Compliance with the requirement to self-isolate
In September 2020, SAGE identified a lack of robust and regular data on compliance with the requirement to self-isolate. Prior to this research, little was known about the extent to which those asked to self-isolate in Scotland managed to comply successfully. Accurately measuring compliance was challenging. When directly asked about how well they managed to follow the self-isolation guidelines, the majority view was that guidelines were followed all of the time. Yet, for many, there was a clear mismatch between their own assessment of how well they managed to follow the guidelines and the separate measure of behavioural compliance derived from other survey responses, the latter indicating that 7 in 10 participants fully complied with the requirement to self-isolate.
Compliance declined over the three waves of survey fieldwork and also varied by case type, with Index Cases more likely than Contact Cases to fully adhere. Contact Cases who lived with someone that tested positive were more likely than those that did not live with a positive case to fully comply. Compliance also varied by sex, age, acceptance of Local Authority support and support for the self-isolation strategy.
The research revealed interesting differences in adherence to aspects of the self-isolation requirement by case type. For example, while Contact Case participants were more likely than Index Cases to begin isolating straight away, Index Case participants were more likely to isolate for the correct number of days and/or to stay at home during self-isolation.
While the most common reason given for a delayed start to self-isolation, or leaving home during it, related to the permitted activity of getting or sending a COVID-19 test, non-compliant activities included going to the shops and for outdoor recreation.
Instances of non-compliance with self-isolation requirements were low across all case types although this was likely, in part, due to the opt-in nature of the survey. It was apparent from the qualitative research that participants were not always clear themselves when they breached the guidelines, with those who admitted breaches describing them as minor infractions, with steps being taken to minimise risk to others.
Knowledge and understanding of the self-isolation requirement
Compliance with the requirement to self-isolate requires both the willingness and circumstances to do so, but also understanding of what it means to self-isolate successfully. One of the aims of this research was to determine the levels of knowledge and understanding of the self-isolation requirement among those asked to self-isolate by Test and Protect.
Awareness, across all case types, of the requirements for positive cases to isolate for 10 days and for a close contact to isolate for the same length of time (even if they later test negative themselves) suggests that the messaging around these requirements has been largely effective. Similarly, awareness of what activities were, and were not, permissible during a period of self-isolation was generally high. However, it was clear that gaps in knowledge exist across different groups of people in the Test and Protect system and around specific aspects of the requirement itself. For example, men and those in the youngest (aged 16-24) and oldest age groups (aged 65 and over) were less familiar than others with the 10-day isolation requirement for positive cases. Men and young people (aged 16-24) were also more likely than others to think that attending a planned medical appointment was permissible during self-isolation and that leaving isolation for outdoor recreation was allowed.
Survey data point to an association between knowledge of the 10-day requirement for positive cases and compliance with self-isolation among Index and Contact Cases. For several activities, and across all case types, there was also a clear association between knowledge of whether an activity was allowed or not and whether a person carried out this activity. While qualitative evidence indicates that this observed relationship between knowledge and compliance may not necessarily be as straightforward as survey data would suggest, addressing the knowledge gaps that exist could have a potentially positive impact on compliance with the requirement to self-isolate. Participants reported that they would like further information and guidance on: permitted tasks during self-isolation; extended isolation periods; requirements for International Travellers; when and how often they should be tested for COVID-19; and how to self-isolate within households with other occupants who did not have to isolate.
Attitudes and views of self-isolation
Willingness to adhere to the guidelines and a belief in the validity of the self-isolation approach have an important part to play in any self-isolation strategy. This research aimed to explore the isolation experience for individuals and the extent to which those asked to self-isolate believed in the strategy as a means of helping prevent the spread of COVID-19.
Acceptance of the self-isolation strategy was high across all case types, and among Index and Contact Cases in particular. There was a consensus that, as a strategy against the spread of COVID-19, it was effective and that individuals were not necessarily best placed to decide whether they should self-isolate or not. Furthermore, among Index and Contact Cases, belief in the effectiveness of the self-isolation strategy increased with age, indicating potential to further educate younger people on the important role self-isolation plays in preventing the spread of COVID-19. However, nearly a fifth of International Travellers were unconvinced that international travel rules would help stop the spread of COVID-19 and any variants.
While there appears to be a relationship between views on the effectiveness of the strategy and compliance with the requirement, we know that there were likely to be multiple combined factors that lead to successful self-isolation.
