Case Studies of Public Health and Behavioural Science Responses to COVID-19

Northeast England COVID Communications Campaign

Lisa Sutherland and Neil Caffery, Drummond Central

In October 2020, seven local authorities in Northeast England joined forces to tackle COVID-19 and commissioned Drummond Central to deliver a communications campaign. The overall aim was to reduce the number of positive COVID-19 cases by March 2021. There was initially a 2-week ‘strategic sprint’ to capture behavioural insights. This included: desk research to identify gaps in local data; 10 stakeholder consultations within public health, business, education, and the voluntary sector; a quantitative survey with a representative sample; 25 qualitative in-depth interviews with citizens; and two focus groups.

Snapshot of the findings

Quantitative survey

People were more concerned about their mental health and wellbeing, staying in touch with family and friends, and enjoying social life compared to worrying about job insecurity, caring duties, and personal finances. The most trusted source of information was the NHS, while councils were perceived as less trustworthy. One fifth agreed that ‘I bend the rules in certain situations as I feel the risks are low’, while a quarter agreed with the statement, ‘I’m finding it hard to always stick to the government guidelines in certain places’.

Qualitative

People’s capability, opportunity, and motivation waxed and waned over time since the first lockdown. In the first lockdown, the behavioural ask was clear, while over the summer it got more confusing, and the effect was complacency. When regional restrictions and tiers were put in place, some good habits were broken and spirits were lowering, with participants questioning the fairness and legitimacy of rules and their ability to adhere to them. People were tired and fatigued, physically and emotionally, making behaviours, at times, quite effortful.

Campaign Strategy

Overall, the strategic themes were togetherness; acknowledging what had been lost and making its recovery attainable; the prospect of reward and incentives (both financial and emotional); tangible steps needed to achieve this; and providing a unique tone of voice encompassing support, empathy, and encouragement.

Messages focussed on taking small steps towards the future we all want (the why) by engaging in different behaviours (the what) through best practice, positive role modelling, and reinforcement (the how). Messages targeted working people and families (the who).

Neil provided examples of the different messages created. All contained a ‘thank you’ message, highlighted the benefit to society, and provided the call to action of visiting a hub website. The campaign was launched in December 2020.

At the time of presentation, the evaluation was underway, consisting of a campaign survey. Initial findings indicated good reach, with 90% positive sentiment, nearly 2 million reach/impressions and over 70,000 video views.

How best do we engage the general population in testing for COVID-19?

Daniella Watson, Qualitative Evaluation Lead, Southampton COVID-19 Saliva Testing Programme

Daniella presented a case study on a pilot programme to assess the feasibility of weekly mass saliva testing for COVID-19. The programme was mainly to test for asymptomatic cases and ran alongside the national swab testing and NHS Test and Trace and was run by the University of Southampton and Southampton City Council. The programme consisted of two phases:

• ‍Phase 1, June 2020 – This involved University of Southampton staff and students, and GP surgeries in Southampton.
• ‍Phase 2, October 2020 – This involved four schools and University of Southampton staff and student.

Participants either received a test kit from school or work or sent to their home address if they were at a university. All participants undertook the test at home, which involved spitting into a tube. Drop off points were in Southampton, where participants could deliver their test kits into the post box. If test kits were dropped off in the morning, then test results would be received by the evening.

A rapid qualitative evaluation was conducted, consisting of interviews and focus groups with 223 people. The aim was to explore participants’ and decliners’ experience of the testing programme. This provided real-time feedback to the testing team to modify the programme to improve uptake. It also contributed to local and national strategy.

The evaluation produced eight recommendations:

1. Testing should be delivered through local organisations to both increase trust in the testing programme but also to promote collective efficacy.  
2. Communication about testing should speak to individuals’ sense of community and altruism to motivate people to take part in programme.
3. Creative and fun educational activities should be used to increase knowledge and understanding of the virus and so increasing motivation to protect each other.
4. Participants and local organisers should be involved in designing their programme, and be engaged in providing continuous feedback to enable real-time programme modifications.
5. Local organisations involved in delivering testing should be enabled to connect with one another to share best practice and create a local testing culture.
6. Those testing positive should be supported financially and psychologically, provided with food and medication, and given reassurance and advice about how to minimise the possibility of transmission of infection to others.
7. Testing should be made as convenient for participants as possible, and all communication needs to be in multiple languages as well as appropriate for children and young people.
8. Thought needs to be given to making testing kits and processes as environmentally sustainable as possible.

