The presenting symptom signatures of incident cancer: evidence from the English 2018 National Cancer Diagnosis Audit.

BACKGROUND: Understanding relationships between presenting symptoms and subsequently diagnosed cancers can inform symptom awareness campaigns and investigation strategies. METHODS: We used English National Cancer Diagnosis Audit 2018 data for 55,122 newly diagnosed patients, and examined the relative frequency of presenting symptoms by cancer site, and of cancer sites by presenting symptom. RESULTS: Among 38 cancer sites (16 cancer groups), three classes were apparent: cancers with a dominant single presenting symptom (e.g. melanoma); cancers with diverse presenting symptoms (e.g. pancreatic); and cancers that are often asymptomatically detected (e.g. chronic lymphocytic leukaemia). Among 83 symptoms (13 symptom groups), two classes were apparent: symptoms chiefly relating to cancers of the same body system (e.g. certain respiratory symptoms mostly relating to respiratory cancers); and symptoms with a diverse cancer site case-mix (e.g. fatigue). The cancer site case-mix of certain symptoms varied by sex. CONCLUSION: We detailed associations between presenting symptoms and cancer sites in a large, representative population-based sample of cancer patients. The findings can guide choice of symptoms for inclusion in awareness campaigns, and diagnostic investigation strategies post-presentation when cancer is suspected. They can inform the updating of clinical practice recommendations for specialist referral encompassing a broader range of cancer sites per symptom.

Measuring and increasing rates of self-isolation in the context of COVID-19: a systematic review with narrative synthesis.

OBJECTIVES: This study aimed to investigate (1) definitions of self-isolation used during the COVID-19 pandemic; (2) measures used to quantify adherence and their reliability, validity, and acceptability; (3) rates of self-isolation adherence; and (4) factors associated with adherence. STUDY DESIGN: This was a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesis Without Meta-analysis (PRISMA) guidelines (PROSPERO record CRD42022377820). METHODS: MEDLINE, PsycINFO, Embase, Web of Science, PsyArXiv, medRxiv, and grey literature sources were searched (1 January 2020 to 13 December 2022) using terms related to COVID-19, isolation, and adherence. Studies were included if they contained original, quantitative data of self-isolation adherence during the COVID-19 pandemic. We extracted definitions of self-isolation, measures used to quantify adherence, adherence rates, and factors associated with adherence. RESULTS: We included 45 studies. Self-isolation was inconsistently defined. Four studies did not use self-report measures. Of 41 studies using self-report, one reported reliability; another gave indirect evidence for the lack of validity of the measure. Rates of adherence to self-isolation for studies with only some concerns of bias were 51%-86% for COVID-19 cases, 78%-94% for contacts, and 16% for people with COVID-19-like symptoms. There was little evidence that self-isolation adherence was associated with sociodemographic or psychological factors. CONCLUSIONS: There was no consensus in defining, operationalising, or measuring self-isolation, resulting in significant risk of bias in included studies. Future definitions of self-isolation should state behaviours to be enacted and duration. People recommended to self-isolate should be given support. Public health campaigns should aim to increase perceived effectiveness of self-isolation and promote accurate information about susceptibility to infection.

The effect of nocebo explanation and empathy on side-effect expectations of medication use following a fictional GP consultation.

The simple act of informing patients about side-effects increases the likelihood they will experience them (i.e. the nocebo effect). Explaining this psychological phenomenon could help to reduce side-effect experience, however, it is yet to be explored if this can be applied to clinical settings where new medication is prescribed. In addition, the degree to which a health-care provider empathetically communicates this to patients may have an impact. To investigate this, we carried out 2 × 2 factorial trial to assess the effect of nocebo explanation and empathy (plus their interaction) on side-effect expectations following a fictional GP consultation prescribing a new medication. Overall, 208 participants were randomised to watch one of the four fictive GP consultations and play the role of the patient. In all videos, participants received information about the reason for the consultation, the recommendation of a new fictive medicine, how to take it, benefits and side-effects. The videos differed in whether the GP provided an explanation of the nocebo effect (yes/no) and whether they communicated in an empathetic style (yes/no). After watching the video, participants were asked about their side-effect expectations and rated the quality of the GP's communication. Two-way ANOVAs revealed no main effect of nocebo explanation on expectation of side-effects warned or not warned about in the consultation. However, there was a main effect of empathy, with participants watching the empathetic consultations having significantly lower expectations of non-warned-about side-effects. There was no significant interaction. Findings suggest that explaining the nocebo effect and GP empathy did little to allay expectations of side-effects that were specifically mentioned in the consultation. However, GP empathy had an effect by helping to reduce additional side-effect expectations participants still had. Future work should extend these findings to real GP consultations where the full dimensions of empathy can be explored.

