Berg 2021# Citation type: SR (rapid, scoping) Public health measure: General PD Mapping to: Uptake, acceptability Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 2: recipients of public communication: audience, setting and equity Theme 5: public trust and perceptions	Overview and aim: Synthesis of evidence on different modes of communication used by health authorities for pandemic risk communication. Type of study and data: Scoping review (rapid). 48 studies. Included surveys (primarily cross‐sectional, n = 15), mixed‐methods (n = 1), qualitative research (n = 10), policy studies (n = 1), experimental (n = 4, 1 RCT), quantitative statistical analysis (n = 18) Inclusion and exclusion criteria: English language, published, published January 2009 to October 2020. Studies on communication related to H1N1, COVID‐19 or flu more generally Participant features and numbers, sampling details: Varied; several surveys randomly or representatively sampled general adult populations within and across countries. Small number qualitative studies with selected population groups (e.g. Aboriginal people from Canada, Spanish‐speaking Hispanic people from US). Other analyses based on media analyses (e.g. websites, press releases, video sites). Included disease(s): H1N1 or pandemic ‘flu' more generally or COVID‐19 Timing: Search dates were based on coverage of the whole H1N1 outbreak (2009 onwards) and coverage of the response phase of the COVID‐19 pandemic. No further information reported Countries included: North America (n = 15; 11 of which were USA), Asia (n = 13; 8 of which were Chinese), Europe (n = 9), Africa (n = 1), Australia (n = 1), global/cross‐continent (n = 9). Income levels range from low to high‐income countries, no further details Intervention or phenomenon of interest: Communication modes used by health authorities during disease outbreaks with pandemic potential Quality assessment: AMSTAR 3/11: [2. Single selection and data extraction; 3. Search was not comprehensive as two databases only; 4. published data only; 5. Excluded studies not reported; 7,8. No quality assessment or use in formulating findings; 10. No publication bias assessment; 11. No declarations of interest for included studies] Funding source: The COVID communication: Fighting a pandemic through translating science (COVCOM) project has received funding from the Trond Mohn Foundation under grant agreement number TMS2020TMT10 and the University of Stavanger. JKO is supported by the National Institute for Health Research Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC).	Reported on: Three main communication mode categories identified in authorities’ risk communication: (1) Communication channels (media types) (2) Source credibility, and (3) How the message is communicated. Communication channels People receive pandemic information through multiple formal and informal channels (e.g. traditional mass media, governmental sources; social media); and are not passive information recipients from a single source but instead select from amongst the total information they encounter. Framing may affect how messages are received. Mass media communication may exaggerate or sensationalise risk communication related to a pandemic outbreak leading to increased fear/panic Building relationships between media and national health authorities may be key, as well as building trust in authorities before a pandemic emerges. Authorities’ and government websites may include language that is too difficult for the general population to read. Even where reading level is considered, other aspects may be poor, such as readability (layout, format), accessibility (e.g. lack of non‐text alternatives for those with vision problems), and timeliness (information not updated in timely way). Social media platforms: There is no evidence on health authorities’ pandemic risk communication via social media, related to self‐protective behaviours. Health authorities may have generally low engagement with their social media posts about pandemic risks. Messages incorporating narratives and imparting self‐efficacy are more likely to be engaged with. Both negative and positive framing of messages are used, and while positive framing may increase engagement, it may also undermine perceived seriousness of the threat (risk). Messages on social media may change over time e.g. an analysis of Twitter found messages concentrated on instructional information in the early pandemic period but shifted to motivational messages to sustain behaviours in the longer term (focusing on the need to protect vulnerable populations). YouTube: may be a source of misinformation for COVID‐19; information from credible sources is under‐represented e.g. 25% of the most popular videos on COVID‐19 (62 million views) included misleading content; such videos are viewed more often than those from credible sources. No evidence on health authorities’ use of YouTube for pandemic risk communication related to health protective behaviours was found. Source credibility (i.e. perceived trust in formal (health authorities, governments, public health professionals) and informal pandemic health risk information sources and impact on protective behaviour): Trust in formal information sources may be associated with greater accuracy of knowledge of risk and adoption of protective health behaviours. Different sources and associated levels of trust may be associated with age: older people typically trust formal sources while younger people have greater trust in informal sources (e.g. social networks). Source credibility does not correlate closely with usage, e.g. health professionals may be most credible but mass media sources most used. Authorities failing to report uncertainty about a pandemic outbreak, or reporting inaccurate information, both lead to loss of trust (credibility) in formal sources of information. Healthcare professionals are often perceived as credible irrespective of the type of media involved, whereas trust in governmental sources may be more changeable, and the role of media type is unknown. Information from health authorities needs to be tailored to meet the needs of different groups (e.g. migrant groups, indigenous groups). Collaboration between health authorities and communities may ensure information needs are appropriately met; using trusted spokespeople may also improve credibility of messages. Tailoring of messages from health authorities may be needed for both the message itself and the mode of delivery.  How the message is communicated : Narrative tone of authorities’ communications can affect people’s emotional state (anxiety, uncertainty) and influence engagement and behavioural responses to risk mitigation messages. Narrative messages that elicit positive emotions may lead to better community engagement, but people may learn more from non‐narrative messages. Jargon should be kept to a minimum or avoided. Written information should be tailored to the intended audience (readability as well as format and layout). Communicating visually (e.g. graphics, images, colours) can significantly influence the reach and reception of messages. Effective risk communication might include several communication modes and include visual information, but visual cues (e.g. colour, preferences) vary across audiences and so need to be considered when tailoring information. Recommendations: Ensure health authorities’ risk communication considers the range of factors (e.g. tailoring, trust, multiple channels, layout, accessibility, readability, timeliness of information, format) that might influence community engagement, knowledge and self‐efficacy, and subsequent behavioural changes to mitigate risk. Health authorities should disseminate information through multiple channels, including through social media, although care is needed to ensure that messages remain consistent and improve credibility (rather than creating confusion as may be the case if messages are communicated rapidly through multiple channels). Misinformation related to pandemic risks may be a substantial problem on social media sites. Countering this (misinformation, rumours and contradictory messages) remains problematic for health authorities. A remaining challenge for health authorities is to engage effectively with social media and to provide readily available, accessible information that is kept up to date, tailored to different reading levels and with consideration of layout to improve access, with the aim of avoiding amplification of risks communicated through mass media messages. Public trust in health authorities changes over time and is related to perceptions of crisis management. This in turn can affect people’s risk perception and behavioural response to risk. Health authorities need to work collaboratively with communities and trusted spokespeople to improve community trust, to ensure that messages are appropriately tailored to communities and to reach different groups, including migrants and ethnic groups, over time as the pandemic response changes. Risk communication messages should be balanced and evidence‐based, motivate self‐efficacy, and include actionable information that people can use to protect their health. Jargon may not have a negative impact in all cases, but may need to be considered as part of the tailoring of information to audiences’ educational and health literacy levels.	Communication purpose: May inform health authorities’ risk communication messages and choice of channels, for communicating about pandemic risk to populations and groups within populations. Identified factors may usefully inform decisions about channels to be used, and tailoring of messages. Related to review questions: Communication of pandemic risk messages from authorities to the community is influenced by many factors, and these may affect behavioural mitigation measures. Such communication need to take account of these factors to ensure that risk communication messages are accessible and available to all groups within the population, to ensure consistency of messages to promote trust and understanding of required behavioural change to protect health.
