REVISED VERSION NOVEMBER 2020

Pandemic fatigue Reinvigorating the public to prevent COVID-19

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Policy framework for supporting pandemic prevention and management 4 Pandemic fatigue

Executive summary

Despite documented public support for pandemic Responding to a request from Member States for support response strategies across the WHO European Region, in this field, this document provides a framework for the Member States are reporting signs of pandemic fatigue planning and implementation of national and subnational in their populations – here defined as distress which can strategies to maintain and reinvigorate public support to result in demotivation to follow recommended protective prevent COVID-19. behaviours, emerging gradually over time and affected by a number of emotions, experiences and perceptions. Pandemic fatigue is an expected and natural response to a prolonged public health crisis – not least because While pandemic fatigue is an individual reaction, the severity and scale of the COVID-19 pandemic have governments acknowledge their responsibility to address called for the implementation of invasive measures with the factors that lead to fatigue. unprecedented impacts on the daily lives of everyone.

Protective Opportunity Capability behaviours

Motivation

Fatigue

The framework is intended to We propose four key strategies for governments to support pandemic prevention and maintain and reinvigorate public support for protective management. behaviours.

Given the complex nature of pandemic fatigue, a multifactorial action plan is needed. Actions must be based on the barriers and drivers Understand people. Collect and use Engage people as part of the experienced by people, and must be evidence for targeted, tailored and solution. Find ways to meaningfully implemented in an integrated way effective policies, interventions and involve individuals and communities across all levels of society. communication. at every level. Strategies to maintain and reinvigorate public support must be informed by public health, societal, cultural and economic Allow people to live their lives, Acknowledge and address the considerations, and must ensure but reduce risk. Wide-ranging hardship people experience and the that no one is left behind. restrictions may not be feasible for profound impact the pandemic has everyone in the long run. had on their lives. Pandemic fatigue 5

For any initiative, policy or communication aiming to maintain and reinvigorate public support for protective behaviours, we propose five cross-cutting principles.

Be transparent by sharing reasons Be as consistent as possible in Strive for predictability in behind restrictions and any messages and actions, and avoid unpredictable circumstances, for changes made to them, and by conflicting measures. example, by using objective criteria acknowledging the limits of science for restrictions and any changes and government. made to them.

Coordinate to avoid mixed messages across experts and Strive for the highest possible level spokespeople. of fairness in recommendations and restrictions.

As a quick list of concrete actions, we propose the following.

Think local. Reach out to civil Prepare safe solutions for Appeal to people rather than society groups and ask them to find upcoming national celebrations blame, scare or threaten them. creative ways of motivating their where people gather across Recognize that everyone is members and peers. geographies and generations. Engage contributing. individuals, workplaces, public transportation systems, the retail sector, retirement homes and more in In every workplace, school, discussions about ways to reduce risk. Be clear, precise and predictable. university, youth club and Provide clear recommendations. Use simple and digestible info­ more, talk to users. Ask them graphics as an effective way of how they would like to implement communicating restrictions and risks – recommended behaviours. Ask them and how they are related. what support they need from you. Understand which measures may be unbearable in the long term. Amend or balance such restrictions with other measures (economic, Conduct regular qualitative and social, psychological), taking into Develop guidance on living life while quantitative population studies. account the epidemiological risk. reducing risk. Find creative ways of Take the findings seriously. Use them communicating such guidance, and to inform action. avoid constant changes.

Make recommended behaviours easy and inexpensive. This can Tailor communication to specific involve the provision of fast and groups that experience demotivation. cheap internet connections, free Test messages and visuals with masks and hand sanitizers, accessible sample populations before launching hand-washing areas, spaces for them. social interaction, opportunities for teleworking, and more. 6 Pandemic fatigue

Introduction

Behavioural insights surveys consistently confirm It provides a framework for Member States to help that the majority of people generally support them plan and implement national and subnational national COVID-19 response strategies, uphold high strategies in this field. It draws on the results of knowledge levels and wish to follow recommended behavioural insights surveys conducted across the behaviours (1). This is notable after half a year of European Region, including those based on a WHO lockdowns, restrictions and significant impacts on tool (2), as well as pre-COVID-19 literature related all of our everyday lives. to public health, health crises, resilience, trust, risk perception, cultural contexts, communication and Still, Member States across the WHO European more. It includes a range of country case examples Region are reporting emerging pandemic fatigue as inspiration.1 It has been reviewed by a range of in their populations. We consider pandemic Member State representatives and topic experts. fatigue as an expected and natural reaction to the prolonged nature of this crisis and the associated This framework is intended to support pandemic inconvenience and hardship. However, it poses a prevention and management. It should be read serious threat to efforts to control the spread of the in conjunction with other key WHO resources, in virus. Until a vaccine or effective treatments are particular Risk communication and community available, public support and protective behaviours engagement readiness and initial response for novel remain critical for containing the virus. The gains coronaviruses: interim guidance (3), and the Risk that each nation collectively achieved through communication and community engagement lockdowns and other measures – sometimes at high strategy for COVID-19 template (4), which supports social and economic costs – must be safeguarded. countries to tailor their own strategies.