Effectiveness of testing, contact tracing and isolation interventions among the general population on reducing transmission of SARS-CoV-2: a systematic review.

We conducted a systematic literature review of general population testing, contact tracing, case isolation and contact quarantine interventions to assess their effectiveness in reducing SARS-CoV-2 transmission, as implemented in real-world settings. We designed a broad search strategy and aimed to identify peer-reviewed studies of any design provided there was a quantitative measure of effectiveness on a transmission outcome. Studies that assessed the effect of testing or diagnosis on disease outcomes via treatment, but did not assess a transmission outcome, were not included. We focused on interventions implemented among the general population rather than in specific settings; these were from anywhere in the world and published any time after 1 January 2020 until the end of 2022. From 26 720 titles and abstracts, 1181 were reviewed as full text, and 25 met our inclusion criteria. These 25 studies included one randomized control trial (RCT) and the remaining 24 analysed empirical data and made some attempt to control for confounding. Studies included were categorized by the type of intervention: contact tracing (seven studies); specific testing strategies (12 studies); strategies for isolating cases/contacts (four studies); and 'test, trace, isolate' (TTI) as a part of a package of interventions (two studies). None of the 25 studies were rated at low risk of bias and many were rated as serious risk of bias, particularly due to the likely presence of uncontrolled confounding factors, which was a major challenge in assessing the independent effects of TTI in observational studies. These confounding factors are to be expected from observational studies during an on-going pandemic, when the emphasis was on reducing the epidemic burden rather than trial design. Findings from these 25 studies suggested an important public health role for testing followed by isolation, especially where mass and serial testing was used to reduce transmission. Some of the most compelling analyses came from examining fine-grained within-country data on contact tracing; while broader studies which compared behaviour between countries also often found TTI led to reduced transmission and mortality, this was not universal. There was limited evidence for the benefit of isolation of cases/contacts away from the home environment. One study, an RCT, showed that daily testing of contacts could be a viable strategy to replace lengthy quarantine of contacts. Based on the scarcity of robust empirical evidence, we were not able to draw any firm quantitative conclusions about the quantitative impact of TTI interventions in different epidemic contexts. While the majority of studies found that testing, tracing and isolation reduced transmission, evidence for the scale of this impact is only available for specific scenarios and hence is not necessarily generalizable. Our review therefore emphasizes the need to conduct robust experimental studies that help inform the likely quantitative impact of different TTI interventions on transmission and their optimal design. Work is needed to support such studies in the context of future emerging epidemics, along with assessments of the cost-effectiveness of TTI interventions, which was beyond the scope of this review but will be critical to decision-making. This article is part of the theme issue 'The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence'.

Observed and self-reported COVID-19 health protection behaviours on a university campus and the impact of a single simple intervention.

During the COVID-19 pandemic, most data on adherence to health protective behaviours were collected via a self-report. We quantified the discrepancy between self-report data and discretely observed behaviour in a sample of university staff and students. We assessed the prevalence of cleaning hands, wearing a face-covering and maintaining distance from others. We also tested whether additional signage reminding people that these behaviours were mandatory improved observed adherence. Prevalence estimates based on self-report were higher than those based on observations. Signage was associated with improvements for observed behaviours (all χ2 ≥ 6.0, P < 0.05). We caution that self-reported data can produce misleading adherence rates.

Mpox knowledge, behaviours and barriers to public health measures among gay, bisexual and other men who have sex with men in the UK: a qualitative study to inform public health guidance and messaging.

