RESEARCH Adherence to the test, trace, and isolate system in the UK: BMJ: first published as 10.1136/bmj.n608 on 31 March 2021. Downloaded from results from 37 nationally representative surveys Louise E Smith,1,2 Henry W W Potts,3 Richard Amlôt,2,4 Nicola T Fear,1,5 Susan Michie,6 G James Rubin1,2 1Department of Psychological ABSTRACT n=552/3068), increasing to 22.2% (14.6% to 29.9%, Medicine, Institute of Psychiatry, OBJECTIVE n=26/117) from 25 to 27 January. Across all waves, Psychology and Neuroscience, Weston Education Centre, King’s To investigate rates of adherence to the UK’s test, intention to share details of close contacts was College London, London SE5 trace, and isolate system over the initial 11 months of 79.1% (95% confidence interval 78.8% to 79.5%, 9RJ, UK the covid-19 pandemic. n=36 145/45 680), increasing to 81.9% (80.1% to 2 NIHR Health Protection DESIGN 83.6%, n=1547/1890) from 25 to 27 January. Non- Research Unit in Emergency adherence was associated with being male, younger Preparedness and Response, Series of cross sectional online surveys. age, having a dependent child in the household, King’s College London, London, SETTING UK lower socioeconomic grade, greater financial hardship 37 nationally representative surveys in the UK, 2 3Institute of Health Informatics, during the pandemic, and working in a key sector. University College London, March 2020 to 27 January 2021. CONCLUSIONS London, UK PARTICIPANTS 4 Levels of adherence to test, trace, and isolate are low, Public Health England, 74 697 responses from 53 880 people living in the UK, Behavioural Science Team, although some improvement has occurred over time. aged 16 years or older (37 survey waves, about 2000 Emergency Response Practical support and financial reimbursement are Department Science and participants in each wave). Technology, Porton Down, likely to improve adherence. Targeting messaging and Salisbury, UK MAIN OUTCOME MEASURES policies to men, younger age groups, and key workers 5King’s Centre for Military Identification of the main symptoms of covid-19 might also be necessary. Health Research and Academic (cough, high temperature or fever, and loss of sense Department of Military Mental of smell or taste), self-reported adherence to self- Health, King’s College London, isolation if symptoms were present and intention to Introduction London, UK Governments around the world have relied on test, 6 self-isolate if symptoms were to develop, requesting Centre for Behaviour Change, trace, and isolate strategies to separate infected people University College London, a test for covid-19 if symptoms were present and London, UK intention to request a test if symptoms were to from non-infected people and prevent the spread of http://www.bmj.com/ 1 Correspondence to: L E Smith develop, and intention to share details of close covid-19. Test, trace, and isolate is a less disruptive [email protected] contacts. measure than alternative population-wide restrictions (or @louisesmith142 on Twitter: in activity. Within the UK, guidance for people who ORCID 0000-0002-1277-2564) RESULTS might have covid-19 has evolved over time but has Additional material is published Only 51.5% of participants (95% confidence interval online only. To view please visit 51.0% to 51.9%, n=26 030/50 570) identified the focused on the need for people with a persistent the journal online. main symptoms of covid-19; the corresponding new onset cough, fever, or loss of sense of taste or C ite this as: BMJ 2021;372:n608 smell to remain at home for at least seven days from on 23 September 2021 by guest. Protected copyright. http://dx.doi.org/10.1136/bmj.n608 values in the most recent wave of data collection (25-27 January 2021) were 50.8% (48.6% to 53.0%, the onset of symptoms (self-isolate), request a test to Accepted: 2 March 2021 n=1019/2007). Across all waves, duration adjusted confirm whether they have covid-19, and, if the test adherence to full self-isolation was 42.5% (95% result is positive, provide details of close contacts to confidence interval 39.7% to 45.2%, n=515/1213); in a dedicated service. These principles are the same in the most recent wave of data collection (25-27 January each of the four UK nations (England, Wales, Scotland, 2021), it was 51.8% (40.8% to 62.8%, n=43/83). and Northern Ireland), although each nation has its 2-5 Across all waves, requesting a test for covid-19 was own test, trace, and isolate system. 