Very limited experience exists on how to best This document includes the following sections. maintain or reinvigorate public support during a global health crisis that expands over months What is pandemic fatigue? (potentially years) and that affects every member National plans of action of every society in every country. – Key strategy: Understand people – Key strategy: Engage people as part of the solution While pandemic fatigue is an individual – Key strategy: Allow people to live their lives, but reaction, governments acknowledge their reduce risk responsibility to address the factors that lead – Key strategy: Acknowledge the hardship people to fatigue. experience – Checklist: Cross-cutting principles This document was prepared in response to requests 10 suggested actions from Member States for guidance on responding to pandemic fatigue and reinvigorating public support for protective behaviours.

1 Please note that the country case examples included in this publication are included for inspiration. There is a lack of evidence related to the health outcomes if interventions implemented during the COVID-19 pandemic, and this relates to the case examples included here as well. Including the case examples here does not imply the expression of any opinion whatsoever on the part of the WHO Regional Office for Europe concerning the appropriateness, acceptability, or impact of these case examples. Pandemic fatigue 7

What is pandemic fatigue? What do we mean by pandemic fatigue? – A natural and expected reaction to Pandemic fatigue is understood in this document as sustained and unresolved adversity in distress as a reaction to sustained and unresolved people’s lives. adversity which may lead to complacency, – Expresses itself as a feeling of distress, alienation and hopelessness, emerging gradually and in some places as emerging over time and affected by a number of emotions, demotivation to engage in protection experiences and perceptions (5,6).2 behaviours and information search and as feelings of complacency, alienation Pandemic fatigue is expressed differently in and hopelessness. different contexts. The pandemic fatigue reported – Evolving gradually over time and affected from countries is expressed through an increasing by a number of emotions, experiences and number of people not sufficiently following or perceptions as well as the cultural, social, accepting recommendations and restrictions structural and legislative environment. and/or decreasing their effort to keep themselves informed about the pandemic. Previously effective core messages regarding washing hands, wearing face masks, and practising proper hygiene etiquette Several components related to individual motivation and physical distancing may seem less effective, have been strongly impacted by the longevity of and many countries have identified a need for the pandemic situation. First, the perceived threat reinvigorating approaches. of the virus may decrease as people become used to its existence – even if the epidemiological data Such reactions are natural and expected at this show that the risk may, in fact, be increasing. At stage of a crisis. At the beginning of a crisis, most the same time, the perceived loss resulting from people are able to tap into their surge capacity – the pandemic response (lockdowns, restrictions) is a collection of mental and physical adaptive likely to increase over time as people experience the systems that humans draw on for short-term long-term personal, social and potentially economic survival in acutely stressful situations. However, consequences of restrictions. For some people, the when dire circumstances drag on, they have to balance may shift, and the perceived costs of the adopt a different style of coping, and fatigue and response may start to outweigh the perceived risks demotivation may emerge (7,8). related to the virus.

These reactions are part of a complex interplay of Second, an ingrown urge for self-determination and many factors that affect protective behaviours. freedom may grow as restrictions continue for a These relate to individual motivation and capability long time, impose inconveniences in everyday life, or as well as to opportunities offered by the cultural, continuously change in ways people feel they have social, structural and legislative environment (see little control over. Fig. 1) (9). Each of these factors can be barriers to and/or drivers of protective behaviours.