ECDC 2020g# (Review of guidelines; non‐SR) Mapping to: Acceptability, adherence; also feasibility/barriers	Overview and aim: Supports public health preparedness planning and response activities based upon physical distancing measures aimed at minimising the spread of COVID‐19. Inclusion and exclusion criteria: Included: Several ECDC documents: Guidelines, rapid risk assessment, technical report, guidance document Countries included: EU/EEA Member states and UK Quality assessment: 1/11 AMSTAR rating:% (non‐systematic review) Funding source: Not reported	Reported on: Focus here is on communication related to physical distancing measures. Public health To facilitate public acceptance of social distancing measures, an anticipated end date should be established and communicated, be made clear to the population that measures could be extended or may be removed/reduced while others remain in place. A comprehensive risk communication strategy should include the rationale and justification behind physical distancing measures and encourage individuals to enact the required changes. Different audiences should be targeted (e.g. minority languages). A system should be put in place to monitor public perceptions of outbreak and the outbreak response. To improve adherence to measures, stigma related to quarantine/self‐isolation needs to be proactively addressed by reinforcing that everyone in the population is at risk. To promote adherence to social isolation measures, support systems should be developed, and populations informed i.e. systems exist to ensure access to essential supplies and services, social networks, those promoting community support, and this is especially important for vulnerable groups (e.g. elderly, homeless, migrant groups). Measures to compensate communities financially for losses (restricted income or employment) due to restrictive physical distancing measures should be considered as another means of promoting adherence to measures. Educational institutions (school measures) Unequal access to digital education may impact on continuity of education which needs to be considered. Social impacts (social isolation) need to be considered; mental health issues may impact on ability to adhere to physical distancing. Need to consider the needs of visiting students or teaching staff from other countries who may have limited resources. For parents, financial compensation may improve adherence, as parents are likely to miss out on work. Workplaces (workplace measures) Strict instructions need to be given to ensure employees with symptoms do not attend work. Use telework from home and videoconferencing for meetings, but this may not be viable for all, and financial losses may follow. Physical distancing measures that can be taken while remaining at work include closing down certain areas where people are in closer proximity to each other and interact more, avoid medium‐to large numbers of people in confined spaces. Financial compensation may increase adherence to workplace measures. Mass gathering cancellation, including faith‐based events: Religious leaders should be engaged in public health messaging as they play an important role in public opinion. Recommendations: Decisions about implementing physical distancing measures need to be tailored to context and setting (social and political factors). Identified importance of promoting solidarity and mutual community support when social distancing measures are implemented. Clear, co‐ordinated, and comprehensive communication of information about physical distancing measures is needed. To improve adherence to physical distancing measures, inequalities in terms of information provision (e.g. vulnerable populations), financial losses (e.g. those unable to work from home), educational disadvantage (e.g. unequal access to digital learning), stigma (for those self‐isolating/quarantined) need to be recognised and addressed, and support systems to ensure essential services and supplies put in place.	Communication purpose: This may inform decisions about how to address potential barriers to physical distancing measures and actions to take, and guide communication with communities about measures that may promote improved acceptance of and adherence to physical distancing measures. Related to review questions: Findings identify a range of factors that may impede uptake of and adherence to physical distancing measures, such as financial losses, stigma, and unequal access to information and support. These vary across populations but need to be addressed to ensure that physical distancing measures are enacted.
Gupta 2021# Citation type: SR Public health measure: General PD Mapping to: Adherence Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery	Overview and aim: To review research studies on knowledge, attitudes and practices towards the COVID‐19 pandemic Type of study and data: SR; N = 21 studies, all cross‐sectional Inclusion and exclusion criteria: None described Participant features and numbers, sampling details: General population (11 studies), healthcare workers (7 studies) and students (n = 3). Sample sizes ranged from approximately 60 to almost 7000 Included disease(s): COVID‐19 Timing: No timing of searches or literature reported. Paper submitted September 2020; included studies will reflect literature available prior to this date. Early pandemic Countries included: China (3 studies), Iran (3), global (2), Nepal (2); single studies in Egypt, USA and UK, Tanzania, Paraguay, Jordan/Arabia/Kuwait, Kenya, Peru, Malaysia, Uganda, Pakistan, India Income levels all middle‐income (low and upper) levels except UK/USA (high‐income) and Uganda (low‐income) Intervention or phenomenon of interest: Knowledge attitudes and practices related to COVID‐19 in general public, healthcare workers and students Quality assessment: AMSTAR 2/11: [rated down all items except 6. Included studies characteristics provided; and 9. Method of synthesis appropriate] Funding source: Not reported	Reported on: General public Overall, levels of knowledge (of disease transmission, symptoms, and prevention measures) in the general population were generally good. Higher education and income levels, female gender, and a non‐rural location were predictors for higher knowledge scores. Age versus knowledge varied amongst the studies. Studies reporting attitudes generally indicated high levels of optimism about overcoming the pandemic as well as some misconceptions about preventive measures (1 study). One study reported that awareness of preventive measures in a vulnerable slum community could be increased by television awareness campaigns and short messages. Healthcare workers With a few exceptions, most studies reported generally high levels of knowledge about the pandemic. Attitudes, such as those related to optimism, were variable. COVID‐19 practices, where reported, were generally high. Older age and more experience were generally associated with higher knowledge levels. Students Knowledge, attitudes and practices were generally good. However, male gender was reportedly associated with lower practice scores for preventive behaviours (1 study). Relationships between attitudes and practices and between risk perception and practices, were reported, but in opposite directions. Recommendations: Findings suggest the general population has a basic level of knowledge about the COVID‐19 pandemic. Commonly accessed information sources may contribute to spread of information and misinformation about required preventive measures within the general public. Government information is required to raise awareness about the causes and effects of COVID‐19. Healthcare workers have a generally good level of knowledge and a positive outlook towards the pandemic, as do medical students in general. Despite the generally high levels of knowledge amongst healthcare workers and students, there is still need for consistent reminders and messaging from authorities to improve public knowledge levels.	Communication purpose: Findings may indicate some factors that might importantly influence knowledge, in particular about the use of preventive measures for COVID‐10. Awareness of preventive measures in vulnerable slum communities could be increased by media campaigns. Related to review questions: Knowledge, attitudes and preventive practices for COVID‐19 may be at high levels in some groups but lower in others. Many factors may influence each of these outcomes and so importantly determine the success or otherwise of public health measures to protect people from COVID‐19.
JHCHS 2019* (Guideline) Mapping to: Acceptability, uptake, adherence Public health measure: 6 (crowd avoidance), one specific example relating to quarantine	Overview and aim: Identification of priority actions ‘for countries, international organisations, and other stakeholders to pursue that would mitigate the public health, economic, social, and political consequences of the emergence of a high‐impact respiratory pathogen.’ (p. 7) Inclusion and exclusion criteria: Included: several high‐level reviews on global preparedness, interviews with international experts in pandemic preparedness and response Type of study and data: Review of reviews and interviews with specialists in the field Countries included: Not explicitly described Quality assessment: (AGREE II)ⁱ: Scope and purpose: 90%; Stakeholder involvement: 62%; Rigour of development: 34%; Clarity of presentation: 67%; Applicability: 50%; Editorial independence: 14%. Funding source: This report was commissioned by and prepared for the Global Preparedness Monitoring Board.	Reported on: Only data most relevant to communication interventions in the context of the current rapid review have been extracted. There needs to be strong, evidence‐based rationale for the necessity of NPIs such as physical distancing, in order that they can be effectively implemented, and the role of such measures communicated to the public. Community engagement may be highly relevant when considering (positive and negative) public reactions to outbreak responses. Such engagement may link strong equitable health systems to pre‐existing community relationships (developed as part of pandemic preparedness measures, prior to disease outbreaks), and enable risk communication to be framed successfully to support non‐pharmaceutical measures. Countries must be able to communicate with their populations about health and protective actions that can be taken, in a timely, accurate and effective manner. Risk communication and surveillance systems and processes can be established to serve routine health purposes but expanded/adapted as needed during emergencies. Public trust is a key element of effective communication and countries, before, during and after an outbreak. Partnership with community members and community engagement (e.g. collaborative decision‐making) can strengthen responses to outbreaks, for instance by increasing cultural appropriateness and acceptability of public health interventions, ensuring they are attuned to local conditions. Such engagement may also help to incorporate community views and values into difficult decisions that may arise during outbreaks, and so help to ensure broad support for required measures. Communication and establishment of trusted communication lines between the community and public health is an essential element of successful public health responses, which enables successful engagement to improve understanding of risks and buy‐in on protective measures. Such communication should be timely, transparent, and understandable. Communication about risk also includes communication with and through trusted partners and news media, in order to disseminate accurate risk and protective measures messages. Such partners may also serve as advocates to strengthen public perception of accurate information. Communication of consistent messages to the public requires collaboration between public and private sectors. Implementing NPIs requires that many challenges be addressed, for instance quarantine measures requiring strict adherence to the protocol, and the public may be more accepting of this where the public trusts the government. Recommendations: Risk communication during outbreaks is an essential component of the response, requiring planning prior to outbreaks and involving communities as well as public health experts. Risk communication messages must be consistent, timely and accurate. Public trust is essential for effective risk communication, and community engagement can facilitate effective public health responses. Authorities must provide strong, evidence‐based rationale for public health measures, such as NPIs, so that they can be implemented effectively and their role in disease prevention be communicated effectively to the affected public.	Communication purpose: Aspects of this report may inform the development of more effective public health communications and engagement, including those around physical distancing. Related to review questions: Describes actions countries can take to prepare, and optimal conditions for, effective communication to the public during a pandemic. Implementing the communication actions may lead to greater acceptability and uptake/adherence to physical distancing measures.