18.0% (95% confidence interval 16.6% to 19.3%, The ability of the test, trace, and isolate system to keep rates of infection under control relies on how well people adhere to guidance on testing, provide details WH AT IS ALREADY KNOWN ON THIS TOPIC of contacts, and self-isolate, which in turn depends on their knowledge, motivation, and opportunity Test, trace, and isolate systems are one of the cornerstones of a national to do so.6 7 From when an infected person develops covid-19 recovery strategy symptoms to when their contacts are allowed to The success of any test, trace, and isolate system relies on people adhering to come out of quarantine, adherence might break isolation if they have symptoms, getting a test if symptoms are present, and down at multiple stages.8 In the UK, knowledge of the passing on details of close contacts if infection is confirmed symptoms of covid-19 has been shown to be poor.9 10 WH AT THIS STUDY ADDS Financial constraints and cramped accommodation have been identified as factors that affect whether Self-reported adherence to test, trace, and self-isolate behaviours in the UK people will remain at home during the pandemic.10-12 population is low; intention to carry out these behaviours is higher Some evidence suggests that men and younger age In the UK, identification of covid-19 symptoms is low groups are less adherent to covid-19 restrictions,13 Continued improvements to support are likely to be crucial in encouraging more as are those who think they have been infected with people to adhere to test, trace, and self-isolate behaviours SARS-CoV-2.14 the bmj | BMJ 2021;372:n608 | doi: 10.1136/bmj.n608 1 RESEARCH Identifying key factors that increase or decrease lived in the UK. Respondents who completed the BMJ: first published as 10.1136/bmj.n608 on 31 March 2021. Downloaded from adherence can be used to inform policies to improve the survey were unable to participate in the following functioning of the test, trace, and isolate system. Since three waves. Owing to an error, a few people completed the start of the covid-19 pandemic, we have worked waves more often than others; 55 people (0.1% of with England’s Department of Health and Social our sample) completed 10 waves or more. Quotas Care to develop and analyse a series of regular cross were applied based on age and sex (combined) and sectional surveys tracking relevant behaviours and government office region and reflected targets based their potential predictors in the UK public. We report on data from the Office for National Statistics.19 data from 37 of these surveys that tracked adherence Therefore, the sociodemographic characteristics of to the key components of the system over time and participants in each survey wave were broadly similar investigate personal and clinical characteristics that to those in the UK general population. Participants might be related to adherence to full self-isolation were reimbursed in points, which could be redeemed when someone has symptoms, requesting a test if in cash, gift vouchers, or charitable donations (up to symptoms are present, and intending to share details £0.70 ($0.98; €0.81) for each survey). of close contacts if symptomatic. We also investigated variables associated with correctly identifying the Outcome measures main symptoms of covid-19. Identification of covid-19 symptoms—One question asked participants to identify the most common Methods symptoms of covid-19, with multiple response options Design allowed (up to four initially, up to five from 25 May BMG Research, a Market Research Society company 2020, wave 18). We coded participants as having partner, conducted a series of cross sectional online identified symptoms of covid-19 if they selected cough, surveys on behalf of the Department of Health and high temperature or fever, and, from 18 May 2020 Social Care starting on 28 January 2020, which we (wave 17), either loss of sense of smell or loss of sense analysed as part of the CORSAIR (the COVID-19 Rapid of taste. In government guidance these symptoms are Survey of Adherence to Interventions and Responses) actively promoted to members of the UK public as the study. Surveys were conducted weekly until 1 July “main” symptoms of covid-19.20 (wave 23), after which survey waves were fortnightly; Fully self-isolating—We measured self-reported self- the weekly survey was resumed between 9 November isolation in participants who indicated that they had 2020 and 13 January 2021. No data were collected experienced symptoms of covid-19 (high temperature http://www.bmj.com/ in mid-August 2020. We used data from surveys or fever, cough, or loss of sense of smell or taste) in conducted between 2 March 2020 (wave 6) and 27 the past seven days. Participants were asked for what January 2021 (wave 42). Data were collected over a reason, if any, they had left home since the development three day period (Monday to Wednesday) for each of symptoms.