2 Pandemic fatigue as a concept is not well defined in the literature. We understand this as the fatigue (distress and potential emerging demotivation) related specifically to the COVID-19 pandemic and the restrictions imposed to contain it. For a discussion of fatigue and how it may change perceptions and behaviours, refer to Increasing belief but issue fatigue: changes in Australian Household Climate Change Segments between 2011 and 2016 (5). 8 Pandemic fatigue

Third, even the most outrageous circumstances pandemic and the threat it poses, and complacency become normal when experienced over longer may result. periods of time. People may become used to the

Fig. 1. The interplay of factors affecting COVID-19 protective behaviours

Peers’ expectations and behaviours Cultural norms, Rights and Awareness values regulations

Protective Access behaviours (water, sanitizer, Workplace/ school Mental (Health) non-public ability literacy transportation) support

Income

Opportunity: Capability: Social and physical Physical and psychological Contextutual Experiences Individual Values and Intentions beliefs

Perceptions Emotions Fatigue

Risk Self-efficacy perceptions

Trust Complacency

Motivation: Automatic and reflective Individual

Fig 1. draws on the COM-B model, a widely used theoretical model to understand the factors affecting behaviours (9). It proposes three overall factors that need to be in place for any behaviour to take place: individual motivation (automatic and reflective), individual capability (physical and psychological) and contextual opportunity (social and physical). The subcomponents of each factor can function as barriers to and/or drivers of the behaviour. Pandemic fatigue 9

National plans of action

Both before and during the COVID-19 pandemic, cutting principles for any policy, intervention or considerable research has been conducted on fatigue communication that aims to reinvigorate public and factors such as trust, risk perception, social and support for protective behaviours (see Fig. 2). cultural norms, and structural opportunity (10–16). Drawing on this research and on the complex nature Surveys across countries show that most people of pandemic fatigue, we propose a multifactorial have a high level of knowledge related to COVID-19 plan of action. protective behaviours and are mostly able to find the information they need. Yet emotions and Overall, we recommend understanding people by contextual factors can have a greater impact on drawing on evidence from epidemiological data and behaviours than knowledge (17), which means population research. More specifically, we recommend that a strategy aiming to provide information focusing on engagement, harm reduction and and public health advice alone may not be recognition of hardship. We also propose five cross- the most effective. Rather, strategies should

Fig. 2. Four strategies and five cross cutting principles

Key strategies in policies, Acknowledge Engage people Allow people Understand and address the interventions and as part of the to live their lives, people hardship people communication solution but reduce risk experience

Cross-cutting principles Transparency Fairness Consistency Coordination Predictability 10 Pandemic fatigue

focus on policies and interventions as well as Supporting documents communication. As noted above, this document should be read in conjunction with other key WHO resources, in The strategies and policy considerations of this particular Risk communication and community framework should always be considered in light engagement readiness and initial response for of the epidemiological situation. It is not the novel coronaviruses: interim guidance (3), and the intention of this framework to discourage against Risk communication and community engagement the implementation of pandemic control measures strategy for COVID-19 template (4), which supports when they are called for. However, governments countries to tailor their own strategies. have opportunities to alleviate the adverse impacts of these measures through careful planning, implementation and communication and through additional social protection measures and policies to ensure that no one is left behind. Pandemic fatigue 11

Key strategy / Understand people

Background Strategic considerations Pandemic fatigue results from various barriers that – Identify priority population groups – those people experience across cultural and national that show signs of demotivation and those with contexts, and that require different kinds of support, increasing transmission. Use population surveys structures and communication. and surveillance data.

Understanding who is experiencing demotivation – Understand what motivates them; understand and the barriers and drivers impacting their ability the barriers they face. Use qualitative and or willingness to take up protective behaviours quantitative population studies, media allows decision-makers to segment and tailor monitoring and hotline feedback. actions to their particular needs. Barriers and drivers can exist within various areas (see – Use what you learn. Use it to identify emerging Fig. 1), and may relate to individual capability or perceptions and needs. Use it to inform pandemic motivation, or to the social, cultural, structural or policies, communication and other interventions. legislative environment. Careful consideration of Behavioural insights are only valuable if they these elements leads to more successful and cost- inform action. effective policies, interventions and communication. – Test new initiatives, messages and For communication in particular, quality over communication with the people whose quantity should be the credo at this stage of behaviours you wish to change. Use (online) focus the pandemic. High-quality, evidence-informed, groups or other research approaches. tailored communication should be directed to key population groups. Many people now – Communicate government needs, priorities have high knowledge levels, particularly of and knowledge gaps to the research community protective measures (1). At the same time, the to ensure that the research agenda is relevant so-called COVID-19 infodemic has resulted in an and timely. overwhelming amount of available information and doubt about which sources are trustworthy (17). For these reasons, less may be more. 12 Pandemic fatigue Case examplesPandemic for inspiration fatigue 12

France Ukraine Documenting personal Engaging experts from Using a behavioural Tailoring health experiences using the health humanities insights survey to inform messages to target creative and innovative in discussions of a strategy for reopening groups methods restrictions schools