BACKGROUND: The 2022-23 mpox epidemic is the first-time sustained community transmission had been reported in countries without epidemiological links to endemic areas. During that period, the outbreak almost exclusively affected sexual networks of gay, bisexual, or other men who have sex with men (GBMSM) and people living with HIV. In efforts to control transmission, multiple public health measures were implemented, including vaccination, contact tracing and isolation. This study examines knowledge, attitudes, and perceptions of mpox among a sample of GBMSM during the 2022-23 outbreak in the UK, including facilitators for and barriers to the uptake of public health measures. METHODS: Interviews were conducted with 44 GBMSM between May and December 2022. Data were analysed using reflexive thematic analysis. Positive and negative comments pertaining to public health measures were collated in a modified version of a 'table of changes' to inform optimisations to public health messages and guidance. RESULTS: Most interviewees were well informed about mpox transmission mechanisms and were either willing to or currently adhering to public health measures, despite low perceptions of mpox severity. Measures that aligned with existing sexual health practices and norms were considered most acceptable. Connections to GBMSM networks and social media channels were found to increase exposure to sexual health information and norms influencing protective behaviours. Those excluded or marginalized from these networks found some measures challenging to perform or adhere to. Although social media was a key mode of information sharing, there were preferences for timely information from official sources to dispel exaggerated or misleading information. CONCLUSIONS: There are differential needs, preferences, and experiences of GBMSM that limit the acceptability of some mitigation and prevention measures. Future public health interventions and campaigns should be co-designed in consultation with key groups and communities to ensure greater acceptability and credibility in different contexts and communities.

Understanding adherence to self-isolation in the first phase of the COVID-19 pandemic in England: a cross-sectional mixed-methods study.

BACKGROUND: During the early "containment" phase of the COVID-19 response in England (January-March 2020), contact tracing was managed by Public Health England (PHE). Adherence to self-isolation during this phase and how people were making those decisions has not previously been determined. The aim of this study was to gain a better understanding of decisions around adherence to self-isolation during the first phase of the COVID-19 response in England. METHODS: A mixed-methods cross sectional study was conducted, including an online survey and qualitative interviews. The overall pattern of adherence was described as never leaving home, leaving home for lower-contact reasons and leaving home for higher-contact reasons. Fisher's exact test was used to test associations between adherence and potentially predictive binary factors. Factors showing evidence of association overall were then considered in relation to the three aspects of adherence individually. Qualitative data were analysed using inductive thematic analysis. RESULTS: Of 250 respondents who were advised to self-isolate, 63% reported not leaving home at all during their isolation period, 20% reported leaving only for lower-contact activities (dog walking or exercise) and 16% reported leaving for higher-contact, and therefore higher-risk, reasons. Factors associated with adherence to never going out included: the belief that following isolation advice would save lives, experiencing COVID-19 symptoms, being advised to stay in their room, having help from outside and having regular contact by text message from PHE. Factors associated with non-adherence included being angry about the advice to isolate, being unable to get groceries delivered and concerns about losing touch with friends and family. Interviews highlighted that a sense of duty motivated people to adhere to isolation guidance and where people did leave their homes, these decisions were based on rational calculations of the risk of transmission - people would only leave their homes when they thought they were unlikely to come into contact with others. CONCLUSIONS: Understanding adherence to isolation and associated reasoning during the early stages of the pandemic is essential to pandemic preparedness for future emerging infectious disease outbreaks. Individuals make complex decisions around adherence by calibrating transmission risks, therefore treating adherence as binary should be avoided.

Help-seeking following a flooding event: a cross-sectional analysis of adults affected by flooding in England in winter 2013/14.

BACKGROUND: Flooding can cause long-term, significant impacts on mental health in affected populations. We explored help-seeking behaviour of households affected by flooding. METHODS: A cross-sectional analysis was conducted on National Study of Flooding and Health data on households flooded in England in winter 2013/14. Participants (Year 1: n = 2006; Year 2: n = 988; Year 3: n = 819) were asked if they sought help from health services and other sources. Logistic regression was conducted to calculate odds ratios (ORs) of help-seeking in flooded and disrupted participants compared to unaffected, adjusted for a priori confounders. RESULTS: The odds of seeking help from any source 1 year after flooding were greater for flooded participants [adjusted OR (aOR): 1.71, 95% confidence interval (CI): 1.19-1.45] and those disrupted by flooding (aOR: 1.92, 95% CI: 1.37-2.68) compared to unaffected participants. This continued in the second year (flooded: aOR 6.24, 95% CI: 3.18-13.34; disrupted: aOR: 2.22, 95% CI: 1.14-4.68), and help-seeking remained greater in flooded than unaffected participants in the third year. Flooded and disrupted participants were particularly likely to seek help from informal sources. Help-seeking was more prevalent amongst participants with mental health outcomes, but a notable proportion of individuals with any mental health outcome did not seek help (Year 1: 15.0%; Year 2: 33.3%; Year 3: 40.3%). CONCLUSIONS: Flooding is associated with increased demand for formal and informal support, persisting for at least 3 years, and an unmet need for help amongst affected individuals. Our findings should be considered in flood response planning to reduce the long-term adverse health impacts of flooding.

