Improving the impact of non-pharmaceutical interventions during COVID-19: examining the factors that influence engagement and the impact on individuals

Over the last 20 years a range of public health emergencies have resulted from the emergence or re-emergence of a pathogen. While the characteristics of each situation has been unique, there have also been underlying similarities. One of the main threads that runs through the history of these events is the need for community participation and engagement in the strategies proposed by governments. Since the first report about a novel strain of coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging in December 2019 [1], governments around the world has acted rapidly to introduce a range of public health measures (referred to as non-pharmaceutical interventions, NPIs) aimed at reducing contact rates in the population and thereby reducing transmission of the virus. These interventions include the measures that individuals and communities can take to slow the spread of infection especially during a period when vaccines and medical treatments are not available [2]. NPIs include compulsory measures underwritten by public health orders, such as closures of various services and establishments, quarantine/isolation and restrictions on movement; and voluntary measures, supported by health promotion, such as disinfection of hands and surfaces, mask use working from home and maintaining a physical distance from other. In some settings these measures are voluntary, whereas in others they are now enforced (such as, via fines and/or jail time). Alongside the use of these measures, there is the critical need to test all people with suspected infection as quickly as possible, to promptly isolate cases, and trace and quarantine their contacts.

Experience from prior events has underscored that considerable cooperation is needed from the public to successfully implement these NPIs during an outbreak or pandemic. However, it is not always easy to predict what the public reaction to an unfamiliar event could be. While pandemic and/or emergency planning guidelines aim to promote compliance with these strategies, badly judged communication approaches can lead to members of the community becoming “complacent, panicked, or otherwise acting in unhelpful ways” [3], setting back or interfering with the ultimate aim of the control efforts. Previous commentaries on pandemic plans suggest that documents have glossed over or failed to account for how members of the public may respond in an infectious disease event [3]. In addition many of these documents are based on the assumption that engagement with the public does not need to happen prior to (an event) but strictly once things start to occur and at that point facts (what is the disease/how is it transmitted) and instructions should be applied only [3]. It perhaps not surprising that these emergency control guidelines and plans lack sufficient recognition of the enablers and barriers to effective public responses [4].

It is essential that we understand the factors that impact engagement with these mitigation strategies, to facilitate realistic expectations amongst the community and to devise appropriate communication strategies to promote acceptance and uptake. A 2010 review paper by Bish and Michie identified several demographic and psychological determinants associated with a higher probability of adopting protective behaviours during a pandemic [5]. Building upon this work and to support current activities for COVID-19, the objectives of this review were to not only identify the key determinants impacting on engagement with individual protective behaviours and NPIs but to also explore the impact of these strategies on the individual. Lastly, we aimed to map the key issues identified using a behaviour change framework so that we could identify relevant interventions to support and enhance community participation.

Across each of the sections that were reviewed for this narrative paper, 53 papers were identified as being relevant and information was extracted using the screening tool. Given the rapid nature of the work and the ongoing developments with the COVID-19 pandemic, supplementary papers were included that have been published since the beginning of this pandemic. Not all papers are referenced into the results section, as some findings have been replicated and supported across numerous studies.

It is critical to firstly acknowledge the key role that psychological and social factors play in underpinning an individual’s willingness and actual adoption of behaviours or practices outlined in the following sections [5]. As these factors or combinations of factors can influence adoption of preventive and avoidance behaviours, we are going to dedicate this first section to reflecting on them. Factors such as how an individual perceives their susceptibility to the infection (rather than their actual risk), whether they believe the infection to be severe if acquired, their perceptions towards the efficacy of the mitigation strategy and their perceptions toward their ability to conduct the activity (self-efficacy), can all contribute to how an individual will engage with a preventive behaviour [10]. Further discussion about these factors is included in the sections below. Additional analysis can be found in the work of Bish and Michie [5], Catherine So-Kum Tang [11] and Joseph T.F. Lau [12] and others. Work published during this current pandemic continues to support the role that perceptions towards risk and efficacy have on the adoption of behaviour [13, 14]. The following sections will focus on the individual strategies or interventions that have been applied during this COVID-19 pandemic.

Willingness to adhere to NPIs may be influenced by the severity of illness observed in the community, relative to the need for income and the level of community, individual, and family disruption. Compliance reflects the interaction of a range of modifiable and nonmodifiable factors including the availability of resources, socioeconomic status, perceived consequences that could result, and their perceived level of personal and local community risk [65‐67]. From the literature, a dominant theme that emerged is how to create an environment that supports and promotes adoption. Previously it has been suggested that we investigate the value of rewards or suasion rather than compulsion or punishment. To support this approach, the strategies that are implemented need to ensure that: (1) they are proportional to the threat; (2) compliant communities’ members are offered reciprocal arrangements; and (3) there is clear and transparent communication from key stakeholders.