Experts at Public health Discussions of pandemic Reopening schools Behavioural insights deepened their restrictions naturally after the lockdown surveys in Ukraine understanding about involve virologists and posed important policy identified men with low people’s experience of the medical specialists. challenges for authorities education as a group with pandemic and related In Germany, however, across the Region. Not low adherence and low restrictions through other voices were being able to offer risk perception related following a group of 60 engaged to help balance education in a safe to COVID-19. To tailor people via an on-line ethical, cultural and environment could quickly communication to this community platform. behavioural aspects lead to public distrust critical group and enhance During the 3 months of while safeguarding public and demotivation. The impact and relevance, the study, the retention health – all critical aspects Government of Romania new COVID-19 messages rate was remarkably of maintaining public used findings from a and visuals were tested high. The participants support and preventing behavioural insights in focus groups. Tailoring who were chosen to be demotivation. The Federal survey conducted in health messages to diverse in terms of age, Government consulted the country to inform specific population groups gender and more replied philosophers, historians their strategy. The study can enhance impact and weekly to one or two of science, theologians, confirmed high support relevance. Focus groups open questions. They pedagogical experts for reopening schools for can also be used to were asked to document and jurists who provided both younger and older revitalize health messages, their life such as filming valuable input, including children. Such studies which is important given themselves while washing on the educational can help governments to that sustained exposure their hands. Although progress of children from identify developments over renders messaging less people reported regular disadvantages families, the time, new issues as they effective over time. hand-washing, researchers legitimacy of restrictions of emerge, and the positive could see that this was freedom, and the balance and negative effects of rarely done effectively. between public support restrictions, messages or Using qualitative methods and moral norms versus actions. and creative approaches coercive state action (19). may uncover new types of insights that can provide valuable information to inform policy (18).

Please note disclaimers on page 2 Pandemic fatigue 13

Key strategy / Engage people as part of the solution

Background Listening to people, understanding their needs, and Humans have an essential need to feel in control planning policies that are responsive to those needs of their own lives, and when this autonomy and that reflect people’s sense of self-identity all is threatened, motivation is easily lost (20). promote feelings of engagement. Stories are also Reinvigorating public support thus involves powerful motivators: research shows that people engaging people as part of the solution (21,22). are more likely to follow actions if information is Above all, engagement should give people a sense presented in a way that matters to them (24). that recommended behaviours are not a matter of capitulation to authority or a reflection of despair, For specific communities and population groups, but a part of something positive, hopeful and (if at engaging trusted voices in promoting protective all possible) fun (16,23). Such engagement can take behaviours as a social norm is likely to increase many forms on national, community and individual support (25–27). During the Ebola crisis, enlisting levels. the faith-based sector and trusted community members was seen as a turning point in the Promoting self-efficacy and positive majority epidemic response (28,29). Experience from the behaviours can be a cornerstone in national COVID-19 pandemic also demonstrates that strategies and communication. Rather than community cultural resources, norms and values focusing on those who do not follow behaviours, it offer vital resources for building and maintaining may be more effective to highlight the many who prevention efforts(16) . do, as well as positive majority norms and the public health gains achieved through collective effort. On an individual level, people can be engaged locally in workplaces, schools, sports clubs and more. 14 Pandemic fatigue

Strategic considerations – Use commitment contracts. Encourage local – Pass the baton on to others. Consider civil initiatives to engage people in setting goals and society groups and leaders who could be pledging to follow behaviours. engaged to take on leadership roles in enabling and promoting protective behaviours: consider – Enlist trusted voices in health messaging, and national youth organizations, local and national showcase those who have tackled COVID-19 in a housing associations, religious leaders, sports positive way or those taking a lead in volunteering clubs and scouting organizations, and business or to help others. community organizations. – Focus messages on strengthening self- – Learn from civil society and actively engage efficacy,shifting from “the pandemic controls them in developing scenarios for future local/ our behaviours” to “we control the pandemic with national lockdowns. our behaviours”. Highlight the tremendous public health gains achieved through collective effort. – Ask civil society to find creative ways of motivating their members and peers. Ask them – Seek to inspire as well as inform. Tap into what support they need from you. Engage the power of stories and those who tell them volunteers. Involve them in the design and well. Find creative ways or new opportunities to delivery of COVID-19 policies, interventions and reiterate messages that engage people. Work messaging. They can all play an active role. with professional writers, journalists, artists, and other types of storytellers to create narratives – In every workplace, school, university, youth based on the insights gathered from working with club and more, ask users to discuss how they communities. would like to implement the recommended behaviours. These discussions can reveal barriers, inconveniences and misperceptions that can be addressed while still maintaining restrictions. Case examples for inspiration Pandemic fatigue 15