Changes in social contacts in England during the COVID-19 pandemic between March 2020 and March 2021 as measured by the CoMix survey: A repeated cross-sectional study.

BACKGROUND: During the Coronavirus Disease 2019 (COVID-19) pandemic, the United Kingdom government imposed public health policies in England to reduce social contacts in hopes of curbing virus transmission. We conducted a repeated cross-sectional study to measure contact patterns weekly from March 2020 to March 2021 to estimate the impact of these policies, covering 3 national lockdowns interspersed by periods of less restrictive policies. METHODS AND FINDINGS: The repeated cross-sectional survey data were collected using online surveys of representative samples of the UK population by age and gender. Survey participants were recruited by the online market research company Ipsos MORI through internet-based banner and social media ads and email campaigns. The participant data used for this analysis are restricted to those who reported living in England. We calculated the mean daily contacts reported using a (clustered) bootstrap and fitted a censored negative binomial model to estimate age-stratified contact matrices and estimate proportional changes to the basic reproduction number under controlled conditions using the change in contacts as a scaling factor. To put the findings in perspective, we discuss contact rates recorded throughout the year in terms of previously recorded rates from the POLYMOD study social contact study. The survey recorded 101,350 observations from 19,914 participants who reported 466,710 contacts over 53 weeks. We observed changes in social contact patterns in England over time and by participants' age, personal risk factors, and perception of risk. The mean reported contacts for adults 18 to 59 years old ranged between 2.39 (95% confidence interval [CI] 2.20 to 2.60) contacts and 4.93 (95% CI 4.65 to 5.19) contacts during the study period. The mean contacts for school-age children (5 to 17 years old) ranged from 3.07 (95% CI 2.89 to 3.27) to 15.11 (95% CI 13.87 to 16.41). This demonstrates a sustained decrease in social contacts compared to a mean of 11.08 (95% CI 10.54 to 11.57) contacts per participant in all age groups combined as measured by the POLYMOD social contact study in 2005 to 2006. Contacts measured during periods of lockdowns were lower than in periods of eased social restrictions. The use of face coverings outside the home has remained high since the government mandated use in some settings in July 2020. The main limitations of this analysis are the potential for selection bias, as participants are recruited through internet-based campaigns, and recall bias, in which participants may under- or overreport the number of contacts they have made. CONCLUSIONS: In this study, we observed that recorded contacts reduced dramatically compared to prepandemic levels (as measured in the POLYMOD study), with changes in reported contacts correlated with government interventions throughout the pandemic. Despite easing of restrictions in the summer of 2020, the mean number of reported contacts only returned to about half of that observed prepandemic at its highest recorded level. The CoMix survey provides a unique repeated cross-sectional data set for a full year in England, from the first day of the first lockdown, for use in statistical analyses and mathematical modelling of COVID-19 and other diseases.

A systematic review of observational methods used to quantify personal protective behaviours among members of the public during the COVID-19 pandemic, and the concordance between observational and self-report measures in infectious disease health protection.

OBJECTIVES: To assess the quantity and quality of studies using an observational measure of behaviour during the COVID-19 pandemic, and to narratively describe the association between self-report and observational data for behaviours relevant to controlling an infectious disease outbreak. DESIGN: Systematic review and narrative synthesis of observational studies. DATA SOURCES: We searched Medline, Embase, PsychInfo, Publons, Scopus and the UK Health Security Agency behavioural science LitRep database from inception to 17th September 2021 for relevant studies. STUDY SELECTION: We included studies which collected observational data of at least one of three health protective behaviours (hand hygiene, face covering use and maintaining physical distance from others ('social distancing') during the COVID-19 pandemic. Studies where observational data were compared to self-report data in relation to any infectious disease were also included. DATA EXTRACTION AND SYNTHESIS: We evaluated the quality of studies using the NIH quality assessment scale for observational studies, extracted data on sample size, setting and adherence to health protective behaviours, and synthesized results narratively. RESULTS: Of 27,279 published papers on COVID-19 relevant health protective behaviours that included one or more terms relating to hand hygiene, face covering and social distancing, we identified 48 studies that included an objective observational measure. Of these, 35 assessed face covering use, 17 assessed hand hygiene behaviour and seven assessed physical distancing. The general quality of these studies was good. When expanding the search to all infectious diseases, we included 21 studies that compared observational versus self-report data. These almost exclusively studied hand hygiene. The difference in outcomes was striking, with self-report over-estimating observed adherence by up to a factor of five in some settings. In only four papers did self-report match observational data in any domains. CONCLUSIONS: Despite their importance in controlling the pandemic, we found remarkably few studies assessing protective behaviours by observation, rather than self-report, though these studies tended to be of reasonably good quality. Observed adherence tends to be substantially lower than estimates obtained via self-report. Accurate assessment of levels of personal protective behaviour, and evaluation of interventions to increase this, would benefit from the use of observational methods.

