You wake up. Your head is pounding. You feel… feverish. You have a new and persistent cough. You were on the vodka last night – you drank more than usual because you were doing so “at home” as the pubs and clubs were all full. Covid?
If you’re the sort of Wonkhe reader that keeps their eye on Wonk corner, you’ll know that one of the issues we’ve been worried about for a while is symptom declaration and compliance with the “test and trace” rules.
Even if you weren’t out (in) drinking, Freshers’ flu is widespread. We only partly mean influenza here – “Freshers flu” is a more general diagnosis, just a catch all name for the collection of minor respiratory ailments, poor diet, anxiety, and poor sleep that students face in September/October.
The reason this “will they get a test” thing matters is partly that if they did, they’d quickly overwhelm the capacity we have. But that’s probably not the big issue.
Evidence suggests there are a higher proportion of asymptomatic Covid cases among younger age groups, meaning that cases and outbreaks are “likely to be harder to detect among student populations” – that SAGE/DfE task and finish group paper rates identifies this as a risk with “high confidence”. Outbreaks may therefore “be large and widespread before they are effectively detected” – as that BMJ article noted, “viral transmission between asymptomatic students can occur at lightning speed”.
Spotting the problem
There’s a number of ways you can notice if students have Covid-19. One is through regular, mass, compulsory testing of particular groups (like students) but for whatever reason this has been ruled out on a national basis, and isn’t recommended in that task and finish group paper. Cynics will say this is because the UK hasn’t been able to scale up testing capacity to the level that it should have by now, optimists will say that there’s good science behind the need to target capacity on at-risk populations and evidenced outbreaks. Add in the complexity of UK HE and it’s probably a bit of both.
The alternative plan involves getting those with symptoms to notice them quickly, and then ensuring they follow the rules on declaration and self-isolation. The problem is that the task and finish group paper finds that current evidence from the general community suggests that uptake of testing among people who have cough, fever or anosmia is low. Estimates range from 12% (among people with symptoms responding to polls) to 35% (derived by dividing the number of cases identified per day in pillar two by NHS Test and Trace by the daily incidence estimated by the Office for National Statistics).
If we combine even this level of willingness with the student “lightning speed” issue, we have a major problem.
The question therefore is whether student compliance with these specific rules is likely to be better or worse than the general population, and in either event what we might do to maximise student compliance. There’s been a fair bit of work done so far on communicating rules around social distancing and the transmission of the virus, probably less on this “what if you have symptoms issue” – and there haven’t been (as far as we know) any student specific studies.
The TAFG does refer to a paper on adherence to the test, trace and isolate system which looks at results from a time series of 21 nationally representative surveys in the UK (the so-called “Covid-19 Rapid Survey of Adherence to Interventions and Responses” study), but this hasn’t been published yet. What has come out is a paper on the factors that influence symptom reporting during an emerging infectious disease outbreak – a rapid review of the evidence. So I thought I’d get hold of a copy and try to sense check some measures to address the issues by spending a morning chatting to student officers from a bunch of students’ unions about its findings.
The paper identifies a small number of themes into two categories – “facilitators” of compliance, and barriers. I’ve looked at the barriers in particular below.
Lack of knowledge
The paper notes that participants in several studies described a poor understanding of the characteristics of a new disease, suggesting that this could act as a barrier to “help-seeking” behaviour. There were also gaps in knowledge about symptoms, gaps in knowledge about testing and gaps in knowledge about treatment – as well as some conspiracies like rumours that “the needle to test you actually is poison and the test kills you”.
SU officers were fairly confident that students will arrive – and this includes students from other countries – knowing the main three symptoms (high temperature, a new continuous cough and a loss or change to your sense of smell or taste). They were less confident that students would know how to access a test, who to contact if they had symptoms, or the severity of the symptoms that should trigger contacting the university or T&T:
A lot of Freshers have a fever and a cough. They don’t know how bad it has to be to get a test and neither do I to be honest”.