Denmark Co-creating solutions: Engaging people to reflect on Engaging staff to plan @hvemdelerduspytmed their own environment kindergarten reopening [who do you share saliva with]

The Danish Lung Association co- The WHO Country Office in Turkey National strategies for the reopening created a campaign with its target has carried out Twitter polls asking of kindergartens in Norway group of young people, encouraging questions such as “What are you included a degree of flexibility. This them to enter a competition to come doing to protect your health?”. way, communities and individual up with ideas for how to spend time These types of low-cost engagement kindergartens could operationalize together in a safe way during the activities may spur people to think restrictions and protection measures pandemic. Actively involving target critically about their own behaviours in ways that were tailored to their groups in the design and delivery of and social environments while context. Kindergarten staff in some engagement activities can ensure serving as a reminder of the ongoing places convened to discuss and that they are tailored and responsive pandemic. collectively agree on sustainable to the perspectives and experiences of local solutions to meet national the people they strive to reach (31). requirements. Recognizing that West Africa people are experts of their own Partnering with trusted voices environment, this approach of demonstrates the importance of America During the Ebola epidemic, Christian enabling local decision-making, Sharing commitment contracts and Muslim faith leaders used ownership and autonomy in national through grassroots movements passages from religious texts to show planning (30). that modified burial rituals were In Florida, two brothers launched the still spiritually acceptable. In cases “Promise to Humanity” campaign where religious rituals are affected with a single goal: to enlist people by COVID-19 restrictions, engaging in signing contracts pledging to religious leaders may increase the follow all guidelines in an effort to acceptability of adapted ceremonies. slow the spread of the virus. After Community leaders often have signing the pledge online, followers a high level of trust and a good could nominate three more people understanding of the community to do the same. Such commitment norms and values, which can be of contracts are known to influence great value to decision-makers in people’s behaviours and keep them policy formulation (33). dedicated for longer (32).

Please note disclaimers on page 2 16 Pandemic fatigue

Key strategy / Allow people to live their lives, but reduce risk

Background The demotivation reported among some people is This approach can also be applied at a national in part a reaction to the longevity of the pandemic. level. Member States who have recently applied While early strategies could draw on far-reaching new restrictions to address case resurgences have interventions such national lockdowns, long- done so mostly locally by applying smart, time- term strategies will need to go beyond a state of limited and risk-based measures rather than broad emergency and allow people to return to something and extended restrictions. This targeted approach that resembles normal life. can reduce COVID-19 spread and its impact on society and the economy while allowing for the Thinking in terms of harm reduction may be a way continuance of elements of normal life. forward. When adopted to address issues such as alcohol abuse and sexually transmitted infections, including HIV, harm-reduction approaches have lowered morbidity and mortality (34). As different as this pandemic is, such approaches may prove useful for those who struggle to abide by restrictions.

A harm-reduction approach recognizes that stopping behaviours entirely may be difficult, but reducing the harms associated with these behaviours may be possible. With this in mind, a harm-reduction approach encourages a spectrum of acceptable behaviours (35). When presented with all-or-nothing scenarios and daunting standards of success, people are more likely to give up easily and revert to very risky behaviour. In the context of the COVID-19 pandemic, this may take the form of throwing a large party because not being social at all has come to feel unsustainable. While small-group socializing may not be 100% ideal, it is preferable to a reactive burst of large-group activities. Pandemic fatigue 17

Strategic considerations – Consider whether all cultural events need to – Help the public differentiate between lower- be cancelled, or if they can be implemented in risk and higher-risk activities, and ensure that safe ways, for example, through a combination there are support mechanisms in place for the of online and physical events with mechanisms to lower-risk options when sustained abstinence is ensure safe practices. Engage in a dialogue with not an option. organizers and find creative solutions together.