Engagement with protective behaviours in the UK during the COVID-19 pandemic: a series of cross-sectional surveys (the COVID-19 rapid survey of adherence to interventions and responses [CORSAIR] study).

BACKGROUND: Behaviour is key to suppressing the COVID-19 pandemic. Maintaining behaviour change can be difficult. We investigated engagement with hand cleaning, reducing the number of outings, and wearing a face covering over the course of the pandemic. METHODS: We used a series of 64 cross-sectional surveys between 10 February 2020 and 20 January 2022 (n ≈ 2000 per wave). Surveys investigated uptake of hand cleaning behaviours, out of home activity (England only, n ≈ 1700 per wave) and wearing a face covering (England only, restricted to those who reported going out shopping in the last week, n ≈ 1400 per wave). RESULTS: Reported hand cleaning has been high throughout the pandemic period (85 to 90% of participants consistently reporting washing their hands thoroughly and regularly with soap and water frequently or very frequently). Out of home activity has mirrored the easing and re-introduction of restrictive measures. Total number of outings were higher in the second national lockdown than in the first and third lockdowns. Wearing a face covering increased steadily between April to August 2020, plateauing until the end of measurement in May 2021, with approximately 80% of those who had been out shopping in the previous week reporting wearing a face covering frequently or very frequently. CONCLUSIONS: Engagement with protective behaviours increased at the start of the pandemic and has remained high since. The greatest variations in behaviour reflected changes to Government rules. Despite the duration of restrictions, people have continued to adopt personal protective behaviours that were intended to prevent the spread of COVID-19.

Exploring the impact of shielding advice on the wellbeing of individuals identified as clinically extremely vulnerable amid the COVID-19 pandemic: a mixed-methods evaluation.

BACKGROUND: The national shielding programme was introduced by UK Government at the beginning of the COVID-19 pandemic, with individuals identified as clinically extremely vulnerable (CEV) offered advice and support to stay at home and avoid all non-essential contact. This study aimed to explore the impact and responses of "shielding" on the health and wellbeing of CEV individuals in Southwest England during the first COVID-19 lockdown. METHODS: A two-stage mixed methods study, including a structured survey (7 August-23 October 2020) and semi-structured telephone interviews (26 August-30 September 2020) with a sample of individuals who had been identified as CEV and advised to "shield" by Bristol, North Somerset & South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG). RESULTS: The survey was completed by 203 people (57% female, 54% > 69 years, 94% White British, 64% retired) in Southwest England identified as CEV by BNSSG CCG. Thirteen survey respondents participated in follow-up interviews (53% female, 40% > 69 years, 100% White British, 61% retired). Receipt of 'official' communication from NHS England or General Practitioner (GP) was considered by participants as the legitimate start of shielding. 80% of survey responders felt they received all relevant advice needed to shield, yet interviewees criticised the timing of advice and often sought supplementary information. Shielding behaviours were nuanced, adapted to suit personal circumstances, and waned over time. Few interviewees received community support, although food boxes and informal social support were obtained by some. Worrying about COVID-19 was common for survey responders (90%). Since shielding had begun, physical and mental health reportedly worsened for 35% and 42% of survey responders respectively. 21% of survey responders scored ≥ 10 on the PHQ-9 questionnaire indicating possible depression and 15% scored ≥ 10 on the GAD-7 questionnaire indicating possible anxiety. CONCLUSIONS: This research highlights the difficulties in providing generic messaging that is applicable and appropriate given the diversity of individuals identified as CEV and the importance of sharing tailored and timely advice to inform shielding decisions. Providing messages that reinforce self-determined action and assistance from support services could reduce the negative impact of shielding on mental health and feelings of social isolation.

