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Effective test, trace and isolate needs better communication and support

New research led by King’s College London has shown that the majority of the UK public report an intention to carry out test, trace and isolate behaviours if they were to develop coronavirus symptoms, but actual adherence is low.

TTI 2

Updated 1 October*

Governments around the world are relying on test, trace and isolate (TTI) strategies to prevent the spread of COVID-19. Within the UK, guidance to implement a TTI system has focused on the need for people with a persistent new onset cough, fever or loss of their sense of taste or smell to take the following steps:

  • remain at home for at least seven days from the onset of their symptoms;
  • request an antigen test;
  • and provide the details of their close contacts to a dedicated service if the test result is positive.

Using data collected between March and August 2020 on over 30,000 people in the UK, the study found that just under half of the sample were able to name the key COVID-19 symptoms as being a persistent new onset cough, fever of loss of sense of taste or smell. Analysis showed that around 70% of people who had not experienced COVID-19 symptoms in the last week intended to self-isolate if they were to develop key symptoms and 50% intended to request an antigen test.

However, of those who reported the key COVID-19 symptoms in the last week, 18.2% reported that they had self-isolated and 11.9% reported that they had requested an antigen test. Of those who reported having been alerted by the NHS contact tracing that they had been in close contact with a confirmed COVID-19 case 10.9% reported staying at home or quarantining for the following 14 days.

Our research indicates the UK public have good intentions to adhere to a test, trace and isolate system but, when they do develop symptoms, there are a number of factors that affect their decisions and their behaviour. These vary from individual to individual and household to household but what our study did indicate was that financial constraints and caring responsibilities are common barriers to adherence. – Senior author Dr James Rubin from the NIHR Health Protection Research Unit for Emergency Preparedness and Response (HPRU EPR) King’s College London

Dr Rubin continued: 'A greater level of knowledge about COVID-19 and protective measures is also associated with better adherence suggesting there is still room for improvement in terms of public health messaging.'

The study is a pre-print and has not been formally published in a journal so has not been subject to peer review. The research was led by the NIHR Health Protection Research Unit of Emergency Preparedness and Response (HPRU EPR), King's College London, in collaboration with researchers from UCL and Public Health England.  

Results indicate that men, younger people, those with young children and key workers were less likely to adhere to protective measures that form a TTI system. Lower socio-economic status and greater hardship during the pandemic were also associated with lower adherence to TTI behaviours.

According to the researchers, the results suggest that adherence could be improved by practical support and financial reimbursement to reduce the burden incurred by self-isolation. Targeted messaging and policies to men, younger age groups, and key workers about the COVID-19 symptoms and the importance of a TTI system to contain the spread of the virus could also improve engagement.

While intention to carry out test, trace and isolate behaviours is high, our results show that adherence is low. This is a common pattern in health behaviours and suggests that while people may be willing to adhere, they may not be able to. There are a number of practical and psychological factors that may be acting as barriers to people carrying out the necessary actions or behaviours to make a test, trace and isolate system effective.– First author, Dr Louise Smith, from HPRU EPR, King’s College London

Dr Smith continued: 'People may not be knowledgeable enough about the key COVID-19 symptoms or what is required from the public to make a test, trace and isolate system work. Simple changes to messaging, such as naming the symptoms of coronavirus on posters, could help increase adherence to test, trace and isolate behaviours. Our results suggest that people who are not adhering to guidance may not be financially able to self-isolate or their living situation may make it difficult. Lastly people’s own beliefs about COVID-19 and how it spreads may also influence the level of adherence.

‘It also must be remembered that behaviours like self-isolation are nuanced and that there are different levels of non-adherence, some of which may not be as risky as others, such as going for exercise and not coming into contact with anyone compared to using public transport or going shopping. Our analyses did not take this nuance into account.’

The data were collected from a national series of cross-sectional surveys done on behalf of the Department of Health and Social Care since early in the COVID-19 outbreak (data collection started on 28 January 2020). Surveys were conducted weekly until 1 July (wave 23), after which survey waves were fortnightly.

Dr Rubin added: ‘Although these data show that there’s obviously room for improvement, we need to bear in mind a few caveats. First, and most importantly of all, they have not been peer reviewed and until they go through the normal peer review process we need to treat them with caution. Second, they date from early March to early August – that is before the Government’s recent announcements about the extra support people will get to self-isolate, and the fines that will be used in the most egregious cases where people break the rules.’

The survey was based on an analysis of a series of 39 surveys commissioned by the English Department of Health during the 2009/10 influenza H1N1 (‘swine flu’) pandemic to identify the factors associated with adherence to recommended behaviours among members of the public. The research team worked with public health stakeholders to prepare a refined set of questions that could be used in any future pandemic. Since the start of the COVID-19 outbreak, the team have worked with the Department of Health and Social Care to develop and analyse a series of weekly cross-sectional surveys tracking relevant behaviours and their potential predictors in the UK public.

*Please note the authors have identified an issue with the underlying dataset that was analysed for this pre-print. Specifically, around 3% of respondents in the dataset reported having been contacted by NHS contact tracers and asked to quarantine. According to official data from NHS Test and Trace, this should be less than 1%. Given this difference, it is likely that we will revise our interpretation of the quarantine data in the final peer-reviewed paper. Until then, as noted in the manuscript, the data relating to quarantine should be treated with caution.

Reference: Smith, L.E. et al. (2020) Adherence to the test, trace and isolate system: results from a time series of 21 nationally representative surveys in the UK (the COVID-19 Rapid Survey of Adherence to Interventions and Responses [CORSAIR] study) Preprint https://www.medrxiv.org/content/10.1101/2020.09.15.20191957v1.full.pdf

Contact: For interviews or any further media information please contact Louise Pratt, Head of Communications, IoPPN: louise.a.pratt@kcl.ac.uk / +44 7850 919020

In this story

James Rubin

James Rubin

Reader in the Psychology of Emerging Health Risks

Louise Smith

Louise Smith

Post-doctoral researcher