Compliance with self-isolation and quarantine measures: literature review
This literature review analyses UK and international research on compliance with self-isolation and quarantine regimes implemented during the current COVID-19 pandemic and previous infectious disease outbreaks.
Since the beginning of the Covid-19 pandemic, self-isolation and quarantine measures have represented a key strategy to contain the spread of the virus. Adherence to these measures is complex and a range of factors can impact whether someone is willing and able to comply. This literature review will provide an overview of self-isolation and quarantine regimes both in the UK and internationally, illustrate the factors associated with compliance and examine the approaches that have been deemed effective in influencing it. It will examine literature covering those who test positive, close contacts, and those returning from international travel.
The analysis of the literature examined here is based on the following key research questions:
- How does knowledge of Covid-19 and self-isolation/quarantine regulation impact people's compliance?
- What are the financial and practical implications of self-isolation/quarantine regulation?
- Are ethnic and linguistic minorities able to access information and support for self-isolation/quarantine?
- What is the role of the community in promoting adherence to the regulations? And how does sense of belonging to a community affect compliance?
- What is the role played by risk perception and wider attitudes in determining adherence to the guidelines?
- What is the psychological impact of self-isolation/quarantine regimes?
- What are the risks and opportunities of introducing monitoring and enforcement of self-isolation/quarantine rules?
This literature review is based on analysis of international scholarly research on compliance with self-isolation and quarantine regimes carried out between February 2021 and July 2021. Priority has been given to sources pertaining to the Covid-19 pandemic. However, some work on self-isolation and quarantine regimes adopted during other infectious disease outbreaks has been included.
The body of evidence selected consists of 97 studies. The review is based on sources written in English, with the majority from the UK context.
Adherence to isolation regimes in the UK has varied over the course of the pandemic, ranging from very low reported rates of compliance at the very beginning to rather high reported levels in recent months. Low rates of compliance have been associated with men, younger age groups, key-workers, lower socio-economic status, greater hardship during the pandemic, incorrect identification of symptoms, lack of knowledge of the regulations if one develops symptoms, and the presence of a dependent child in the household.
Knowledge about Covid and self-isolation/quarantine requirements
Data on knowledge about Covid-19, and self-isolation/quarantine rules and guidelines, suggest a need for better communication. A lack of knowledge or an incorrect interpretation of official messages hinders public health efforts and damages the effectiveness of the adopted strategies to tackle Covid-19 even among those who wish to comply.
Focusing on clearer and more effective information campaigns, and on the provision of easier access to reliable sources of information, is fundamental and could also promote confidence in political and health authorities, and trust in official health advice. This is especially true in the era of social media, as it can be challenging for some to identify trustworthy advice given the proliferation of 'fake news'.
Rates of compliance are heavily influenced by financial constraints and depend on income support, job protection and support with accommodation. The economic risks of self-isolating are often perceived as more significant than risks to health, particularly for people from more disadvantaged backgrounds.
Providing financial support and reimbursement of any potential income loss arising from the need to self-isolate or quarantine has been at the core of state interventions in Scotland, across the UK and in a number of countries around the world. There has been a significant effort to align public health responses with people's lived realities, in the awareness that the ability to comply with the public health measures depends on people having the resources to do so, in particular if they are easy to obtain and provided promptly.
Furthermore, the evidence that working outside the house is related to lower compliance identified a need to improve or enforce guidelines in workplaces and support those who are pressured into returning or continuing to work.
Other types of successful support packages offered by local governments and community based teams include provision and delivery of food and medicines, care for older relatives, dog walking, assistance with self-isolation accommodation, cleaning supplies, and personal protective equipment.
Cultural and language barriers to compliance
The ability to self-isolate tends to be lower in certain minority ethnic groups, possibly due to a combination of socio-economic, linguistic and cultural factors. Terms such as 'self-isolation' are not always well understood when translated, as the translated words may not retain the exact meaning as the original.
The importance of providing accessible information in a range of languages and to communities with varying degrees of health literacy plays a vital role in promoting adherence to isolation regimes. Furthermore, it is key to target communication inequalities by consulting representatives from minority groups, ensuring that the interventions are developed in partnership with the interested population.
Community support for adherence
Adherence to self-isolation/quarantine regulations can be influenced by interpersonal interactions and perception of others within the community, with research showing that people feel encouraged to comply if they see others doing so. Some research has found that compliance is also affected whenever index or contact cases have become a target of stigma in the community. This can create a reluctance to get tested or concerns about the consequences of triggering self-isolation for others.
Looking at ways to link people up with community support mechanisms, for example developing community-based peer education programmes and empowering community stakeholders to contribute to the Covid-19 response, might improve adherence. Furthermore, emphasising the relatively high prevalence of compliers, rather than accentuating the minority of non‐compliers with self-isolation and quarantine regulations, might elicit higher feelings of social connectedness and foster adherence based on positive attitudes towards others.
Sense of civic duty and community belonging
Research shows how compliance with rules improves when this is perceived as a contribution to the wellbeing of the community as a whole. Therefore, appealing to a sense of civic duty, community belonging and altruistic motivations has been identified as a successful strategy to promote compliance with self-isolation and quarantine regimes. The literature suggests that any communication that 'we are all in this together' from political leaders determines a sense of collective self-efficacy and hope. Public health officials have also been encouraged to emphasise civic duty in order to increase the perceived benefit that complying will have on public health.
The belief that Covid-19 does not pose a serious risk (especially in the case of asymptomatic disease) and the inability to see self-isolation as beneficial are associated with lower adherence. Risk perception tends to vary according to demographic variables like age and gender, with men and younger people being more permissive and less risk averse than women and older people.
Communications focusing on risk of transmission or the exponential nature of transmission might improve compliance. The positive role played by fear of Covid-19 has also been explored and some research shows how those with higher fear scores are more inclined to be compliant with regulations on isolation. Yet, the adoption of fear messages might have some limitations in some contexts, where prosocial messages could prove more effective. A message that is perceived as too threating could cause people to engage in defensive avoidance, hence to disregard the message altogether. There is also a possibility that messages associated with negative emotions might produce unnecessary mental health concerns.
A link between poorer mental health and non-compliance with self-isolation and quarantine has been observed, with feeling depressed, anxious, lonely or bored indicated as reasons for breaking the rules.
Mitigation measures have included access to emotional support or clinical interventions delivered remotely where possible. Recommendations have also been made for mapping local resources and sources of support from voluntary and community organisations. Promoting virtual social interactions, online social reading activities, classes, or exercise routines have also been suggested.
Given the disproportionate prevalence of mental health difficulties in BAME groups, and the disproportionate impacts on these groups from Covid-19, the governments of all four nations have been invited to engage directly with representatives of BAME communities in order to develop culturally appropriate and readily accessible mental health support.
Monitoring and enforcement of self-isolation/quarantine rules
With an increase in case numbers and the emergence of new strains of the virus over the course of the pandemic, stricter measures have been implemented internationally to reduce transmission. These have included the introduction of the legal duty to self-isolate and of fines, random checks, managed quarantine hotels for international travellers and the closure of various locations, including shops, restaurants, cultural attractions and so on. While institution-based isolation (e.g. in hotels) has proved to be more effective than home-based isolation in increasing compliance, evidence on other kinds of enforcement solutions is mixed and presents a dimension of cultural variation. Enforcement approaches could pose a number of issues, for example discourage testing uptake and honest reporting during contact tracing, or impact more on low-income individuals when it comes to fines. Furthermore, these measures risk focusing on the wrong solutions to low rates of compliance, namely poor knowledge of what is required during self-isolation or lack of adequate financial, practical and social support.
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