A qualitative process analysis of daily contact testing as an alternative to self-isolation following close contact with a confirmed carrier of SARS-CoV-2.

BACKGROUND: In July 2021, a randomised controlled trial was conducted to compare the effect on SARS-CoV-2 transmission of seven days of Daily Contact Testing (DCT) using Lateral Flow Test (LFT) and two Polymerase Chain Reaction (PCR) tests as an alternative to 10 days of standard self-isolation with one PCR, following close contact with a SARS-CoV-2 carrier. In this qualitative study, we used a nested process evaluation to aid interpretation of the trial and provide insight into factors influencing use of tests, understanding of test results, and how tests were used to inform behavioural decisions. METHODS: Interviews were conducted with 60 participants (42 randomised to DCT and 18 randomised to self-isolation) who had been in close contact with a confirmed SARS-CoV-2 carrier and had consented to take part in the trial. RESULTS: Data were organised into three overarching themes: (1) assessing the risks and benefits of DCT (2) use of testing during the study period and (3) future use of testing. Attitudes toward DCT as an alternative to self-isolation and behaviour during the testing period appeared to be informed by an assessment of the associated risks and benefits. Participants reported how important it was for them to avoid isolation, how necessary self-isolation was considered to be, and the ability of LFTs to detect infection. Behaviour during the testing period was modified to reduce risks and harms as much as possible. Testing was considered a potential compromise, reducing both risk of transmission and the negative impact of self-isolation, and was regarded as a way to return to normal. CONCLUSION: Participants in this study viewed DCT as a sensible, feasible, and welcome means of avoiding unnecessary self-isolation. Although negative LFTs provided reassurance, most people still restricted their activity as recommended. DCT was also highly valued by those in vulnerable households as a means of providing reassurance of the absence of infection and as an important means of detecting infection and prompting self-isolation when necessary.

COVID-19 survey burden for health care workers: literature review and audit.

OBJECTIVES: Concerns have been raised about the quantity and quality of research conducted during the COVID-19 pandemic, particularly related to the mental health and wellbeing of health care workers (HCWs). For understanding the volume, source, methodological rigour and degree of overlap in COVID-19, studies were conducted among HCWs in the United Kingdom (UK). STUDY DESIGN: Mixed methods approach, literature review and audit. METHODS: First, a literature review of published research studies and second, an audit of studies HCWs have been invited to complete. For the literature review, we searched Medline, PsycINFO and Nexis, webpages of three medical organisations (Royal Society of Medicine, Royal College of Nursing and British Medical Association), and the YouGov website. For the audit, a non-random purposive sample of six HCWs from different London NHS Trusts reviewed email, WhatsApp and SMS messages they received for study invitations. RESULTS: The literature review identified 27 studies; the audit identified 70 study invitations. Studies identified by the literature review were largely of poor methodological rigour: only eight studies (30%) provided response rate, one study (4%) reported having ethical approval, and one study (4%) reported funding details. There was substantial overlap in the topics measured. In the audit, volunteers received a median of 12 invitations. The largest number of study invitations were for national surveys (n = 23), followed by local surveys (n = 16) and research surveys (n = 8). CONCLUSION: HCWs have been asked to complete numerous surveys that frequently have methodological shortcomings and overlapping aims. Many studies do not follow scientific good-practice and generate questionable, non-generalisable results.

Tiered restrictions for COVID-19 in England: knowledge, motivation and self-reported behaviour.

OBJECTIVES: To test whether public knowledge and confidence in one's understanding of the local restrictions, motivation to adhere to local restrictions, and self-reported behaviour (going out for exercise, to work, socially) differed according to tier level. STUDY DESIGN: Cross-sectional, nationally representative, online survey of 1728 participants living in England (data collection: 26 to 28 October 2020). METHODS: We conducted logistic regression analyses to investigate whether knowledge of restrictions, confidence in knowledge of restrictions, motivation to adhere to restrictions, and self-reported behaviour were associated with personal characteristics and tier. RESULTS: Between 81% (tier 2) and 89% (tier 3) of participants correctly identified which tier they lived in. Knowledge of specific restrictions was variable. 73% were confident that they understood which tier was in place in their local area, whereas 71% were confident they understood the guidance in their local area. Confidence was associated with being older and living in a less deprived area. 73% were motivated to adhere to restrictions in their local area. Motivation was associated with being female and older. People living in tiers with greater restrictions were less likely to report going out to meet people from another household socially; reported rates of going out for exercise and for work did not differ. CONCLUSIONS: Although recognition of local tier level was high, knowledge of specific guidance for tiers was variable. There was some indication that nuanced guidance (e.g. behaviour allowed in some settings but not others) was more poorly understood than guidance which was absolute (i.e. behaviour is either allowed or not allowed).