– Develop guidance on how to carry on with life – Encourage individuals and communities to while reducing the risk of transmission. Guidelines identify harm-reduction strategies that fit their can offer options for safer dinner parties, needs. children’s play dates, workplace interactions, dates, funerals, weddings, travel, etc. Find – Shift messaging from “do not” to “do creative ways of communicating these. Stick differently”. with recommendations rather than constantly changing them. – Avoid judgment and blame related to risky behaviours, as this can contribute to shame – Start preparing for end-of-year celebrations, and alienation more than engagement and and think ahead to other large-scale motivation. celebrations over the year. How can individuals, workplaces, public transportation, the retail sector and retirement homes, for example, be engaged to reduce risk leading up to these events where people meet across geographies and generations? Ask for their input and develop the guidance they need. Provide clear recommendations. 18 Pandemic fatigue Case examplesPandemic for inspiration fatigue 18

Netherlands Denmark United States of When abstinence is not A new format for Safe social interaction: America an option: the “cuddle cultural events the floating cinema Keeping track with a buddy” contact budget

Recognizing that people The annual Copenhagen In Israel, a local business An American need physical contact, Pride festival is usually a opened a floating cinema epidemiologist suggested a including during a large-scale public event where people can rent a basic method of reducing crisis, authorities in with colourful parades in boat on a lake and enjoy harm in everyday life: the the issued the streets and widespread a movie while respecting use of a contact budget. guidance to single people celebration. This year, rather physical distancing Just as a household budget seeking intimacy during the than cancelling the event, requirements. Encouraging provides an overview of pandemic. They advised organizers extensively and supporting start- where money is spent them to find just one changed the format to ups and local businesses and where savings can be cuddle buddy rather than include mainly online as to think creatively and made, a contact budget being intimate with several well as physical activities. “do differently” is key to allows individuals to partners. Similar guidance Engagement with a broad ensuring the provision keep track of exposure. has been issued in several range of stakeholders and of social spaces and Recognizing that some countries. Supporting national health authorities recreational opportunities – level of risk is unavoidable, people to balance high- allowed for a safe event critical elements in methods and tools like risk and low-risk activities and the continuation of an countering pandemic this may help people to rather than issuing all-or- annual celebration that is fatigue (37). consciously and critically nothing recommendations important to many people. examine their own habits may help to prevent Similar harm-reduction and choices to minimize demotivation (38). strategies and guidance risk (39). can be tailored to rituals and holidays of social and cultural importance. With a specific goal in mind – such as meeting loved ones – and with people involved in setting the rules, the motivation is likely to be high (36).

Please note disclaimers on page 2 Pandemic fatigue 19

Key strategy / Acknowledge and address the hardship people experience

Background Surveys show that the perceived loss related to Pandemic restrictions have imposed both hardship pandemic restrictions can be higher than the and inconvenience in everyday life, and everyone perceived loss related to the virus itself. has experienced some kind of loss – of income or a Behavioural insights surveys often show, for job, of educational progress, of being with friends example, that fewer people have a high perception and family, of engaging in sports activities, or of the of risk related to the virus itself, and that more chance to participate in important rituals such as people indicate stress caused by concerns related to weddings, graduations, funerals and more.2 It is well the pandemic response, such as losing their job or established that the pandemic and its restrictions income (1). have led to stress, loneliness and boredom, and have had a negative impact on well-being and Under such circumstances, it is not a small request mental health among many (1,40,41). Those already to ask for continued population support. If this experiencing disadvantages have been shown to be hardship is not well understood, acknowledged and affected even more negatively (42–45). addressed by those asking for population support, people may very well lose motivation and COVID-19 initiatives, policies or communication may become unsuccessful. The fatigue resulting from hardship can be addressed by building resilience and alleviating difficulties where and when possible, including through financial, social, cultural and emotional support offered by the government and civil society.

2 The greatest losses relate to the serious illness and death caused by COVID-19. Additional guidance is needed on providing support to those who have experienced illness or lost loved ones. 20 Pandemic fatigue

Strategic considerations – Explore if difficult-to-follow restrictions – Identify and address the barriers and can be balanced with other measures to hardships people face, and understand which alleviate negative impact. This could take the measures may be difficult to follow in the long form of financial support schemes, or social, run (for example, isolation that results in loss of psychological or mental health support such as employment or income). free online services.

– Make new habits of protection behaviours less – Create opportunities for people to fill their costly. In terms of money: how can protection time productively if isolated or unemployed due behaviours be as inexpensive as possible? And in to the pandemic, such as training or employment terms of effort: how can we make recommended programmes, employment subsidies, or start-up behaviours as effortless as possible for people? incentives. Help them to build more structure into everyday life and engage in activities that – In all communication, acknowledge the have positive effects, such as being outdoors, hardships that people face or fear, such as exercising and enjoying safe socializing. loneliness or loss of income. Empathy, hope and understanding above punishment, shame and – Avoid an economy-versus-health dichotomy. blame. Personal economic hardship can result in demotivation, and so pandemic response – Explore how difficult-to-follow restrictions measures may include efforts to keep the can be amended while taking into account the economy and businesses going. epidemiological risk. Case examples for inspiration Pandemic fatigue 21