The study confirms that self-isolation can be mentally challenging and distressing for some. Irrespective of the reason for self-isolating, around half that took part in the survey reported that the experience had impacted negatively upon their mental health. The burden on mental health was most pronounced among young people aged 16-24 and those who had to self-isolate more than once. Among International Travellers the detriment to mental health from self-isolation was more acute among those in managed isolation, many of whom found hotel quarantine both financially and emotionally challenging.
The association between compliance and perceived impact on mental health, together with the relationship between experience of repeated self-isolation and negative mental health impacts, point to how emotionally challenging self-isolating can be for some people and the impact that mental health issues may have on adherence to self-isolation guidelines.
There was also clear evidence of how financially challenging self-isolation was for some. Young people were most likely to cite that self-isolation had a negative impact upon their employment and income, although this was by no means unique to them. Those living in Scotland's two most deprived SIMD quintiles were most likely to state lost income and/or job loss/missed work opportunities as a result of the need to self-isolate. Improving awareness of the formal support on offer may, in part, help to address some of these challenges.
The majority of Index and Contact Cases that took part in the research reported being tested more than once. However, given the criteria around international travel and self-isolation, it was not surprising that International Travellers were the case type most likely to be tested multiple times.
Conducting the survey fieldwork over waves revealed a decrease in Index and Contact Case participants reporting being tested as a result of experiencing symptoms and a corresponding increase in the proportion tested after being identified as a close contact. The observed increase in home testing, and the proportion receiving test results within an hour, coincided with the introduction of free lateral flow tests. Home testing kits were most commonly used by those living in Scotland's more deprived areas. The consensus was that the instructions for testing were clear and easy to understand.
It does appear to be the case that Index and Contact Case participants whose last test result was positive were more likely than those testing negative to fully comply with the requirement to self-isolate. While the relationship between testing and compliance was likely to be a nuanced one, it may be the case that the messaging around the need to isolate for the required period of time, irrespective of the test result, requires to be restated on a regular basis.
Scottish Government guidance, during the lifetime of this research, was for the public to follow the self-isolation guidelines, FACTS and the COVID-19 restrictions in place, irrespective of vaccination status. Data on vaccination status were collected to learn more about how it related to the requirement to self-isolate and to explore the impact this may, or may not, have on planned future behaviour.
There was little difference noted between current vaccination status (no doses, 1 dose, or both doses) and self-isolation behaviours. However, some interesting differences emerged by age and case type when participants were asked about their likely behaviour once all were fully vaccinated against COVID-19. International Travellers were least likely to report being willing to self-isolate again if asked to do so under these circumstances, while those aged 64 and under were more likely to say they intended to come into close contact with friends or family than those 65 and above. The majority, across all case types, appeared happy to come into close contact with others again once fully vaccinated, and as many as half reported being likely to visit vulnerable family and friends once fully vaccinated. These findings on likely future behaviour will remain pertinent as more becomes known about the protection current vaccines offer against variants of the COVID-19 virus.
Support during self-isolation
It is recognised, and widely accepted, that there were many factors that make self-isolation challenging for an individual. This research aimed to identify and understand more about the support needs and challenges encountered by those asked to self-isolate. The findings identified ways the messaging around formal support could be strengthened, as well as how the support on offer could be adapted to help those self-isolating as much as possible.
Most Index and Contact Cases were aware of being offered some level of formal support, particularly the option of being contacted by their Local Authority, when asked to self-isolate. However, a notable proportion did not recall any formal support offer being made, yet would have liked more support to be available, or at least made evident to them, particularly with regards to the clarity of information on self-isolation requirements and in light of any changes to regulations.
Reported formal support uptake among Index and Contact Cases was low, and this was particularly true for several, potentially vulnerable, groups including: those who did not have the back up of informal support from friends, family and neighbours, those on lower incomes and those with a limiting long-term illness.
There appears to be scope to increase awareness of what formal support was available, how this can be accessed, and from whom. Of concern was the apparent lack of knowledge of the Self-Isolation Support Grant among those most likely to be eligible for it – e.g. those on lower household incomes. Building the profile of the formal support on offer could have positive impacts on both compliance with and experiences of self-isolation, particularly among some sub-groups of society who could benefit from extra support during the 10 days. Acceptance of Local Authority support was associated with compliance with the requirement to self-isolate.
Findings indicate that, when accepted, the formal support on offer during self-isolation was mostly well-received and effective at meeting the practical and financial support needs of those seeking support. That said, many asked to self-isolate were clear that they did not need formal support. Family, friends and indeed employers played a crucial role in providing practical and emotional support during self-isolation, and it is likely that many will choose to access these support sources in the future even if more formal support is available.
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