Why simply asking people to self-isolate won't cut it

Self-isolation is the quickest way to get things 'back to normal'. And, with the country unlocking further on 4 July, it's as vital as ever that people follow guidance to avoid spreading the virus.

So our Behavioural Science and Disease Prevention Workstream are asking the question - how do you get people to self-isolate?

The government approach to getting people to self-isolate is just to get people to self-isolate. Behaviour change is never that simple. 

In the absence of a cure or a vaccine, the government instruction for people with symptoms of Covid-19 to self-isolate is key to ensuring that the virus is contained and that things get 'back to normal'.

You might expect that an instruction to self-isolate delivered by a government would be followed without question. Add in the context of a contagious and deadly virus and you might be surprised that anyone would act contrary to such an instruction. If behavioural science has taught us one thing, though, it is that human behaviour is complex. 

Take the example of adherence to prescribed medication when you're unwell, which we have seen described as a 'no-brainer'.

It is described as a 'no-brainer' because, unlike many cases of Covid-19, you start off knowing you're ill, you have already been to see a doctor and have a prescription in your hand. But even before Covid-19 we knew there were plenty of people who did not get as far as the doctor's surgery (e.g., Ison et al., 2018). 

What's surprising to everyone except behavioural scientists is that approximately 40-60% of medicines are not taken as prescribed (e.g., Mahtani et al., 2011).

Reasons for non-adherence are complex and include:

• people's knowledge and understanding about what to do and when
• having access to the medication at the right time and place (and being supported by others to take it)
• people's beliefs in the necessity for medication
• concerns for any adverse consequences (e.g., Horne et al., 2013)
• habits around treatment-taking (e.g., Conn & Ruppar, 2017)

Broadly speaking, though, the influences on adherence to instructions can be encapsulated in people's perceptions of their capabilities, opportunities and motivations (Michie et al., 2011).  

All this means it is unsurprising that the report presented to the government's Scientific Advisory Group for Emergencies (SAGE) in April 2020 estimated that approximately 50% of people experiencing symptoms of Covid-19 were not self-isolating for seven days.

Instructing people to self-isolate is necessary but not sufficient to encourage people to self-isolate, and a more scientific approach to changing this crucial behaviour is urgently required. 

So far, so unsurprising. Without appropriate intervention, you might expect that roughly 50% of people with symptoms will not adhere to instructions.

What is worrying, though, is the fact that the majority of people (up to 80% by some estimates) who will be instructed to self-isolate for fourteen days will not have any symptoms whether they have the virus or not (e.g. having entered the UK from overseas, or been in contact with a person who has tested positive). 

Self-isolating for fourteen days without any symptoms is a much bigger 'ask' than taking a tablet with your breakfast, and particularly so for people who have caring responsibilities or are the sole earner in a household.

In short, self-isolating for fourteen days is likely to be too big an 'ask' for people without symptoms, and we urgently need the government to recognise that simply instructing people to self-isolate is insufficient and that more nuanced advice, based on behavioural science, is required to support this complex change in behaviour. 

Health Psychologists, who have specific expertise in behavioural science, have the tools with which to address complex and important questions such as adherence to self-isolation. For example, we know why people don't take their medication as prescribed and can apply similar solutions to the behaviour of self-isolation.  

Although such solutions may on the face of them appear 'simple' and 'common sense', they are as 'simple' and 'common sense' as the interface on a smartphone - namely 'simple' because it is underpinned by decades of empirical research. But while we don't have the luxury of decades to accumulate knowledge about Covid-19 we do have the tools to develop a rapid response to tackle complex issues surrounding the adherence to self-isolation instructions. 

Given that people are currently experiencing challenges with existing Covid-19 mitigation measures we urgently need to:

• gather objective data on the extent to which people are or are not self-isolating.
• identify influences on people's adherence or nonadherence to instructions to self-isolate.
• understand influences on breaches in self-isolation.
• review systematically the literature for examples of interventions that have been successful in encouraging symptomatic and asymptomatic people to self-isolate.
• examine the training that is being delivered to contact tracers and others who are providing instructions to self-isolate to ensure that it is informed by behavioural science theory and evidence, and improved where possible. This includes not just what to say and do, but how to say it and ways to support how to do it. 
• identify existing and novel solutions that ensure that people feel they are capable of self-isolating, are provided with the physical and social opportunities they need in order to self-isolate, and to ensure people's motivation to self-isolate is sustained. 

The decision on 9th June 2020 that schools would not reopen fully until September 2020 means there is now a window of opportunity in which to study the complex issue of adherence to the self-isolation instructions that will facilitate the re-opening of schools. 

However, to do this, we first need government to understand that getting people to self-isolate is not as simple as just telling them to do it: you need to help people feel capable, ensure they are given opportunities, and support their motivation. 

Written on behalf of the BPS Behavioural Science and Disease Prevention Workstream:

• Christopher J. Armitage (document lead), University of Manchester
• Madelynne A. Arden, Sheffield Hallam University
• Lucie Byrne-Davis, University of Manchester
• Paul Chadwick, University College London 
• John Drury, University of Sussex
• Jo Hart, University of Manchester
• Emily McBride, University College London
• Daryl B. O'Connor, University of Leeds
• Gillian W. Shorter, Queen's University Belfast
• Vivien Swanson, University of Stirling/NHS Education for Scotland
• Angel Chater (Behavioural Science and Disease Prevention workstream lead), University of Bedfordshire

References

Conn, V. S., & Ruppar, T. M. (2017). Medication adherence outcomes of 771 intervention trials: Systematic review and meta-analysis. Preventive Medicine, 99, 269-276.

Horne, R., Chapman, S. C. E., Parham, R., Freemantle, N., Forbes, A., & Cooper, V. (2013). Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the necessity-concerns framework. PLOS ONE, 8, Article Number: e80633. doi: 10.1371/journal.pone.0080633  

Ison, M., Duggan, E., Mehdi, A., Thomas, R., & Benham, H. (2018). Treatment delays for patients with new-onset rheumatoid arthritis presenting to an Australian early arthritis clinic. Internal Medicine Journal, 48, 1498-1504. doi: 10.1111/imj.13972 

Mahtani, K. R., Heneghan, C. J., Glasziou, P. P., & Perera, R. (2011). Reminder packaging for improving adherence to self-administered long-term medications. Cochrane Database of Systematic Reviews. Article Number: CD005025. doi: 10.1002/14651858.CD005025.pub3 

Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6. Article Number: 42. doi: 10.1186/1748-5908-6-42