Norway Russian Federation Acknowledging hardship to motivate youth Tackling structural barriers

The Norwegian Minister of Health gave a speech Tackling structural barriers is a prerequisite to any acknowledging the hardship experienced by young people sustained behaviour change. In the Russian Federation, and thanking them for their contributions to society. several measures have been put in place in this regard. Norway has also consulted with youth on safe solutions Lump-sum payments have been provided to families with for graduation celebrations and initiation ceremonies children, and financially vulnerable families with children at universities. This seems to have paid off: population aged 3 to 7 years are eligible for a monthly allowance. surveys in Norway show that youth are more adherent to Citizens who have lost their jobs can apply for this COVID-19 restrictions than those aged 50+, in contrast to allowance in 2020 independent of their financial status. many other countries. Even when hardship itself cannot In Moscow, older people have been supported to engage be alleviated, understanding and empathy can be strong in physical activities taking place outside and in a safe motivators for continued support (48,49). manner.

Spain France Removing structural barriers Stepping up with timely responses Preventing domestic violence through social protection schemes to emerging challenges during the pandemic

Many countries have implemented As in other countries, a behavioural In response to increasing reports of social and economic supports for insight survey documented over time domestic violence since the beginning those most affected by pandemic how the mental health of the French of the pandemic, the Government restrictions. launched a population was severely affected by of Bulgaria adopted a national national Minimum Living Income the lockdown. In response, factual programme to prevent violence and scheme. Offering monthly payments information from the survey was protect women and children. It aims of up to US$ 1145 to the nation’s provided to government officials. to maintain services and offer help to poorest families, the programme Practical measures to promote those who need it. Such programmes will support 850 000 households. good mental health included a have been initiated in many countries Eligibility is not contingent on free national telephone hotline and and may help to alleviate some of the unemployment or lack of income, information as to where to get help negative social consequences of the which allows people to continue a for those experiencing psychological pandemic (47). level of employment. As such, they distress (41). can meet basic needs while still seeking to improve their situation through employment or vocational training (46).

Please note disclaimers on page 2 22 Pandemic fatigue

Checklist / Cross-cutting principles

The four key strategies for reinvigorating public perception, social and cultural norms, and structural support for protective behaviours must be applied opportunity. These principles should be applied based on the epidemiological situation and on across policies, interventions and communication, societal and economic considerations to ensure and can be used as a checklist. They prompt that no one is left behind. To support this process, decision-makers to ask: will people consider these we propose five cross-cutting principles that draw actions to be appropriately transparent, fair, on evidence relating to factors such as trust, risk consistent, coordinated and predictable?

Transparency Fairness Consistency Knowing the rationale for decisions To trust authorities, people need Ensuring consistency in an ever- increases motivation to follow to feel that all relevant opinions changing situation is next to them (50). Be transparent in sharing the have been included (10,11) and impossible. Still, consistency can be reasons behind recommendations that decisions have been based on pursued by making sure that the risk and restrictions. Acknowledge the objective criteria, not on arbitrary being communicated in messages limits of science and government in grounds or the interests of certain and restrictions is always in line with terms of predicting the development groups. Strive for the highest possible the current epidemiological risk, and of this pandemic and what level of fairness in recommendations that the actions of leaders are in restrictions will be necessary at any and restrictions. All people have felt line with what is being recommended later stage, share uncertainty and the consequences of the pandemic, for the public. Authorities should also take responsibility for the decisions and catering only to the needs of avoid inconsistent responses, such that need to be made on uncertain some will be perceived as unfair by as lifting restrictions in one sector (for grounds. Making promises you cannot others. Creating structural conditions example, increasing the number of keep or being unwilling to share for health equity is another critical spectators allowed at sports events) reasons for actions leaves room for aspect, which involves clearly while tightening them in another (for misperceptions, myths and even communicating the need for equity, example, imposing new restrictions conspiracy theories. Clarity and for example, by compensating for or on restaurants), without providing simplicity are key: messages that alleviating restrictions particularly for a clear rationale and explanation. are not clear or simple enough to those who are suffering the most. Consistency may also be established understand and act upon lead to through the regular use of specific uncertainty and distrust. terms and numbers, such as transmission rates, case rates and fatality rates. Pandemic fatigue 23