COVID-19 vaccination acceptability in the UK at the start of the vaccination programme: a nationally representative cross-sectional survey (CoVAccS - wave 2).

OBJECTIVES: Investigate factors associated with the intention to have the COVID-19 vaccination following initiation of the UK national vaccination programme. STUDY DESIGN: An online cross-sectional survey completed by 1500 adults (13th-15th January 2021). METHODS: Linear regression analyses were used to investigate associations between intention to be vaccinated for COVID-19 and sociodemographic factors, previous influenza vaccination, attitudes and beliefs about COVID-19 and COVID-19 vaccination and vaccination in general. Participants' main reasons for likely vaccination (non-)uptake were also solicited. RESULTS: 73.5% of participants (95% CI 71.2%, 75.7%) reported being likely to be vaccinated against COVID-19, 17.3% (95% CI 15.4%, 19.3%) were unsure, and 9.3% (95% CI 7.9%, 10.8%) reported being unlikely to be vaccinated. The full regression model explained 69.8% of the variance in intention. Intention was associated with: having been/intending to be vaccinated for influenza last winter/this winter; stronger beliefs about social acceptability of a COVID-19 vaccine; the perceived need for vaccination; adequacy of information about the vaccine; and weaker beliefs that the vaccine is unsafe. Beliefs that only those at serious risk of illness should be vaccinated and that the vaccines are just a means for manufacturers to make money were negatively associated with vaccination intention. CONCLUSIONS: Most participants reported being likely to get the COVID-19 vaccination. COVID-19 vaccination attitudes and beliefs are a crucial factor underpinning vaccine intention. Continued engagement with the public with a focus on the importance and safety of vaccination is recommended.

Learning about COVID-19 across borders: public health information and adherence among international travellers to the UK.

OBJECTIVE: Public health control measures at borders have long been central to national strategies for the prevention and containment of infectious diseases. Travel was inevitably associated with the rapid global transmission of COVID-19. In the UK, public health authorities tried to reduce the risks of travel-associated spread by providing public health information at ports of entry. This study investigates risk assessment processes, decision-making and adherence to official advice among international travellers, to provide evidence for future policy on the provision of public health information to facilitate safer international travel. STUDY DESIGN: This study is a qualitative study evaluation. METHOD: International air passengers arriving at the London Heathrow Airport on scheduled flights from China and Singapore were approached for interview after consenting to contact in completed surveys. Semi-structured interviews were conducted by telephone, using two topic guides to explore views of official public health information and self-isolation. Interview transcripts were coded and analysed thematically. RESULTS: Participants regarded official advice from Public Health England as adequate at the time, despite observing differences with intervention measures implemented in their countries of departure. Most participants also described adopting precautionary measures, including self-isolation and the use of face coverings that went beyond official advice, but reported adherence to guidance on contacting health authorities was more variable. Adherence to the official guidance was informed by the perceived salience of specific transmission possibilities and containment measures assessed in relation to participants' local social and institutional environments. CONCLUSION: Analysis of study findings demonstrates that international air travellers' responses to public health advice constitute a proactive process of risk assessment and rationalised decision-making to guide preventive action. This process incorporates consideration of the current living situation, trust in information sources, correspondence with cultural logics and willingness to accept potential risk to self and significant others. Our findings concerning international passengers' understanding of, and compliance with, official advice and mitigation measures provide valuable evidence to inform future policy and generate recommendations on the presentation of public health information to facilitate safer international travel. Access to a central source of regularly updated official information would help minimise confusion between different national guidelines. Greater attention to the differentiated information needs of diverse groups in creating future public-facing guidance would help to minimise the uncertainties generated by the receipt of generic information.