ACTS & CABINS: Using behavioural insights to understand and improve self-isolation adherence amongst contacts of cases in COVID-19 in Wales

Dr Richard Kyle¹, Dr Kate Isherwood¹, Lesley Lewis², James Bailey¹, Dr Alisha Davies¹ (Author affiliations: 1. Research and Evaluation Division, Public Health Wales. 2. Health Improvement Division, Public Health Wales.)

Dr Richard Kyle and Dr Kate Isherwood presented two studies conducted within Public Health Wales, which aimed to establish and understand the enablers, barriers, and risk factors for adherence to self-isolation guidance:

• Study 1: COVID-19 Contacts Adherence Confidence Text Survey (ACTS), which gathers insights at the start of a period of self-isolation.
• Study 2: COVID-19 Contacts Adherence to Self-isolation Behavioural Insights Survey (CABINS), which gathers insight after a period of self-isolation.

Study 1: ACTS

ACTS was a real time piece of work. Eligible participants were those who were a contact of a confirmed case of COVID-19, had been contacted by NHS Wales Test, Trace Protect (TTP) in the past 24 hours, and were over the age of 18 years. All of the participants in ACTS have been informed that they had to self-isolate, and all had been contacted by the system and required to self-isolate.

Every day, a sample of eligible participants were sent up to four SMS messages:

• SMS 1: Participants selected their language preference – either English or Welsh.
• SMS 2: Participants were asked, ‘How confident are you that you know what you need to do now?’
• SMS 3: Participants were asked a service improvement question about what was good about the experience and what could be done better.
• SMS 4: Participants were invited to take part in an anonymous two-minute survey and directed to a different platform. The survey included questions on risk perception, how clear the guidance was, whether they felt they it would be a challenge to isolate from others and not leave the home, whether they were generally following COVID-19 guidance, whether they had support available, and their intentions to have the COVID-19 vaccine. They were also asked to identify what challenges they think they might face by selecting them from a list. The survey was informed by the BPS guidance to improve adherence to self-isolation.

Results

The first text was sent in November 2020. 56,882 initial text messages were sent with 17,690 responses (response rate: 31.1%), and 4,754 responses to sub-survey (response rate: 26.9%).

The advantages of ACTS included using real-time data, which provided insight on a daily basis. This meant there was the opportunity to makes changes in line with Government changes and findings.

The findings have been reported to Public Health Wales incident management team, the Gold strategic group, the NHS TTP programme Board, and Leads from Local Public Health Teams. The results have informed local and national risk communication, have provided insights into the awareness of financial support, and feeds into the Welsh ‘Protect’ strategy.

At the time of presentation, the results were not available publicly but are now published (Kyle, Isherwood, Bailey, & Davies, 2021).

Study 2: CABINS

Eligible participants for the CABINS study were those who had been contacted by TTP, had completed their self-isolation period, and were over the age of 18. Eligible individuals were contacted by Beaufort Research (a commissioned market research company) and asked to complete a 15-minute telephone survey. They were also asked if they consented to taking part in a future focus group. The survey had two waves:

• Wave 1: The telephone survey was completed November – December 2020 by 1,011 participants. Focus groups were conducted with 24 participants in January 2021.
• Wave 2: The telephone survey was completed February 2021 with approximately 1,000 participants. Focus groups would be conducted in March 2021 with approximately 24 participants.  

The telephone survey focussed on the following topics, based on the BPS self-isolation guidance (Arden, et al., 2020): household composition, knowledge of the guidance, challenges to self-isolation, risk perception, adherence to self-isolation guidance, precarious employment, social norms and intention to self-isolate in future. Questions on vaccine intention and the Welsh Government self-isolation support grant were included in Wave 2.

Four focus groups were conducted in Wave 1 and split between young people (aged 18-30), older people (30+), those living in areas of high deprivation, and Black, Asian and Minority Ethnic populations. They included those who self-reported to adhere to self-isolation and those who did not.

The advantages of the study included using the BPS guidance to self-isolation as all questions mapped onto the COM-B model so can see what enables or hinders self-isolation

At the time of presentation, the results were not presented, however are now published (Kyle, Isherwood, Bailey, & Davies, 2021).