Li 2020# Citation type: SR (rapid) Public health measure: General PD Mapping to: [major outcome categories] Uptake, adherence Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 2: recipients of public communication: audience, setting and equity	Overview and aim: To identify how health provider should advise parents or families to obtain health education information (in relation to an infectious disease outbreak) Type of study and data: Rapid SR; observational studies (cross‐sectional survey studies); 24 studies included, n = 35,967 participants Inclusion and exclusion criteria: Included: People from the general population Observational studies available in English or Chinese before March 31, 2020 Excluded: participants from specific groups within the population (e.g. specific occupational groups) Participant features and numbers, sampling details: 35,967 participants sampled from across SARS, MERS and COVID‐19 outbreaks. Most (19/24) sampled adults aged 16 years and older; no further details reported Included disease(s): COVID‐19 (6 studies), SARS and MERS (18 studies) Timing: Authors note that accurate, reliable information about a disease outbreak is needed, and that this needs to be timely and kept up‐to‐date over the course of the pandemic/outbreak. Countries included: China (12 studies), Saudi Arabia or the Middle East (6), France (2), single studies in Hong Kong, Australia, Turkey, Canada Approximately half of studies (13/24) in upper‐middle income countries, remainder high‐income Intervention or phenomenon of interest: Health education and health promotion issues during COVID‐19, SARS and MERS outbreaks Quality assessment: AMSTAR 6/11: [1. No protocol, stated explicitly not registered; 5. No excluded studies provided 8. General limitations of studies described but not linked to findings specifically 10. Publication bias not assessed 11. COI for included studies not reported]. Funding source: This work was supported by grants from National Clinical Research Center for Child Health and Disorders (Children’s Hospital of Chongqing Medical University, Chongqing, China) (grant number NCRCCHD‐2020‐EP‐01) to EL; Special Fund for Key Research and Development Projects in Gansu Province in 2020, to YC; the Fourth Batch of “Special Project of Science and Technology for Emergency Response to COVID‐19” of Chongqing Science and Technology Bureau, to EL; special funding for prevention and control of emergency of COVID‐19 from Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province (grant number No. GSEBMKT‐2020YJ01), to YC; The Fundamental Research Funds for the Central Universities (lzujbky‐2020‐sp14), to YC.	Reported on: 9 studies mentioned information channels where people obtained health education information; 3 studies focused on health education campaigns. Lack of public awareness of infectious disease Findings were mixed. Some (7) studies showed the public had little knowledge about how to face emerging diseases, while others (3 surveys) indicated strong knowledge, attitudes and practice of COVID‐19 but also indicated that more public information and education were needed. Lack of epidemiological knowledge of MERS was mentioned in 1 study, and pilgrimage travellers lacked awareness of MERS outbreak and the implications of this (5 studies). Mode and health education reliability Various information‐seeking strategies and preferences were identified. Participants reported a range of sources and channels to obtain information about COVID‐19 or SARS, and increasingly, people consulted more than one information source to find relevant information on a disease outbreak. Traditional mass media is commonly used (e.g. newspapers, radio, television), but people also consult the Internet and social media, as well as their social networks to obtain relevant information although these latter sources may be less credible. The effect of health education Findings from 4 studies reported but most (3/4) did not clearly report preventive behaviours associated with physical distancing. One study reported crowd avoidance behaviours, but this has been reported elsewhere in the original review (Zhong 2020). Recommendations: Improving public awareness of infectious diseases can positively influence preventive behaviours to slow disease transmission. However, stigma, discrimination and fear may also be present and may delay care or early quarantine or treatment, which in turn may increase spread of disease. It is therefore important to promote better knowledge while working to prevent stigma. Health education needs to be tailored to particular groups within the general public, such as children, the elderly and other vulnerable groups or those with particular needs (e.g. travellers likely to come into contact with the infectious disease). People often use multiple sources of information, and while new media may be more easily accessible there may also be a growing risk of misinformation with some of these sources. Public health agencies, governments and health authorities might be relied upon to deliver accurate, timely information and health education about an infectious disease and its prevention, changing over the stages of a pandemic or outbreak as required.	Communication purpose: Findings may be useful for planning public health education and information, particularly when considering purpose(s), media and channels for such communication. Related to review questions: Public information or education about an infectious disease may improve knowledge and awareness of the disease and required preventive measures. However, there needs to be an awareness of the potential for stigma and discrimination and communications need to address these potential adverse consequences directly. A range of channels (media) are accessed by the public for public health information. Information and education should be credible and accurate, and public communication strategies might be planned with this in mind. Special groups may lack adequate knowledge about emerging diseases and communication strategies that specifically target special groups may be needed.
Majid 2020#^ Citation type: SR (scoping) Public health measure: General PD Mapping to: Acceptability, adherence Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 5: public trust and perceptions	Overview and aim: To examine how knowledge, awareness and misconceptions influence risk perceptions and behaviours. Type of study and data: Scoping review (cross‐sectional, cohort, qualitative, mixed methods); n=149 studies. Inclusion and exclusion criteria: Included: primary quantitative, qualitative, and mixed‐methods studies (including social media analyses) on response to global outbreak/pandemic (with focus on SARS 2003, influenza A/H1N1 2009, MERS 2012, EBV 2013, COVID‐19 (2020)). Excluded: mass media communication strategies (e.g. newspapers, television); abstracts, theses, dissertations and published papers without empirical primary data. Participant features and numbers, sampling details: No details systematically synthesised. Included disease(s): H1N1 (66 studies), EBV (42), SARS (32), MERS (10), and COVID‐19 (1). Timing: Searches for evidence were conducted March 2020. Authors note that information provided and effects on behaviour can change over the course of a pandemic outbreak (e.g. as reports on the pandemic decrease, so too may willingness to adhere to public health measures). Countries included: Studies took place across all continents except South America. Ranged from high income countries (US (26 studies), Hong Kong (13), Canada (11), Netherlands (10)), to middle income (China (9), Malaysia (5)) to low‐income countries (Sierra Leone (1), Liberia (4), Guinea (2)). Far more studies (120+) conducted in high rather than low (21 studies) income countries. Intervention or phenomenon of interest: Knowledge, awareness and misconceptions about infectious disease outbreaks and effects on preventive behaviours (e.g. physical distancing). Quality assessment: 3/11 [no items met except 6. Included study characteristics reported; 7. Quality of included studies assessed; 9. Synthesis methods (appropriate for scoping review)]. Funding source: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Umair Majid receives financial support from the Canadian Institutes of Health Research and the Government of Ontario, Canada. Neither party was involved in the design and conduct of this research.	Reported on: Knowledge levels of disease, pandemic outbreak episodes, and modes of transmission or infection, were generally high across studies (8 studies). Information sources: People typically relied on multiple information sources during a pandemic (e.g. social media, print media, government websites) and sources were themselves of diverse format, language and target audience and including a range of disease, risk, transmission, prevention and aid topics. Various mass media sources were used (e.g. newspapers, magazines, radio, public service announcements, governmental education initiatives, text messages), but in some studies, mass media information was seen as alarmist and inaccurate. Several studies reported on the importance of information exchange with family, peers and healthcare workers, and the role of trust that may be linked to knowledge and behaviour. Social media was common as an information source, but people’s concerns about inaccuracies and rumours were noted. Community leaders, healthcare providers, the media, and government play an important role in communicating infection and disease information. Information provided and effects on behaviour can change over time during a pandemic e.g. as numbers of articles on the pandemic declined, so too did willingness to adhere to measures such as physical distancing. Social distancing: Adoption of measures such as crowd avoidance increased with the spread of infection, but the proportion of people adopting physical distancing measures varied across countries (e.g. crowd avoidance 10‐53%; variation in public transportation use ranging from dramatic decreases to a majority still using). Some studies reported a proportion of people (20‐30%) still attended work and school even at the pandemic peak; others that people closely adhered to measures, some because of fear of legal repercussions. Several studies reported avoiding contact with other people, including physical contact, avoidance of sick people, limiting home visitors. Social pressures: Several studies reported that community or family pressures promoted adherence to hygiene/physical distancing measures e.g. social network knowledgeable about health‐related behaviours positively associated with adoption of physical distancing and hygiene practice. Knowledge, risk perceptions and behaviour: High knowledge and personal risk perceptions promoted uptake of physical distancing measures e.g. positive association between risk perception and adherence to quarantine protocols, although this was not uniform across studies. Participants generally expressed high levels of knowledge and support