Sarah Chapman looks at the latest evidence from a A rapid review is a simplified systematic review that can be done in a few weeks to produce timely evidence for decision-making. More by researchers at King’s College London, published this week, on how to improve adherence to quarantine. What makes us more likely to stick at it and follow the rules? In a second review, they have looked at what makes quarantine more tolerable.
Lockdown, quarantine, social distancing, isolation. Coronavirus has brought with it new words, new rules, and new ways of living. Never has good communication, using plain language, been more important than now. Whilst harking back to World War 2 seems to be popular at the moment, the vast majority of us are under restrictions entirely unfamiliar to us, and changing so rapidly that it’s hard to keep up. As our scientists are pulling off incredible feats of producing evidence on many things coronavirus-related, there is a need to communicate effectively so that we all understand what is required of us. Now is the time for plain speaking and some great, simple graphics to help everyone understand vital information.
While all of us need to know WHAT we need to do, and also why, ensuring that people follow quarantine rules might need more than *just* clear communication. Researchers at Kings College London have done this rapid review to see what published, peer-reviewed evidence there is on what influences people to stick to quarantine – or to flout the rules. Let’s take a look.
What is quarantine?
The researchers explain that quarantine is the separation and restriction of movement of people who have potentially been exposed to a contagious disease, in order to limit disease spread.
This is different from isolation, which applies to people who have been diagnosed with the disease, but they point out that the terms are sometimes used interchangeably. Getting to grips with new terms, and when the same terms may not always be used to mean the same thing each time, is confusing for people in situations like ours.
Right now in the UK (and in many other countries), we are all in quarantine – required to stay at home, apart from under particular circumstances.
What do we already know about quarantine?
The bottom line is that quarantine only works to limit the spread of disease if people stick to it. How well quarantine works is less certain, and we don’t yet know how effective it is compared with other measures such as social distancing, school closures and cancellation of mass gatherings. But if public health officials decide that it is necessary, it is important to understand what makes people more likely to do it.
Update on 14 September 2020 – today an updated Cochrane Rapid Review was published, which brings together 51 studies (most of which are mathematical modelling studies) looking at the effects of quarantine. The included studies consistently report benefits of quarantine for reducing the number of people who get infected with the virus and die from it. You can read about the new Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More on the The ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. More of quarantine in this blog.
What makes people more likely to stick to quarantine rules, or less likely to?
The researchers looked for research studies that could help answer this question. These were studies that involved people asked to enter quarantine for at least 24 hours and not in hospital, and which had looked at people’s reasons for sticking to quarantine or not sticking to it.
They were able to include 14 studies in the review to help answer the question. These studies were done before the coronavirus pandemic and relate to other disease outbreaks (such as Ebola) in a variety of countries across the globe. It wasn’t possible to add together Data is the information collected through research. More from different studies, but the researchers have described what they found. They also remind us we should be cautious about the evidence as the quality of the papers is not known and there may be studies that were missed.
What proportion of people comply with quarantine?
Overall, they found that this varies greatly, ranging from none at all to almost everyone (0% to 93%).
The most common factors influencing people’s quarantine behaviour
The following factors also influenced people in other behaviour aimed at protecting health, such as handwashing and avoiding crowds.
Their knowledge about the infectious disease outbreak and what the rules were about quarantine
Both too little and too much knowledge can be a bad thing, it seems. Examples include the closure of five Australian schools during an influenza pandemic, when a lack of clear instructions about quarantine saw people making it up for themselves, and quarantined villages during the Ebola epidemic where resident health professionals considered themselves more knowledgeable about infection A way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. More than volunteers sent to support, but were reluctant to follow measures they thought too strict.
It shouldn’t surprise us that social pressure was found to be influential, whether that was from heads of households (in Senegal villages) or the wider community (in Canada and elsewhere). This can work both ways, making people more likely to follow quarantine rules or, as in the case of the Australian schools mentioned above, less likely – when rumours circulated that others weren’t sticking to it.
I’m sure we can all think of ways in which we are seeing that happening now. There was outrage expressed on the app joining members of my local community earlier this week, in response to a leaflet inviting people to attend a local event. Even had stricter quarantine measures not been announced shortly afterwards, I think local pressure would have been enough to prevent that event from going ahead.
Perceived benefits of quarantine
The researchers found various examples demonstrating that if people think quarantine works (because they notice disease spread is slowing, for instance), they are more likely to follow quarantine rules. Makes sense, doesn’t it?
Perceived risk of disease
The more likely people thought it was that they could pass on, or get, the disease, the more likely they were to follow quarantine rules.
Practicalities of being in quarantine
Three studies reported that people had to break quarantine to get supplies or medical help. Our current UK quarantine (but not isolation) rules allow us to leave the house to shop for basic necessities, for any medical need or provide help or care for a vulnerable person, to travel to and from work where it is not possible to work from home, and for one form of exercise a day (alone or with members of your household).
Other examples of practical considerations that were influential include whether or not children could be cared for by adults in the household, fear of loss of income, and the need to attend important events.
Making quarantine tolerable
In a second rapid review, also published this week, the Kings College team looked at evidence on the psychological impact of quarantine and how its negative effects might be reduced. Again, there was no formal assessment of An investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. More quality and the authors point out these and other limitations, but their findings should be useful pointers for those making decisions in these testing times.
Unsurprisingly, there is a great deal of overlap with the things they found are likely to be important for encouraging people to comply with quarantine and the recommendations that emerge from both are similar. Their results suggest that officials should try to make quarantine as tolerable as possible by “telling people what is happening and why, explaining how long it will continue, providing meaningful activities for them to do while in quarantine, providing clear communication, ensuring basic supplies (such as food, water, and medical supplies) are available, and reinforcing the sense of altruism that people should, rightly, be feeling.”
They found too that healthcare workers need special attention, being liable to feel particular psychological effects of quarantine. Feeling supported by their immediate colleagues is key, this review suggests. Never have we been more grateful for them…
Writings from many different cultures and periods of history have had their own versions of “this too shall pass”. Let’s try to all hang onto that.
What’s keeping you going in quarantine? We’d love to hear what’s helping you. Join in the conversation on Twitter with @CochraneUK @SarahChapman30 or leave a comment on the blog. Please note, we will not publish comments that link to commercial sites or appear to endorse commercial products.
Sarah Chapman has nothing to disclose.
Page last updated 14 September 2020.