Emotionally driven behaviours such as fear and threat also need to be considered. However, appealing to fear may be useful in some situations but not in others, as it may lead to defensive reactions [68]. Coupled with this, is the issue of optimism bias, which is a cognitive bias that causes someone to believe that they themselves are less likely to experience a negative event [69]. This bias is common and transcends gender, nationality, and age. Concerns about risk are often heightened during novel threats (especially for an infection that people have no physical awareness of) and in situations when people feel they have limited or no control. As acknowledged by Peter M. Sandman and Jody Lanard, it is common for people to feel anxious and potentially alarmed when faced with this unknown situation [70]. To get used to the new threat on the horizon, people may start acting like it is already present. For example, Sandman and Lanard postulated that a person may start wearing a mask on the subway as a form of emotional preparation for a feared future disease outbreak. This behaviour allows people to ‘emotionally rehearse’ the situation, as it is a functional response. It needs to be legitimized and requires acknowledgement that this is an unfamiliar space, while avoiding promotion of over-reactions. As suggested, “fearful people feel better, not worse, when their fear is legitimized; it is a relief” [70]. As suggested by Sandman, an unfamiliar situation should be made as familiar as possible, so that citizens begin to take the risks a little more for granted and that the outrage level will decrease [71]. A key issue that was raised by Bavel and colleagues was around the impact that continued exposure to negative framed messages can have on people [10]. As highlighted in their review, was the suggestion that the intense media focus on the number of people infected and dying may potentially sensitize people to neglect their own personal risk [10]. More work is needed around this issue and how message framing may impact.

Masks are currently being promoted as a means of source control i.e. reducing the risk of transmission by people who have been infected but are asymptomatic and contagious. The challenge with this, is that we do not currently understand whether members of the public fully understand this concept. In the echo chambers of social media, there are posts focused on ‘mask use for all’ and ‘wearing masks for others’, however we do not have a strong understanding of whether this sentiment transcends into the wider community. Social media misinformation and lack of well-designed education programs without community engagement can impact on compliance, acceptability and proper mask wearing. This issue merits further examination. Further issues which have been raised around the use of universal mask use during COVID-19 include what type of mask should be recommended (cloth mask or surgical mask), whether the use of masks will lead to panic buying or hoarding (and potentially supply chain issues/shortages for healthcare workers), whether children aged 2 years and over should be wearing masks (or face shields) and around how to optimize the usefulness of the products. To support and encourage uptake, it has been suggested that their use should be restricted to situations where they will confer a benefit. This includes times when a person is in enclosed spaces such as on public transport, at the shops or at places of worship, workplaces or at entertainment venues [72]. It could be theorized that by encouraging more targeted use of masks, this may assist with enhancing compliance. Community members may appreciate the heightened risk of exposure in situations where physical distancing is not feasible or where there is more chance of prolonged and close exposure to people and hence the rational for mask use. They may be able to tolerate shorter periods of masks use, despite concerns about the mask being uncomfortable. In communicating about the use of facemasks, efforts should be made to normalize the behaviour, to reduce the risk of discrimination or stigma targeted at those that are exempted from use (for physical or mental health reasons) and which continue to focus on the community being part of the solution. As suggested by Wang et al. public health messages to the public must include: the rational for wearing the mask, how to select the proper mask, how to dispose the mask and a reminder to continue with other prevention and control measures [73].

Strategies and interventions to promote hand hygiene are well studied in the healthcare setting, but when it comes to the promotion of community compliance, the literature is somewhat more limited. Finding interventions that successfully improve hand hygiene remains a challenge; studies conducted to date have failed to show any impact on hand hygiene behaviours between intervention and control groups [74]. Despite this, there has been key work around communication to promote hand washing/hygiene. One such study highlights that currently communication materials infrequently exhibit information consistent with theories of communication for behaviour change. Instead they rely on fear-based messaging, instead of using positive emotional cues or social norm appeals. In moving forward, it is suggested that hand washing/hygiene educational materials should adopt concepts from positive deviance [75]. In addition to hand hygiene, it is necessary to investigate strategies to promote cough etiquette. While there is agreeance that we should not be promoting people to sneeze or cough into their hands (unless they can directly wash them), the recommendation to cough or sneeze into ones elbow may not be a social norm in all countries and for some people is may not be habitual. Further mass media and the use of targeted social media campaigns may help to normalize this behaviour. Lastly, there has been some discussion around replacing one behaviour with another. For example, instead of touching your face, hold a pen or take a sip of water. If we are going to try and implement these sorts of messages, we must design these campaigns with the communities.