for physical distancing measures, but fewer people reported adhering to measures. Misconceptions: Misconceptions fell into several categories. Regarding the disease/infection: People may be confused about symptoms and similarity with other diseases and misinterpret disease fatality e.g. people with chronic disease believing H1N1 to be immediately fatal, based on their experience of the SARS outbreak. People may also hold mistaken beliefs about transmission (e.g. believing infection to be due to witchcraft, or transmissible through air at long distances or via food). There may also be misconceptions about treatments (e.g. believing saltwater to be effective) which people act on, information on which commonly came from social media posts and which people maintained was correct despite correct information provided from healthcare workers or government. People also had misconceptions about medical treatments e.g. believing that seasonal flu vaccine would protect them from H1N1. People held various misconceptions and conspiracy theories about disease origins (e.g. the disease did not exist, or came from another country or from God), or believed that people got what they deserved based on moral actions to understand the disease’s origins. Misconceptions arose from several sources, including media, social media, family and healthcare workers, including information that was stigmatising to particular individuals or groups. People may not verify information they receive from social networks. Misinformation from different sources can spread rapidly; this may be due to lack of access and availability of accurate information (forcing people to seek alternative sources of information that may be prone to misinformation), deep mistrust of government sources or to conflicting or contradictory public health messages. Misconceptions may affect healthcare‐seeking and physical distancing behaviours. Some studies reported that those holding conspiracy beliefs were more likely to report greater mistrust of governments and healthcare, more stigmatising beliefs and lower support for physical distancing and quarantine (i.e. conspiracy theories and misinformation tend to be negatively associated with community‐based prevention behaviours). Recommendations: Knowledge, awareness, and misconceptions influence risk perception and behaviours, but changes depend on a range of factors such as country, population, and societal characteristics. During pandemics, knowledge generally spreads rapidly, and both accurate and inaccurate information spread quickly, but it is unclear how individuals and communities navigate accurate knowledge that promotes protective behaviours and inaccurate information that does not. Misconceptions may play a role in determining whether people with accurate knowledge develop high‐risk perceptions that then lead to behaviour change; where misinformation can effectively dilute the perception of risk and also lead to ineffective protective behaviours. Misconceptions may also increase risk perceptions (where there is uncertainty), leading to people adopting behaviours they believe are effective even if they are not. Social pressures may exert a strong positive influence on protective behaviours. However, they may also be the source of misconceptions. Introducing information that contradicts misconceptions may help, but this depends on the source and format of the information and on the level of trust people have in the source. Information that contradicts existing misconceptions may require people to process information at a higher level to inform their decisions and behaviours; this may delay the adoption of protective behaviours, lead to information overload and negative emotional states. Information that challenges or contradicts misconceptions, communicated from a trusted source, may reduce misconceptions if the communication is coherent. Frequent, drastic changes in reporting may be perceived as inaccurate by the public and lead to a loss of trust. Authorities should communicate clearly about what is known and what is not to build and sustain trust.	Communication purpose: Findings may inform development of information materials for communicating with communities and individuals; and may help to identify areas where misconceptions are common and may require particular information to be communicated.   Related to review questions: People may rely on several diverse information sources during a pandemic outbreak, including social networks and social media; but some may be prone to inaccuracies and misinformation. Trust is importantly linked to knowledge and protective behaviours during a pandemic, therefore trusted sources such as community leaders and government play a key role in communicating information about the pandemic and protective measures required by individuals and the community. Social pressures and influences may promote adherence to physical distancing measures; as did higher perceived risk, but behaviour change was not consistently at a high level and is influenced by a range of factors. A range of misconceptions, arising from a range of sources including social media and social networks, may exist about the disease and symptoms, transmission, treatments and origins. These can co‐exist alongside accurate information. Both tend to grow rapidly as the pandemic progresses, and misinformation can grow in the absence of available or accessible information, or in the presence of conflicting public health messages. People may also not tend to check information they receive from social networks. Misconceptions may negatively affect adoption of protective behavioural measures during a pandemic, and so are important to address. It may be important to work to counter misinformation or misconceptions by providing contradictory information, but this requires more cognitive work from people. Misconceptions may be more common amongst those with less trust of the government or of healthcare; therefore, community leaders, healthcare providers, the media and government all play an important role in communicating accurate information about disease and required health protection measures during a pandemic.
Noone 2021# Citation type: ScR, rapid Public health measure: General PD Mapping to: Adherence Mapping to: Theme 3 support for individual and population behavioural changes	Overview and aim: Assessment of the focus, quality and generalisability of the evidence on determinants of adherence to physical distancing measures. Specific questions included: Focus (what measures were assessed? How was adherence conceptualised and measured?); Quality (how great is the risk of bias?); and generalisability (where was the research set? Were representative groups studied?). Type of study and data: Scoping review; 84 studies, quantitative (59 cross‐sectional, 20 longitudinal, 5 randomised or non‐randomised). Inclusion and exclusion criteria: Included: evaluation of adherence to physical distancing measures, including potential determinants of adherence as independent variables. Quantitative study design; published in any language Excluded: studies focusing only on intention to adhere. Participant features and numbers, sampling details: 26% of studies used nationally representative samples for study; remaining were based on convenience sampling of some type. Included disease(s): COVID‐19. Timing: Searches July 2020 (first wave of the COVID‐19 pandemic). Searches were restricted to 2020. Countries included: 42 (50%) USA; majority of the remainder occurred in Western Europe, few taking place in Africa, Latin America and Asia (India, Japan, Thailand, China, Korea, Saudi Arabia, Qatar, Brazil). Indicates that most studies were undertaken in high income countries. Intervention or Phenomenon of interest: Potential determinants of adherence to physical distancing measures. Quality assessment: AMSTAR 8/11 [5. no list of excluded studies; 10. Publication bias not mentioned/assessed; 11. Sources of support included studies not reported]. Funding source: NW was funded by a summer scholarship award from Evidence Synthesis Ireland, Cochrane Ireland and the HRB‐Trials Methodology Research Network. HD was funded by the Health Research Board and the Irish Research Council under the COVID‐19 Pandemic Rapid Response Funding Call [COV19‐2020‐097].	Reported on: Adherence conceptualised (e.g. reduced mobility, stay at home, physical distance from others) and measured in a range of ways, mostly relying on smartphone GPS location data (n = 30) or on self‐reported adherence (e.g. to PH measures, reduced contacts) (n = 53). Coding using Theoretical Domains Framework for potential determinants of adherence to physical distancing measures identified the following: ‘Environmental Context and Resources’ (coded 388 times across 76 studies) was the most commonly coded domain; broadly covers elements of an individual’s circumstances, including economic circumstances (e.g. debt relief), their demographic features and the public health policies and pandemic severity in their location that might promote or inhibit adaptive behaviours. ‘Beliefs and Consequences’ (coded 34 times across 21 studies); broadly covering acceptance of reality or outcomes of a particular behaviour, included people’s beliefs supporting physical distancing; risk perception; anticipated regret (motivated by avoiding infecting others); and consequents (perceived severity). ‘Emotion’ (coded 28 times across 12 studies); included fear, anxiety, stress; with specific examples including the cost of adherence to measures. ‘Social Influences’ (coded 26 times across 16 studies); broadly covering interpersonal processes leading to changes in feelings, thoughts or behaviours included social norms, social comparisons (others’ physical distancing behaviours) and power (stay‐at‐home orders). Other domains related to communication and PD were typically less frequently coded but included Knowledge (understanding of COVID‐19) and Skills (e.g. health literacy). Recommendations: Several potential determinants of physical distancing adherence were identified, with adherence conceptualised and measured in a range of ways. These may serve as potential targets for strategies (interventions) seeking to improve adherence to physical distancing measures during a pandemic.	Communication purpose: Findings may be useful when planning communication and support for communities undertaking physical distancing measures.   Related to review questions: Potential determinants of physical distancing adherence appear wide‐ranging. Aspects related on a practical level to individuals’ context and resources, such as economic circumstances and the local pandemic situation, may be important. People’s beliefs in support of physical distancing, perceptions of risk and anticipated regret may also influence their behaviours related to adherence. Other aspects related to emotional state, social influences, knowledge of COVID‐19 and skills may also play a role in determining people’s adherence to physical distancing measures.