References

Arden, M., Armitage, C., Lewis, L., Whittaker, E., Hart, J., O'Connor, D., … Chater, A. (2020). Encouraging self-isolation to prevent the spread of Covid-19

Kyle, R., Isherwood, K., Bailey, J., & Davies, A. (2021). Self-isolation confidence, adherence and challenges: Behavioural insights from contacts of cases of COVID-19 starting and completing self-isolation in Wales

Advising policy makers and public health on behavioural science and COVID-19 disease prevention Prof Angel Chater, Professor in Health Psychology and Behaviour Change, University of Bedfordshire

Prof Angel Chater presented a case study of mobilised voluntary expertise, namely the Behavioural Science and Disease Prevention Taskforce (BSDP) and the Health Psychology Exchange (HPX). She started by thanking everyone who had been involved.

At the start of the pandemic, Prof Chater, in her role as Chair of the BPS Division of Health Psychology (DHP), was asked what the health psychology response would be. This led to the past, present, and future DHP chairs (Prof Jo Hart, Prof Angel Chater, and Prof Lucie Byrne-Davies) developing the HPX collective. Over 150 people signed up where they pooled resources and offered virtual support across different areas.

Key stakeholders were invited to the BSDP. Seventeen core members formed the taskforce, who represented science, practice, and policy across the four nations. Meeting weekly, and then fortnightly, the taskforce agreed a core theoretical framework (the COM-B model and Behaviour Change Wheel) and used open science principles so that outputs could be disseminated as widely as possible. Outputs were agreed to be evidence-based and if the evidence was not there then it would be developed, for example rapid reviews were generated by members of the HPX. The Public Health Forum, led by Dr Ellie Whittaker and Lesley Lewis, was also useful to uncover challenges faced within public health. This included a need for guidance on public health messaging, how to support self-isolation, and guidance for other behaviours not linked to COVID-19 but impacted by it, for example physical activity.

A strategic map was developed, that the task force followed. This involved always using a multidisciplinary approach and had a strong psychology identity with a need to ensure there was a collective voice. The need to translate knowledge was acknowledged, by linking with public health agencies and engaging in webinars with Public Health England, the BPS, and the Behavioural Science in Public Health Network. Providing access to behavioural science through consultancy was also important, so all guidance included signposting to behavioural science support through DHP. Additionally, links with HPX provided consultancy opportunities for doing rapid reviews, offering advice and support to different organisations, and engaging in research and evaluation. The Open Science Framework was used, and all rapid reviews were published as preprints.

Seventeen official outputs were developed, which took an average of 18 volunteers, 10 iterations for each document, and between 4 and 155 days. It was noted that this was completed on top of everyone’s day jobs. The guidance documents were unified through the COM-B model. Each of the documents uses a behaviour change road map template and a series of questions of what might be influencing behaviour based on COM-B.

Key recommendations from across the BSDP taskforce are:

1. Use and embed behavioural science and health psychology across the whole system
2. Minimise the ‘I’ and emphasise the ‘we’ – create a collective approach in everything
3. Ensure messages from a credible source and are relevant to and accessible by the target population
4. Be evidence-based – consult behavioural scientists – use expert consensus/rapid reviews
5. Co-create with all stakeholders
6. Ensure all policies and campaigns have a behavioural diagnosis – highlight COM-B drivers with clear behavioural actions and outcomes
7. Support local translation – identify stakeholders, local insights and champions
8. Work collectively as one system to build and maintain TRUST

More work is needed to embed behavioural science into the public health system but we can build behavioural science into the workforce, through training, employing a health psychologist, or investing in a health psychology champion. We need to avoid expectations that behavioural science support is ‘free’ and acknowledge that the time has to come from somewhere.

Prof Chater finished by thanking everyone who had been involved in developing this body of work for their voluntarily support.

All documents produced are on BPS DHP website: Behavioural Science and Disease Prevention Guidance, Investment in Behavioural Science Call to Action, Physical Activity, Sedentary Behaviour, Healthy Eating, Alcohol use, Stopping Smoking, Sleep Hygiene, Delivering effective public health campaigns, Health Psychology and Behavioural Science during COVID-19, The Psychology of Hand Washing, Encouraging Hand Hygiene in the Community, Self Isolation, Optimising Vaccine Uptake, Vaccine Uptake review, Contact Tracing.