Adherence to protective measures among healthcare workers in the UK: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) are frontline responders to emergency infectious disease outbreaks such as COVID-19. To avoid the rapid spread of disease, adherence to protective measures is paramount. We investigated rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK HCWs who had been to their workplace at the start of the COVID-19 pandemic and factors associated with adherence. METHODS: We used an online cross-sectional survey of 1035 UK healthcare professionals (data collected 12-16 June 2020). We excluded those who had not been to their workplace in the previous 6 weeks, leaving us with a sample size of 831. Respondents were asked about their use of PPE, hand hygiene and physical distancing in the workplace. Frequency of uptake was reported descriptively; adjusted logistic regressions were used to separately investigate factors associated with adherence to use of PPE, maintaining good hand hygiene and physical distancing from colleagues. RESULTS: Adherence to personal protective measures was suboptimal (PPE use: 80.0%, 95% CI 77.3 to 82.8; hand hygiene: 67.8%, 95% CI 64.6 to 71.0; coming into close contact with colleagues: 74.7%, 95% CI 71.7 to 77.7). Adherence to PPE use was associated with having received training about health and safety in the workplace for COVID-19, greater perceived social pressure to adopt the behaviour and availability of PPE. Non-adherence was associated with fatalism about COVID-19 and greater perceived difficulty of adopting protective measures. Workplace design using markings to facilitate distancing was associated with adherence to physical distancing. CONCLUSIONS: Uptake of personal protective behaviours among UK HCWs at the start of the pandemic was variable. Factors associated with adherence provide insight into ways to support HCWs to adopt personal protective behaviours, such as ensuring that adequate PPE is available and designing workplaces to facilitate physical distancing.

Predicting Expectations of Side-Effects for Those Which Are Warned Versus Not Warned About in Patient Information Leaflets.

BACKGROUND: Research investigating predictors of side-effect expectations is disparate and largely based on hypothetical vignettes. PURPOSE: To carry out a secondary analysis of a randomized controlled trial and investigate the predictors of side-effect expectations for side-effects that were, or were not, warned about. METHODS: Two hundred and three healthy adults completed measures concerning demographics, psychological factors, baseline symptoms, and medication-related beliefs before reading one of two types of patient information leaflet (PIL) (standard or positively framed PIL) for a sham medication and asking them about their side-effect expectations. Associations between these measures and side-effect expectations whilst controlling for the PIL received were assessed using regression analyses. RESULTS: 82.8% of participants expected side-effects that were warned about in the PIL, and 29.1% expected side-effects that were not warned about. Participants who were younger, from White backgrounds, less optimistic, experienced increased anxiety and received the standard PIL were more likely to expect side-effects that were warned about. Those with higher beliefs about medicine overuse and lower trust in medicine development were more likely to expect side-effects that were not warned about. Higher somatization, baseline symptoms, modern health worries scores, and lower trust in pharmaceutical companies were associated with increased expectations for all side-effects. The results suggest we can not only rely on altering side-effect risk communication to reduce side-effect expectations and therefore nocebo effects. We must also consider patients' beliefs about trust in medicines. More work is needed to investigate this in a patientsample in which the medication is known to them.

Understanding patterns of adherence to COVID-19 mitigation measures: a qualitative interview study.

BACKGROUND: Evidence highlights the disproportionate impact of measures that have been introduced to reduce the spread of coronavirus on individuals from Black, Asian and minority ethnic (BAME) communities, and among those on a low income. An understanding of barriers to adherence in these populations is needed. In this qualitative study, we examined the patterns of adherence to mitigation measures and reasons underpinning these behaviors. METHODS: Semi-structured interviews were conducted with 20 participants from BAME and low-income White backgrounds. The topic guide was designed to explore how individuals are adhering to social distancing and self-isolation during the pandemic and to explore the reasons underpinning this behavior. RESULTS: We identified three categories of adherence to lockdown measures: (i) caution-motivated super-adherence (ii) risk-adapted partial-adherence and (iii) necessity-driven partial-adherence. Decisions about adherence considered potential for exposure to the virus, ability to reduce risk through use of protective measures and perceived importance of/need for the behavior. CONCLUSIONS: This research highlights a need for a more nuanced understanding of adherence to lockdown measures. Provision of practical and financial support could reduce the number of people who have to engage in necessity-driven partial-adherence. More evidence is required on population level risks of people adopting risk-adapted partial-adherence.