PHAC 2022# Public Health Agency of Canada. Adjusting public health measures in the context of COVID‐19 vaccination At: Adjusting public health measures in the context of COVID-19 vaccination - Canada.ca Citation type: GL Public health measure: General PD Mapping to: Acceptability, uptake, adherence Mapping to: Theme 2: recipients of public communication: audience, setting and equity Theme 3: support for individual and population behavioural changes	Overview and aim: Provides considerations for adjusting PHMs as vaccination coverage increases and as numbers of new and active cases changes within the population and public health and health system pressures ease. Type of study and data: Guideline; best available evidence and expert opinion; and informed by PHAC 2021 (individual and community PHM measures; itself developed from rapid evidence reviews, policy advice from PH agencies (WHO, CDC), economic advice and research). Included disease(s): COVID‐19. Countries included: Canadian context; some included evidence from Canadian agencies, others from international or national sources (e.g. WHO, UNICEF, ECDC, CDC, SAGE UK). High income countries well‐represented; but within these disadvantaged and/or remote groups considered. Timing: Guideline developed to assist with planning and adjusting PHMs in response to changes in COVID‐19 activity occurring over time. Last modified Feb 22. Intervention or Phenomenon of interest: Considerations for adjusting PHMs including key communications required. Quality assessment: AGREE II scope and purpose 61.1%; stakeholder involvement 19.44%; rigor of development 7.3%; clarity of presentation 66.67%; applicability 2.08%; editorial independence 0%. Funding source: Not reported; this technical guidance was developed in consultation with the Canadian Pandemic Influenza Preparedness (CPIP) Task Group and with federal, provincial and territorial partners via the Technical Advisory Committee (TAC) and/or the Special Advisory Committee (SAC). This guidance was also developed in consultation with other government departments, various multilateral partners, Indigenous stakeholders, and other external stakeholders with an interest in this subject matter.	Reported on: Guidance focuses on individual and community‐level considerations for PH measures (PHMs) in the context of increasing levels of COVID‐19 vaccination, as well as changing levels of community transmission. Distinguishes between core PHMs (basis of good PH practice, always apply – e.g. staying home when ill) and additional PHMs (more stringent measures when needed for prevention or control of COVID‐19; may relate to physical distancing, masks etc). Core PHMs may become the norm, but periods where additional PHM use (individuals and/or communities) are needed may occur. In such circumstances, additional measures should be proportionate to the local community risk, weighed against unintended effects of the PHM and responsive to local context; that is, measures are to be promoted during an outbreak and relaxed when outbreak is controlled. PH agencies should proactively communicate, in an accessible way, when changes to individual or community‐based measures are likely to occur and provide a rationale for the changes when they are enacted. Such transparent communication can improve PHM adherence as people understand the reasons for the measures, the effectiveness of the measures, and they can prepare for the changes to come into play. Some people within communities (e.g. those at risk of more severe disease) may choose to enact additional measures even during periods of low community transmission. Clear communication is needed to reduce discrimination and stigmatisation of such individuals by emphasising that such decisions and behaviours (i.e. for individuals to protect themselves) are acceptable. Encouraging people to consider ways in which they can benefit others and contribute to keeping everyone in the community safe may help to promote acceptability, as when people feel part of a community response, they may be more likely to adhere to PHMs; and this is especially so if they see others following the same measures. Within the population, some people may be unwilling or unable to be vaccinated against COVID‐19; avoiding stigmatisation based on vaccination status is important when adjusting PHMs, although agencies or operators in some settings may provide different advice to those who are not fully vaccinated. When planning for adjustment of PHMs (i.e. whether to reinstate, maintain, or ease measures), agencies will need to consider several factors, amongst them local COVID‐19 epidemiology and PH capacity; individuals’ ability to adhere to measures; vulnerabilities of individuals and communities; and costs and social disruption associated with implementing PHMs. For individuals, in relation to additional PHMs: Individuals who are at risk of more severe disease, or who are partially or unvaccinated are encouraged to conduct a personal risk assessment to help to decide whether to consider specific additional PHMs, such as crowd avoidance, physical distancing. Individuals at lower risk are advised to follow local/federal PHA advice. Community‐level strategies for adjusting PHMs to local settings may be uniquely tailored and should also consider issues for those ineligible for vaccination. Communication such as signage at entry points may be useful to communicate the need to stay away (or exclusion) from public spaces if unwell; or scaled‐up case and contact management activities (e.g. backward contact tracing) in communities where populations are vulnerable, at risk of severe disease and/or have lower rates of vaccination coverage. Agencies may also consider policies to minimise interactions and promote physical distancing, based on local risk assessment and consideration of the people within the community/setting who may be most affected (e.g. those at risk of severe disease; congregate living facilities). Communities at both low and high risk are advised to follow local PHA advice. Further factors, such as social, environmental and economic factors (e.g. housing, water quality/access, food security, pre‐existing health conditions, precarious income/education/employment) need to be taken into account when adjusting PHMs for people living in remote and isolated communities. Additional barriers for individuals living in such communities also need to be considered and appropriately addressed when considering PHMs and vaccination coverage. Recommendations: The risk of COVID‐19 is associated with many factors, that change over time. Local responses based on assessment of such factors is required, leading to adjustment in PHMs. Agencies should proactively plan and communicate with communities about expected adjustments to measures, including reasons for the decisions. There should also be planning in place to support those at higher risk of COVID‐19 (e.g. at risk of more severe disease; not fully vaccinated) to adjust measures based on their own circumstances, including communication to normalise such actions where required.	Communication purpose: May inform development of communications around PH measures, and adjustments required to these over time and with changing COVID‐19 risk level within communities. Related to review questions: Describes features of effectively communicating to support preventive measures, including physical distancing, against a backdrop of changing COVID‐19 risk. Acknowledges that personal information and decision‐making required for some individuals to follow additional measures; and the role that PH agencies have in communicating with communities to prevent stigma and promote collective actions for the common safety. Improving such communication may help to promote and improve acceptability of PHMs and changes to these over time, and to support adherence to required measures for communities and for individuals, including where there is a difference in the level of adoption of PHMs required based on personal risk.
Sarria‐Guzman 2021# Citation type: SR Public health measure: General PD Mapping to: Uptake, adherence Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 2: recipients of public communication: audience, setting and equity	Overview and aim: To identify and synthesise research on knowledge, attitudes and practices (KAP) related to COVID‐19 in America. Type of study and data: SR; cross‐sectional survey; N=13 studies, >18,000 participants. Inclusion and exclusion criteria: Included: research on KAP; peer‐reviewed, published English‐language studies; conducted in American continent. Excluded: abstracts; non‐peer‐reviewed source; non‐English; review or meta‐analysis; non‐American setting; high risk of bias (Hoy tool). Participant features and numbers, sampling details: All studies adults aged 18 years or older. General public (7/13 studies), elderly with chronic conditions (3/13), healthcare workers and endodontists (2 /13) and farming/non‐farming Latin migrant workers (1). Household income varied across studies, several included participants from lower socioeconomic groups. Included disease(s): COVID‐19. Timing: Searches conducted for research published 1 December 2019 to 24 September 2020. No further details. Countries included: 8/13 USA, 2/13 Brazil, 1 each Paraguay, Ecuador, Colombia All high or upper middle countries. Intervention or Phenomenon of interest: Knowledge, attitudes and practices towards COVID‐19 in the general population and within specific groups. Quality assessment: AMSTAR 4/11: [1. No protocol/plan referred to 3. Databases only, no supplemental searches 4. Published, English language studies only 5. No characteristics of excluded studies provided 8. Quality assessment not integrated/used for interpretation 10. Publication bias not reported 11. No COI of included studies reported]. Funding source: Not reported	Reported on: All included studies assessed knowledge; two thirds also assessed attitudes and practices. General public: KAP of the public importantly influence the behaviours and transmission of COVID‐19, with factors such as gender, age, educational level, income and political preferences reported to be influential factors. Knowledge about COVID‐19 and protection (prevention) may be lowest amongst those with lower education or employment status. Knowledge of COVID‐19 symptoms, risk factors and prevention measures were commonly obtained via social media, particularly amongst younger people while adults preferred government or international health organisation sites. Better knowledge was often associated with positive attitude and with appropriate preventive behaviours, and people accessing information via official government sites often adhered to measures such as physical distancing. In contrast, those preferring to access information from social networks more often had knowledge gaps related to COVID‐19 and were more likely to undertake risky behaviours. Misinformation (e.g. conspiracy theories about the virus) are common (e.g. 25% of American adults surveyed believed COVID‐19 to be a bioweapon), commonly originating from and spread via social media. Traditional media (e.g. national newspapers and public television) were typically the most trusted information sources. However, local sources (family, friends, coworkers, healthcare workers) were often the primary information source and a source of discussions about events, particularly healthcare workers who may provide relevant and timely information on risks and prevention measures. Even amongst groups with good knowledge of COVID‐19 transmission and prevention measures, such as Latino immigrant workers in the USA, there may be structural issues such as the need to work out of the home, visiting family or church attendance, that increase exposure and potential transmission of COVID‐19. People with chronic diseases: Most elderly people with at least one chronic condition perceived COVID‐19 as a serious threat but knowledge of symptoms and preventive measures varied across studies, with some indicating generally poor knowledge levels (e.g. one third unable to identify symptoms or infection prevention measures) and others with good knowledge (e.g. more than two thirds of those surveyed able to identify common symptoms and preventive measures). Some studies have suggested that where knowledge is poor in particular groups (e.g. elderly patients with diabetes in Brazil), the information provided may be inadequate. Recommendations: Many factors influence KAP levels related to COVID‐19, and can be categorised as: scientific and social factors i.e. reliability of information and source credibility; sociodemographic aspects i.e. gender, age, education, ethnic background, income and political preference; interpersonal relationships i.e. social belonging and family relationships. While people access information from various sources (television, websites, newspapers and social networks), social media is popular but may be the source of many inaccuracies and misinformation. Most people do not check the source of COVID‐19 information presented on social media, and this can lead to poor behaviours and decision‐making. Governments should ensure that high‐quality research and expert opinion are delivered clearly, accurately and impartially through a range of media (e.g. awareness campaigns, television). Materials to educate the public about COVID‐19 are critical to ensuring people understand what is required to prevent disease transmission. Healthcare workers also need specific, up‐to‐date information from reliable sources (e.g. WHO, CDC) in order to be able to adopt the required mitigation and prevention measures in different settings. Generally, the most marginalised communities (lower education and income levels) are often the most affected by pandemic outbreaks, with lower KAP amongst the elderly, less educated and rural residents. Health agencies and governments need to communicate effectively using a range of media or channels, to reach different parts of the community, including disadvantaged groups and those without Internet access. Educational activities may need to be accompanied by economic support to facilitate adherence to behavioural risk mitigation strategies. Preventative behaviours may vary across different family dynamics, as families with small children are more careful in following preventative behaviours than single people.	Communication purpose: Findings may inform communication with populations for effectively informing them of disease risks and prevention measures, including those at disadvantage and/or those at higher risk of complications due to COVID‐19. Related to review questions: Public KAP related to COVID‐19 critically influence the spread of disease, but levels are variable within and across population groups. People obtain information from a variety of sources e.g. traditional and social media sources, but some (social media in particular) may be more prone to spreading misinformation than others. In some cases, the information may itself be inadequate to support informed decisions regarding adoption of preventive measures. To support better knowledge and behaviour change related to prevention of disease, official sources need to target different groups within the population, including those who are particularly vulnerable to COVID‐19 complications or who are greater disadvantage, such as those who are educated to a lower level, in remote areas, or of lower income or employment levels. Information provided must be accurate, timely, comprehensive and delivered through different channels. Lack of information (gaps) or misinformation may lead to risky behaviours. Improving the accuracy, reliability and dissemination of information related to preventive behaviours is therefore critical to controlling disease transmission. For some groups, even where knowledge of disease and prevention measures is good, there may be structural issues, such as the need to work outside the home or larger family groups, that necessitate additional supports such as financial support.