Coordination Predictability Stakeholder coordination creates Predictability is a basic psychological trust (51). Maintain relations with need that prevents stress and stakeholders, strive for unity, and mental overload. This pandemic is avoid mixed messages from characterized by everything but experts, spokespeople, government predictability. Still, countries can representatives and health workers. strive for predictability by setting Everyone is entitled to their expert objective epidemiological criteria opinion; however, everyone also for restrictions (and their shifts needs to be aware that sharing early up or down) on, for example, travel, research results or their personal risk gatherings, educational institutions perceptions in the public debate may and workplaces. Countries can also affect trust in experts in general, communicate clearly the timelines particularly if these results and for restrictions and follow up on perceptions are not in line with those these so people know what to expect. of other experts. 24 Pandemic fatigue Case examplesPandemic for inspiration fatigue 24

Norway Making decision-making processes transparent Showing empathy

Norway has upheld a high level of transparency in Recognizing the significant losses that people have decision-making and the role of expert bodies. The experienced during the pandemic, the WHO Country rationale for decisions has been clearly communicated to Office in Kazakhstan addressed the nation on social the public, including instances where decisions departed media to remember the loss of health-care workers on the from the recommendations made by expert bodies to the occasion of the national day of for the victims Government (55). of COVID-19. Providing space for grief and demonstrating empathy for the considerable impact that the pandemic has had on people are more important now than ever, as trauma reactions are to be expected (52).

Ireland Germany Tailoring easy-to-understand Leaders walking the talk Decision to be open and honest messages for different audiences about the unknowns In many countries, leaders have Several countries have sought sought to lead by example, including In Latvia, a strategy of honesty was to demonstrate the relationship through isolating themselves, agreed on as a fundamental political between levels of risk and different wearing masks, and cancelling principle. When COVID-19 emerged, behaviours in simple tables or personal events or celebrations. the authorities conducted daily press infographics (53). prepared When quarantine was deemed conferences and answered each an overview from which tailored necessary in Germany, Chancellor and every question. In cases where infographics are selected and Angela Merkel self-isolated from they had no answer, they admitted used individually for targeted 22 March to 2 April after her doctor this and promised to follow up audiences (see https://assets.gov. tested positive for the virus. She with more information as soon as ie/87604/405b1065-055a-4ca8-9513- recorded a podcast about her possible. Demonstrating honesty and 390ce5298b10.pdf) (54). quarantine experience, and shared transparency is essential to building that she had been lonely. and maintaining trust.

Please note disclaimers on page 2 Pandemic fatigue 25 10 suggested actions

We offer this list for decision-makers who are seeking recommendations for concrete actions. All of these actions relate to the strategies and principles outlined above.

01 04 07

Think local. Reach out to civil Start early to prepare safe Appeal to people rather than blame, society groups and ask them to find solutions for upcoming national scare or threaten them. Recognize creative ways of motivating their celebrations where people gather that everyone is contributing. members and peers. Ask them what across geographies and generations. support they need from you. Engage Engage individuals, workplaces, public volunteers. Youth organizations, transportation systems, the retail housing associations, religious sector, retirement homes and more in 08 leaders, sports clubs and scouting discussions about ways to reduce risk Be clear, precise and predictable. organizations, and business and during the time leading up to these Use simple and digestible community organizations can all play events. Ask for their input and develop infographics as an effective way an active role. the guidance they need. Provide clear of communicating restrictions and recommendations (56-58). epidemiological risks – and how they are related. 02 05 In every workplace, school, university, youth club and more, ask the Understand which measures may 09 users to discuss how they would like be unbearable in the long term – Conduct regular qualitative or to implement the recommended for example, extended isolation qualitative population studies. Take behaviours. These discussions may that results in loss of employment the findings seriously. Use them to reveal barriers, inconveniences or income. Amend or balance inform action. and misperceptions that can such restrictions with other be addressed while maintaining measures (economic, social, restrictions. psychological), taking into account the epidemiological risk. 10 Tailor communication to specific 03 groups that experience demotivation. 06 Test messages and visuals with Develop guidance on living life sample populations before launching while reducing risk. For example, Make recommended behaviours them. make recommendations for safer easy and inexpensive. This can dinner parties, children’s play dates, involve the provision of fast and workplace interactions, dates, cheap internet connections, free funerals, weddings and travel. Find masks and hand sanitizers, accessible creative ways of communicating hand-washing areas, spaces for such guidance. Avoid constant social interaction, opportunities for changes. teleworking, and more. 26 Pandemic fatigue

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Member States

Albania Republic Iceland of Ireland Romania Israel Russian Federation Kazakhstan Bosnia and Herzegovina Latvia Bulgaria Spain Czechia Monaco Denmark Tajikistan Netherlands Turkey North France Macedonia Ukraine Norway Germany