Ensure adherence to public health safety measures

Contain and Control COVID-19

Douglas Owens and Jason Wang on ensuring adherence to public health safety measures

In the early months of the global COVID-19 outbreak, modeling studies offered strong evidence supporting the importance of preventive measures. Precautions such as social distancing and quarantines had the potential to limit the spread of the highly contagious novel coronavirus, but COVID-19 would likely come roaring back if the public didn’t continue to observe the safeguards.   

Public health officials have been tasked with communicating threat without alarm and with convincing millions of people to drastically change their behaviors to protect themselves and others against an invisible, evolving and largely unknown menace. Leaders around the world have adopted a variety of approaches for their different and diverse audiences, but a significant challenge has been the duration of the pandemic, says Douglas Owens, MD, professor of medicine and director of the Center for Health Policy. “From a public health standpoint, we’ve seen that it was probably easier in some respects to achieve adherence early on, but maintenance of these behaviors can be very hard,” he says.

To succeed, government officials must find a way to inspire social solidarity in the broad community and provide support for people who struggle as a result of their compliance with safety measures, says Jason Wang, MD, PhD, associate professor of pediatrics and of medicine. Below, he and Owens discuss challenges and strategies for persuading the public to follow oft-changing guidance over the course of a long-term pandemic.

What has to be accomplished in order to see broad adherence to public safety measures?

Wang: Two things. One is that we have to build slowly, based on cultural context, some sort of a social solidarity — the idea that we have to fight this virus together. To fight a pandemic in a democracy, it’s important to have a very strong social solidarity, and we haven’t had it yet. I think that’s in part due to this being an election year.

Secondly, we have to support people. If you ask essential workers to stay home and they need to make a living, you need to figure out a way to support them, if that’s what’s needed. Or if they go to work, they must have somebody to take care of their kids, if the kids are at home doing classes online.

What, if any, protective actions people take is highly correlated with whether or not people believe that they’re going to get sick from the virus

What makes a difference to people as they decide what protective actions to take, according to research?

Wang: What, if any, protective actions people take is highly correlated with whether or not people believe that they’re going to get sick from the virus. It’s also correlated with things like the availability of materials. For example, in countries where it’s difficult to get soap or sanitation materials, people are obviously not going to be able to wash their hands as often.

Also, adherence to different innovations, in some sense, really depends on the social circumstances of that person. There are countries where it’s difficult to do social distancing because it’s very crowded. Or if people are essential workers — if they need to go out and work, to go to the grocery store, things like that — they are less likely to completely observe social distance measures.

Owens: From a public health standpoint, we’ve seen that it was probably easier in some respects to achieve adherence early on, but maintenance of these behaviors can be very hard. That was likely the case with the original shelter-in-place orders: Things that people consider nonessential for a month might not be nonessential for six months. And so, one of the big challenges ahead is figuring out how to maintain these behaviors over long periods of time.

How important is it that messaging be consistent?

Owens: The United States has had many challenges with public health messaging during this pandemic. Different parts of the government haven’t been on the same page, so people haven’t been getting a single message — no matter whose message you think is correct. No matter how you feel about restrictions, getting many different messages makes it harder for you to agree to take recommended actions and to get behind the effort.

Most plans for reopening have had staged tiers, where a community is able to open up businesses and services once certain criteria are met. That’s another area where there’s been a lot of different standards and messaging: For example, in one county, you might be able to have hair salons open, but then in a neighboring county, you can’t. It’s another challenge that makes people wonder what to think about the virus.

There are also many different cultural contexts to consider. In Santa Clara County, for example, you have people with very different health beliefs and very different understandings. You also have a complex problem of trying to reach people in five or 10 different languages.

What can officials do when new evidence makes it necessary to change their public health messaging?

Wang: We have to be very careful when we do messaging around this pandemic. We need to make sure that if you must change recommendations, you give the rationale and you help regular citizens understand why you changed course. There’s a lot that we don’t know about the virus, and we have to be humble and be ready to change practice when new evidence emerges.

In this pandemic, the traditional experts — people who have been studying viruses for years — also need to keep up with the literature, because of the changing understanding of the biology and transmission. This pandemic is a once-in-a-century event; what they think is happening might not be what’s actually happening. They need to have a systematic way of synthesizing the literature and keeping up with it, in order to make the best judgment of what to do.

How can public health strategies convince people to comply?

Wang: We need to be persistent in the messaging and to be creative in the way we do it. For example, a study from Temple University asked people to rate how attractive somebody is wearing a mask and not wearing a mask; they found that people tend to rate wearing the mask as more attractive. So you could say, “Most people believe you’re more attractive when you wear a mask.” And for children, to get them to wear masks, you need to create a princess mask or a superhero mask. Also, wearing a mask is a modeled behavior. So, if a mother or teacher is wearing a mask and you are a child, you’re more likely to wear a mask.

Self-efficacy is also important — making sure that people feel like they’re not powerless. That makes them more likely to take action.

Have other countries used stricter measures than the United States?

Wang: In many Asian countries, they monitor you. For example, I was in Taiwan, and during the 14-day quarantine period, they monitored me with my cellular signals. That meant if they weren’t getting a signal from my phone, or at least from the parameter that they assigned, then they sent in the police and public health officers. My phone had a terrible signal, and they came to my residence to see if we were at home.

When you have something like that, people can feel restricted. They counteracted that strategy by offering to bring people food and bring them masks. They also pay you during the quarantine — $33 a day. Maybe I think it’s not worth my time, but my teenage daughters loved it. So, there are strategies governments have used to make sure people won’t revolt from these kinds of public health orders.

Douglas Owens, MD
Professor of Medicine and Director of the Center for Health Policy

Jason Wang, MD, PhD
Associate Professor of Pediatrics and Medicine