WHO 2017* (guideline) Mapping to: Uptake, adherence, acceptability; also feasibility and barriers	Overview and aim: Provides up‐to date evidence‐based systems‐focused guidance on emergency preparedness and response, based on systematic analyses of the literature, and developed particularly for the public health aspects of emergencies. Inclusion and exclusion criteria: Included: Evidence assembled under 3 overarching themes (A‐C), 12 questions framed and used to guide the development of evidence reviews; included the following research types: 1. Quantitative research with comparison groups (randomized, non‐randomized) 2. Quantitative research with descriptive survey methods 3. Qualitative research 4. Mixed‑method research and case studies. Intervention or phenomenon of interest: Emergency responses ranged from infectious disease to floods, earthquakes, volcanic eruption, bioterrorism, food‐borne illness, and radiological radiation emergencies. Countries included: Studies of all UN countries were reviewed; however, most analysed emergency events in high‐ and middle‐income countries in Asia, Europe, North America, and Oceania. Quality assessment:(AGREE II) Scope and purpose: 81% Stakeholder involvement: 86% Rigour of development: 83% Clarity of presentation: 88% Applicability: 67% Editorial independence: 100%. Funding source: Core WHO funds were used to finance 70% of the total cost of the project. This was supplemented by Pandemic Influenza Preparedness (PIP) risk communication capacity building project funds, and unearmarked funds provided to the WHO Health Emergencies Programme by the Government of Japan and the Government of the United Kingdom of Great Britain and Northern Ireland.	Reported on: (A) Approaches for building trust and engaging with communities and affected populations. (B) Approaches for integrating risk communication into existing national and local emergency preparedness and response structures, including building capacity for risk communication. (C) ERC practice – from strategising, planning, co‐ordinating, messaging, channelling different methods and approaches of communication and engagement, to monitoring and evaluation – based on a systematic assessment of the evidence on what worked and what did not work during recent emergencies. Recommendations (directly relevant to review questions): A.1 Higher trust in ability of governments and public officials is associated with greater likelihood of the recommended actions being adopted. In order to build trust, risk communication interventions should be timely, transparent, easy‐to‐understand and consistent (i.e. not conflicting), and should link with self‐efficacy, including encouraging engagement and dialogue with the public. Risk communication interventions should clearly and openly acknowledge uncertainty, be targeted towards the groups or populations affected and information should be disseminated in multiple ways (platforms, methods, channels). Strong recommendation; moderate‐quality evidence. A2. Communication by authorities to the public should include explicit, clear and consistent information about what is known and what is not (uncertainty associated with events, risks and interventions) at a given point in time. Communication of uncertainty can have unintended negative effects, such as loss of trust, for instance, if contradictory messages are communicated. Strong recommendation; moderate‐quality evidence. A3. Involve people the community trusts in decision‐making to ensure interventions are collaborative, contextually appropriate and that communication is community‐owned. This may increase preparedness, and response to an emergency event. Involvement prior to an event is likely to be more successful than those undertaken only during an event. Strong recommendation; moderate‐quality evidence. C1. There is no one strategy to ensure successful communication in emergency situations. Therefore, strategic communication planning is an overarching best practice that should be presented prior to the recommendations on new practice. C2. Evidence shows that knowledge of the affected community needs to be considered by strategic planning efforts so that diverse needs of different populations are able to be met. Involvement of local stakeholders, who can communicate key messages and move populations from awareness to action, is also key. C3. Social media and traditional media should be used as part of an integrated strategy to convey accurate, verified information. Strong recommendation; moderate‐quality evidence. Social media can be used to engage the public, create situational awareness, monitor and respond to rumours, public reactions and concerns during an emergency, and to facilitate responses (peer‐to‐peer and local level).; however, use and application of social media as a sole strategy may have significant limitations (e.g. misuse, cultural concerns, varying degrees of affordability). Conditional recommendation, moderate‐quality evidence. C4. Risk messages should be consistent, and come from different information sources, as these are more likely to be trusted and acted upon. Messages should not be explained in technical terms, as confusion or misunderstanding can stop people from undertaking the required mitigation measures, whereas avoiding technical language may increase mitigation behaviours and is feasible. Messages should be available early in the emergency before misinformation or rumours can become established. Messages should promote specific actions people can take to protect their health. Such messages should be adapted to cultural contexts and need to be reviewed throughout the emergency. Strong recommendation; moderate‐quality evidence.	Communication purpose: This may be useful for improving communication with communities by emphasising the provision of clear, transparent and consistent risk information (messages) that is disseminated widely and through different media, informs people about specific actions for protection of their health, and builds trust through transparency and acknowledgement of uncertainty. Findings may also inform efforts to engage local stakeholders in risk communication planning and dissemination. Related to review questions: Recommendations link effective risk communication strategies with enhanced trust and understanding of public health messaging, which may increase uptake of and adherence to risk mitigation measures (such as physical distancing measures).