In situations where there are low levels of perceived risk, parents may lack the motivation to enforce their children to avoid social interactions. Compounding this are opportunity issues such as conflicting messages coming from schools and health departments or insufficient information coming to support parents to home-school. This is perhaps not surprising given the results from a literature review from Uscher-Pines et.al that reviewed pandemic policies and practices around school closures and found that there is limited literature on school practices to promote physical distancing, as well as limited incorporation of school practices to promote social distancing into state government guidance documents [76]. In future events, it is suggested that public health officials must clearly communicate with parents both why the intervention (school closure) is necessary, and what the benefits to the community will be. The same messages need to be delivered by the schools as they may be a trusted agent in some communities.

Some of the most important lessons about the use of quarantine come from its application in Liberia for the Ebola epidemic. As summarized in a paper by Umberto Pellecchia [77], one of the key issues was the lack of community engagement and low levels of ownership within the community in the decision making and implementation process. Ensuring that the communication about the situation (especially in the issue of school closure), is not simply subjugated by external agents. Use the local knowledge and practices of the community to create an environment of dialogue. He suggested that scheduled meetings or forums for awareness at neighbourhood or village levels could have greater impact than high- level meetings in which citizens only receive ‘echoes’ of information via mass media [77]. Lastly, he proposed that we need to work with local leaders (Principles, Religious leaders, Community leaders) as well as healthcare providers/public health practitioners, and communication specialists to enhance reaching local communities during times when their engagement with these strategies is needed. These local agents may be seen as more trustworthy and hence will be accepted as more credible and satisfactory [78].

Having reliable and trustworthy information is key in this situation for citizens to act upon and slow down the spread of COVID-19. The challenge is that health literacy levels (or the skills needed to obtain, understand, and process) vary across communities. As an impact of lower health literacy, people are less likely to access services or to understand the issues related to their health. During a pandemic, this may equate to mistrust in the recommendations and/or misunderstandings about risk, and lower levels of uptake of recommended interventions, including testing. Complicating this picture, is that in an exploding market of COVID19 facts and fiction, simply knowing about the risks (i.e. functional health literacy) is insufficient; individuals also need to be able to critically assess the information. It is critical that we ensure that communication approaches are tailored so they meet the needs of the target communities, in terms of messages and dissemination strategies. We need to increasingly draw on the known principles of communication [79]. One example could be to utilize personal stories into our communication strategies to normalize our thinking about these strategies. Patient stories are often used to promote best practices around quality and safety in healthcare, the issue is that this thinking has not been applied in our communication around community mitigation strategies for COVID-19. We also need to think carefully about how we use objectiveness and empathy, solidarity, and altruism to garner engagement.

This review was intended to be a rapid review of the literature to support the current actions being implemented worldwide. It differs from previous studies in that goes beyond the psychological determinants that impact on compliance to also look at other know factors that either impact on engagement or arise because of participation. It can serve as a benchmark to see how knowledge and recommendations have changed because of new evidence emerging during the COVID-19 pandemic. However, it has several limitations which need to be acknowledged. Firstly, it is not a systematic review, it does not include all the published literature on a topic. The selection and inclusion of findings may have been subject to unconscious bias. However, our team of investigators included people from both academic and health departments which may have reduced this issue. We purposefully chose not to comment on the quality of the papers within this review and chose not to limit ourselves to past pandemics but to capture the literature focused on both hypothetical and real situations. Both qualitative and quantitative studies were included to garner a rich understanding of each NPI strategy. As part of our reflection on these issues, we have ensured that we have included suggested readings to support people’s understanding.

One of the key steps in this context is to ensure that we have community participation and co-design on the development of communication messages and practical materials to support those who are imposed upon to comply with these community strategies. It is also important to map the strategies or interventions to ensure that we are addressing the relevant key individual and contextual factors that have been identified in this study and others. Lastly, we need to ensure that we have a community voice in all the interventions that we plan. Working with the community to design new communication messages, community outreach initiatives and support documents will ensure that they have a higher level of authenticity and that they are received and adopted by those we need to effectively engage.