7%) reported that they or someone in their household had symptoms of COVID-19 (cough or high temperature / fever) in the last seven days. Of these people, 75.1% had left the home in the last 24 hours (defined as non-adherent). Factors associated with non-adherence were being male, less worried about COVID-19, and perceiving a smaller risk of catching COVID-19. Adherence was associated with having received help from someone outside your household. Results should be taken with caution as there was no evidence for associations when controlling for multiple analyses. Of people reporting no symptoms in the household, 24.5% had gone out shopping for non-essentials in the last week (defined as non-adherent). Factors associated with non-adherence and with a higher total number of outings in the last week included decreased perceived effectiveness of Government "lockdown" measures, decreased perceived severity of COVID-19, and decreased estimates of how many other people were following lockdown rules. Having received help was associated with better adherence. ConclusionsAdherence to self-isolation is poor. As we move into a new phase of contact tracing and self-isolation, it is essential that adherence is improved. Communications should aim to increase knowledge about actions to take when symptomatic or if you have been in contact with a possible COVID-19 case. They should also emphasise the risk of catching and spreading COVID-19 when out and about and the effectiveness of preventative measures. Using volunteer networks effectively to support people in isolation may promote adherence. WHAT IS ALREADY KNOWN ON THIS TOPICO_LIThe UK Government introduced "lockdown" measures, including physical or social distancing, on 23rd March 2020 due to COVID-19. C_LIO_LIGovernment guidance states that people with symptoms of COVID-19 should not leave their home, also known as self-isolation. C_LIO_LIThere is no research investigating adherence to self-isolation and lockdown measures, or factors associated with self-isolation or lockdown measures in the UK. C_LI WHAT THIS STUDY ADDSO_LIApproximately 10% of participants indicated that they had had symptoms of potential COVID-19 (cough and high temperature / fever) in the last week. Of these participants, 75% had left their home in the last 24 hours. C_LIO_LIFactors associated with non-adherence to self-isolation measures included being male, less worried about COVID-19, and perceiving a smaller risk of catching COVID-19. However, these results should be taken with caution as there was no longer evidence for associations when correcting for multiple analyses. C_LIO_LI25% of people who reported no symptoms in their household reported having gone out shopping for items other than groceries, toiletries or medicines in the last week; this was not allowed by Government guidelines in place at the time of data collection. C_LIO_LIFactors associated with non-adherence to lockdown measures, and increased number of outings in the last week, included decreased perceived effectiveness of Government "lockdown" measures, decreased perceived severity of COVID-19, and decreased estimates of how many other people were following lockdown rules. C_LI