WHO 2020# Overview of public health and social measures Available: Overview of Public Health and Social Measures in the context of COVID-19 (who.int) Citation type: GL Public health measure: General PD Mapping to: Uptake, acceptability, adherence Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 3: support for individual and population behavioural changes Theme 4: community engagement to support communication	Overview and aim: To provide an overview of PH and social measures for preventing or slowing COVID‐19 transmission and identify strategies to limit potential harms (social and economic impact). Type of study and data: Overview of several guidelines and policy briefings. Included disease(s): COVID‐19 but also drawing on pandemic preparedness literature more generally. Timing: May 2020 Authors note need for authorities and governments to regularly review and calibrate the PH/social response as pandemic changes over time. Changes need to be communicated to the public over time; and strategies to minimise unintended effects of PH/social measures applied and adapted over time. Countries included: No specific country identified. Intervention or phenomenon of interest: Public health/social measures (including personal measures, PD, movement measures & special protection measures) to suppress disease, as well as social and economic impacts and possible strategies to mitigate negative impacts. Quality assessment: AGREE II: scope and purpose 66.7%; stakeholder involvement 30.56%; rigour of development 19.8%; clarity of presentation 50.0%; applicability 6.25%; editorial independence 12.5%. Funding source: Not reported.	Reported on: Social and PH measures include special measures to protect vulnerable groups, including people at risk for severe disease (e.g. older people, those with underlying medical conditions); those with social vulnerabilities (e.g. refugees, migrant workers, the homeless); those living in closed settings (e.g. detention centres, camps); and those more likely to be exposed occupationally (e.g. health workers, frontline responders). Response must be calibrated to the local context (e.g. commensurate with intensity of transmission nationally and/or subnationally) & reviewed regularly as the pandemic evolves to ensure feasibility, sustainability & acceptability; must also balance interventions to directly target COVID‐19 with strategies to limit short‐ and long‐term impacts on health and socioeconomic well‐being (e.g. those arising from loss of income, loss of services) that might arise from restrictions. Advanced planning is needed to avert possible indirect health impact that may follow overwhelming of health systems or interruption to other health/social services. Unintended negative consequences of measures need to be identified and managed alongside policies to maintain essential healthcare services; protect access to food, water and other essential goods and services; protect income; support communities; and ensure human rights for all (including considerations of gender). Authorities should select from the range of available PH and social measures and calibrate and implement the response depending on the local COVID‐19 situation (intensity of cases). Measures should be commensurate with intensity of COVID‐19 transmission, and adapted to local context to ensure feasibility, sustainability and acceptability. Time limits for the length of implementation of measures should be provided. Measures may also be adapted to the community, as appropriate, to include local culture, living conditions and resources and services. Duration of measures may also be informed by local context. Change to PH and social measures, together with rationale for the change, need to be clearly communicated to the public. Coordination of PH and social services is key to ensure that members of the public know how to seek testing or medical attention, isolate, trace and quarantine to protect themselves and others in the community. Engagement of the public is needed to ensure success of PH and social measures. To achieve this, regular dialogue through trusted channels is needed, so that people have access to the right information at the right time and so can make informed decisions to protect themselves or their families. Decision‐makers should engage with communities and communicate openly and regularly about how to implement measures, at all stages of the pandemic and recovery. Successful implementation of PH and social measures includes the following, amongst others: Communicating effectively and engaging communities: For individuals/community: Communicate the risk clearly and provide information on how people can best protect themselves and others; Use clear, simple language and messages and encourage information sharing & demystify science; Focus on what people can – rather than cannot – do; Provide information on how to help others needing assistance; Emphasise personal responsibility and the role of each individual in preventing disease and saving lives; Address stigma by emphasising respect for others and each person’s human rights. At government level: Communicate about risks, plans and policies often and regularly; Develop strategies to counter misinformation and myths; Involve the community in decision‐making (with the aim of strengthening community engagement for PH measures); and identify and engage local networks and communities, leaders and influencers. Promoting adherence: For individuals/community: Promote access to essential services (e.g. food shopping; online meetings) and provide support to those in isolation/quarantine; Implement simple measures such as markings at appropriate distances for spacing as a reminder (e.g. in shops, clinics, school desks) or one‐way flow to reduce number of contacts. At government level: Train local workers/volunteers in communication and skills such as contact tracing, home visits; Plan regular, iterative response assessment so that measures can be adapted over time, and changes can be communicated to the public. Mitigating unintended effects of PH/social measures includes the following: Support families and the community: Promote community support for sick or vulnerable; Encourage social interaction via virtual methods; Help social/community services enhance resilience in communities. Protect income and economy: Promote and encourage flexible leave and payment policies, part‐time or adapted work; Promote income maintenance; offer social and economic support. Protect access to food and water: Encourage home preparedness for quarantine/isolation, support access to food and supplies; Promote priority access to shops and services for vulnerable. Maintain essential health services: Inform the public about safe care‐seeking behaviours by disseminating information, including information about new pathways to services, opening hours and precautions needed. Recommendations: Public health and social measures to prevent and suppress COVID‐19 must be applied appropriately to the local context, and with unintended (adverse) effects of such measures acknowledged and targeted with strategies to minimise negative outcomes.	Communication purpose: This report may inform development of public communication strategies over time to inform people of preventive measures and alterations to measures, as well as strategies to counteract negative effects of PH/social measures to control disease. Measures should be communicated clearly, and regularly, to the public; should be informed by the local context & should provide information on the length of implementation. Community engagement is needed to help ensure the success of PH/social measures and adherence and acceptability of these within communities. Related to review questions: Describes communication and actions to be undertaken by authorities to promote adherence to PH and social measures, and to offset unintended effects of such measures. Strategies to provide support such as economic support, essential services and supplies, and to promote informed decisions, may be particularly key to promoting and supporting adherence to measures to protect health.
WHO 2020a# At WHO-2019-nCoV-RCCE-v2020.1-eng.pdf January 2020 interim guidance Citation type: GL; interim guidance Public health measure: General PD Mapping to: Uptake, acceptability Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 4: community engagement to support communication Theme 5: public trust and perceptions	Overview and aim: To provide actionable guidance for countries to implement effective risk communication and community engagement (RCCE) strategies, with the aim of protecting the public’s health in the early COVID‐19 response Type of study and data: Interim guidance Included disease(s): COVID‐19 Timing: January 2020 (early pandemic) Countries included: WHO, international Intervention or Phenomenon of interest: Guidance on RCCE strategies Quality assessment: AGREE II: scope and purpose 63.90%; stakeholder involvement 8.33%; rigour of development 4.20%; clarity of presentation 52.78%; applicability 2.08%; editorial independence 0%. Funding source: Not reported	Reported on: RCCE is a core component of health emergency preparedness and response. Data extracted focuses on findings most focused on communication in relation to promotion of preventive physical distancing measures. Clearly and proactively communicating about what is known, what is not, and what is being done to obtain information with the aim of saving lives, is a critical intervention in public health responses to any event. This helps to prevent spread of misinformation which can otherwise undermine the response, builds trust, and increases the chances that people will follow public health advice. Proactive and consistent public communication and engagement can reduce confusion; help people to understand their risk; identify how this might differ from authorities’ risk perceptions; and enables understandable, accessible and trusted information to be delivered to the public. Assessment of readiness (for countries without known cases): Assessment should include preparation to communicate with unknown information and certainty; assessment of (sub)national communication capacity; identification of main actors and development of partnerships; planning for implementation of RCCE plan; training staff on these RCCE plans and procedures. Assess the communication capacity of the relevant stakeholders and channels of communication used by those. Identify and plan communication roles of each stakeholder. Identify target audiences. Pre‐test public communication messages; identify key media and communication channels and their reach, level of public trust. Ensure that communicators are appropriately skilled and trained. Establish engagement methods with affected communities in order to understand people’s concerns, attitudes and beliefs; gather information on knowledge and behaviours (e.g. preferred information sources and formats), existing community leaders/influencers (e.g. community or religious leaders, unions) that could be leveraged for community engagement. Prepare to begin public communication before the full picture is known. Establish monitoring (and if needed, response) systems to address rumours, misinformation and common questions. RCCE initial response (for countries with cases) Initial response should include establishing and building trust with the public through two‐way communication and engagement. Such activities should happen regularly and address misinformation, rumours, and common questions; encourage people to adopt protective behaviours; communicate uncertainties; assess public risk perceptions; and provide information and guidance. Messages should be coordinated, consistent and timely. Public communication should include early frequent announcement of the health threat; this should be updated after analysis of public risk perceptions and tailored accordingly. Communicate information early, even if incomplete, and communicate openly about uncertainty (i.e. manage uncertainty). Communicate the degree to which uncertainty exists. Trusted, effective communication channels that people use regularly should be used, and trusted leaders or influencers identified. Information should be tailored, translated into community languages and adapted to appropriate literacy levels. Communication should clearly explain what is known and what is uncertain; this should be updated over time as new information emerges. Monitoring for rumours and misinformation should be conducted, and response mechanisms developed; feedback (e.g. mass and social media, hotlines) should also be monitored and used to improve and adapt the communication and community engagement strategy. Recommendations: Effective RCCE strategies form a critical part of the public health response to an emergency. They are multifaceted and require assessment, co‐ordination and ongoing monitoring and adjustment.	Communication purpose: Findings may inform communication strategies particularly information provision to the public and may assist with planning and implementing communication and community engagement.   Related to review questions: Clear, accurate and consistent communication of information, from and through trusted sources, may build trust and increase the likelihood of people following public health advice. Monitoring and addressing misinformation and rumours, and questions from members of the public, may also help to promote uptake of public health advice. Community engagement is also critical to understanding public perceptions and concerns and to identifying feedback to improve subsequent communications and information provision.
WHO 2021a# Considerations for implementing and adjusting public health and social measures in the context of COVID‐19. Interim guidance 14 June 2021 Citation type: GL Public health measure: General PD Mapping to: Acceptability, adherence, feasibility Mapping to: Theme 1: features of public communication: content, timing and duration, and delivery Theme 2: recipients of public communication: audience, setting and equity Theme 3: support for individual and population behavioural changes Theme 4: community engagement to support communication Theme 5: public trust and perceptions	Overview and aim: To provide guidance to Member States on introducing, lifting or adjusting public health and social measures (PHSMs) Type of study and data: GL (interim update, June 2021) Included disease(s): COVID‐19 Timing: Guidelines not specific to a particular stage of pandemic but focusses on need for adjustment of PHSMs over time according to COVID‐19 prevalence and communication and support measures needed to enable adjustment to measures over time Countries included: WHO, international Intervention or Phenomenon of interest: Guideline for countries to assess situation at national and subnational levels and need for introducing, adapting, or lifting PHSMs Quality assessment: AGREE II: scope and purpose 63.9%; stakeholder involvement 33.33%; rigour of development 6.3%; clarity of presentation 72.22%; applicability 0%; editorial independence 22.92%. Funding source: Not reported	Reported on: Globally, COVID‐19 control will continue to rely on PHSMs for the foreseeable future, which is influenced by different vaccination levels and unequal access to vaccines around the world, but also by changing community transmission levels, and emergence of variants of concern. Adjusting public health and social measures: Decisions about implementing, lifting, or strengthening PHSMs should include consideration of several factors, including: Measures which are effective and have the highest acceptability and feasibility (and minimise negative consequences) should be adopted. Assessment of feasibility and acceptability should be based on participatory approaches rather than one‐way communication; and engaging with the community will help to promote adherence. When the local situation changes (i.e. changes in case numbers, situational assessment), additional measures should be introduced or re‐introduced rapidly. If stricter PHSMs are implemented, this needs to be balanced against socioeconomic impacts (particularly in settings highly dependent on daily wages and the informal economy) and balanced against the positive and negative outcomes for the community as a whole and for individuals. These include effects on health and mental health, human rights, economic considerations, socioeconomic disparities, public health programme continuity, and treatment of non‐COVID medical conditions. Public attitudes (sentiment) towards PHSMs are also key. If PHSMs are lifted, new increases in cases should be considered and key transmission drivers must be well understood, as well as adequate health systems in place, and risk to vulnerable individuals minimised. Protecting vulnerable populations (e.g. those at risk for severe disease, such as those older than 65 years, comorbidities, marginalised groups) should be central to decision‐making; with awareness that vulnerable communities may need support to meet essential needs if PHSMs are introduced or removed. Assessment of such needs is critical, and vulnerable populations must be safeguarded by mobilising resources and engaging supports as well as community sectors to learn about their concerns and receive feedback. Key concerns include access to health services, food provision or income support, safe housing and safe public transport. Community engagement and risk communication: When PHSMs are changed, communities should be regularly and fully informed, engaged and enabled prior to the changes occurring. This will help communities to engage with the PHSM and to develop trust. Trust is critical and needs to be built and fostered, particularly where there is little or no involvement of the local population in decision‐making. Communication and community engagement strategy should be put in place prior to changing PHSMs; and the strategy should be developed in consultation with stakeholders, including those from the community. Plans should include consideration of target audiences, communication channels, and community engagement activities to inform the community. Key information to be conveyed by such plans should include that which is important to the community e.g. extent and duration of measures. Governments and authorities should regularly communicate epidemiological data to the public to build trust and to promote acceptance and sustained adherence to PHSMs. Risk communication must be clear, concise and transparent; include a rationale for the change to measures; and should be developed with communities in whom the PHSM is to be enacted or changed. It is particularly important that communities are given recognised roles to provide input and take ownership of how and when PHSMs will be changed. Communities are critical for the implementation of PHSMs and contribute to mitigating the impacts of certain measures, including the role of volunteers and other community organisations in strengthening community services for those in need (e.g. providing food or other essential supplies to those in isolation or quarantine). Mechanisms to enable feedback on PHSMs changes and societal impacts are needed to allow these to be quickly identified and addressed. Community engagement is critical in identifying solutions to promote uptake of measures that best fit with local needs, and this may improve adherence to measures. Working with local community networks to build capacity and train local leaders may be beneficial. Managing misinformation and information overload must be managed proactively by providing the right information at the right time, to the right people via trusted channels. Monitoring needs to be put into action in order to identify patterns as they emerge and to allow tailored communications to be delivered. Individualised public health measures: In settings where PHSMs are robustly implemented to prevent COVID‐19 transmission, relaxing some measures for some people (e.g. those fully vaccinated) may help to limit negative social and economic impacts of the measures. In such situations, the ethical implications of adjusting some measures for some people need to be fully considered, particularly in light of unequal access to vaccines within and across countries. Recommendations: Establishing, adjusting, or reinstating PHSMs are needed to control COVID transmission and outbreaks. Decisions to adjust measures should be made rapidly in response to local transmission levels. All such decision‐making needs to balance the benefits and potential harms of enacting measures on both individuals and communities. Engagement with communities and stakeholders is needed throughout planning and decision‐making stages. Communication and support should be planned and in place in advance of any changes to PHSMs, and communication should occur regularly to keep the public informed about the situation. Special attention is needed to ensure that vulnerable/disadvantaged communities are engaged and communicated with effectively.	Communication purpose: Guidance can inform strategies for planning and implementing public communication and support as PHSMs are adjusted to respond to changing COVID‐19 transmission levels within communities. Related to review questions: Proactive communication in advance of PHSM changes Identifies the need for clear, purposeful communication with communities about PHSMs and changes to these occurring over time. Highlights the need for community engagement and involvement of stakeholders in decisions about adjustments to PHSMs and to the public communication around these measures. Clear, transparent, timely communication tailored to local communities may help to build trust, to improve feasibility of implementation of the measures, and to improve acceptability and adherence to PHSMs.
Primary studies
Lim 2020# (primary) Maps to: Uptake	Overview and aim: Assessment of initial perceptions and responses towards COVID‐19 in Singapore, China and Italy in order to identify factors associated with anxiety and behavioural change (included avoidance of workplaces, public spaces, social engagements or public transportation, and changes to work‐related or personal travel plans) Inclusion and exclusion criteria: Included: invited (via email and SMS) online panel members (received incentive for completing), as well as Facebook users who clicked the survey link advertised (but did not receive incentive) Type of study and data: Online questionnaire‐based survey; 4,505 respondents (February to March 2020) Countries included: Singapore, China, Italy Quality assessment: Response rate: +++ (Singapore); ++ (China); + (Italy); Overall: ++ Sample methodology: ++ Authors declared no COI exists; sample underrepresented older people(China), younger people (Singapore), men and those without tertiary education (all 3 countries); majority of Italian respondents were from Lombardia and Veneto; preprint paper (not peer reviewed)	Reported on: Most respondents (all countries) reported high knowledge of COVID‐19 symptoms and modes of transmission. Most respondents (all countries) actively searched for information, with main sources identified as the Internet and social media. However, most respondents also rated traditional media (television, radio, print) and government sources as the most trusted sources of information. Most respondents (all countries) reported high levels of information sufficiency and self‐efficacy, although fewer respondents from China reported having sufficient information about risk of infection and why authorities were taking specific control measures. Compared to other countries, anxiety towards COVID‐19 was higher in China, positive behavioural responses were higher in Italy and superstition and fatalism were higher in Singapore. Most respondents (all countries) reported high acceptance of restrictive public health measures and confidence in authority was similar in Singapore and Italy. Higher self‐efficacy was associated with lower anxiety levels (all countries), and willingness to comply with restrictive measures and greater information sufficiency were associated with more positive behavioural changes to reduce spread of infection to themselves or others. Higher anxiety was associated with higher superstition and fatalism, and regarding traditional media as the most trustworthy information source (Singapore and Italy). Recommendations: Across all three countries, information sufficiency and self‐efficacy were strongly associated with lower anxiety. Across all three countries, higher acceptance of restrictive control measures and information sufficiency were strongly associated with greater positive behavioural response. Communication strategies that increase self‐efficacy and information sufficiency may reduce anxiety and promote positive behavioural changes. Study recommends early dissemination of information from trusted health and government authorities about signs and symptoms of the disease, risk reduction measures, protective behaviours and why specific control measures are being taken, via a variety of online and traditional media outlets.	Communication purpose: Findings may be useful for enabling communication; facilitating decision‐making and supporting behaviour change in relation to modifying or engaging in specific behaviours to reduce people’s risk of infection for themselves or others. Related to review questions: Lower anxiety was associated with higher self‐efficacy and information sufficiency. Higher acceptance of restrictive control measures and information sufficiency were associated with participants modifying or engaging in specific behaviours to reduce the risk of infection to themselves or others (included avoidance of workplaces, public spaces, social engagements or public transportation, and changes to work‐related or personal travel plans).