When I had it I think I was in denial for days. The thought of dealing with it all was just overwhelming when I had so many other things going on”
There was confusion across my Zoom calls about whether students with symptoms are supposed to tell universities as well as the NHS service, and whose responsibility it was to inform the rest of a “household” (as well as confusion about whether household communication should happen upon experiencing symptoms or upon getting a positive test):
I don’t know what they think we are going to do, post a note under everyone’s door on our floor and say ‘hi you can’t leave the building for two weeks’. And I don’t know if they are allowed to get a test or if they’re supposed to do you?”
Fear and stigma
In the paper anticipated stigmatization and the desire to avoid this created a barrier to reporting symptoms – people worried about experiencing stigma in the workplace, in the wider community, and were concerned about social stigma that may be attached to family members of those who had developed severe illness.
Student officers were almost universally agreed that this would be a major issue:
Nobody wants to be that person that got your floor shut down for two weeks do they, and at the least you’d put that off for a day or so in case your cough was a hangover”
Imagine being Patient 0 at your uni or on your course. It would be worse if you’re from a country already being blamed by the community for the virus in the first place”
In addition fear emerged as a recurrent barrier to symptom reporting, including fear of what may happen if a person caught the disease, fear of receiving treatment, fear of being infected in a healthcare setting and so on.
Student officers were concerned about this for students who believe themselves to be in “at risk categories”, but expressed a broader set of fears:
In that first few weeks students won’t want to miss out. With even less face to face contact and opportunities to meet people FOMO will be huge”
Oh students have no idea what will happen when they call the NHS and that’s a problem. I mean most students hate using the phone altogether”
Does the uni get told if you phone NHS Test and Trace? I don’t know and if I don’t know I doubt students do”
Students are going to worry that if they tell people about where they have been for the last three or four nights that they’ll end up fined or blamed or even deported. They might get a test but they would need reassuring about how tracing works I think”
And some had other fears:
Look. Near me you need to drive half an hour to get a test and nobody knows when you get the results. Some students I know would worry that they were overwhelming a system when others needed a test more. Others would worry that without a turnaround time they might be confirming their mates to two weeks’ quarantine”
Some students would tell NHS Test and Trace but not their uni for sure, because once they tell the uni all that tracking data about where you’ve been is in play”
Low concern about symptoms
In the evidence review paper, many experienced low concern about symptoms and this acted as a barrier to compliance. For some people, this took the form of a fatalistic approach and others just did not feel sufficiently ill to report symptoms or access healthcare:
Oh yeah there’s definitely students who buy into the whole herd immunity thing who just want it over with for them”
It’s back to that Freshers Flu thing though isn’t it. Who wants to wreck Freshers for everyone in their flat just because their head is pounding from last night.”
I always felt ill in my first year, all year. I’d have ended up making everyone in my flat have to self-isolate all year”
In the paper economic barriers to accessing healthcare were also experienced, because participants could not afford healthcare, or were worried about a negative impact on their employment or had no paid sick leave.
Student officers were worried about students with part time jobs – but they had broader concerns about “costs”:
I would worry about losing out on work for sure. Even if your employer was good about it and loads would not be, jobs are harder to get right now and its how everyone else at work would react”
It’s not just losing income though is it. It’s losing out on the things you’ve paid for. Some students are getting hardly any face time on campus this term, they’re not going to want to give that up”
Oh yeah there’s loads of students I know who are like “I want to get my money’s worth” and that’ll be even worse this year.
Some were concerned about the “sunk costs”:
Our uni has been telling people that breaking the rules would be a disciplinary, which I keep saying is going to mean nobody admits where they’ve been or what they’ve been doing even if it was safe.
Yeah and actually students are worried about letting their family down and wasting the money spent on them most years, this would make it worse”
Others worried about students’ management of their mental health:
What people have got to remember is that a lot of students are balancing and managing their own mental and physical health all the time. If the physical risks of quarantine are low and the mental risks are high I know what students are going to do.”
And even where providers had considered some of the “costs”, student officers were less convinced that partners would be so understanding:
It’s not so bad at the start of term but our students are not going to want to miss the start of placements, and some of the placements aren’t going to put up with being messed around I don’t think”
Practicalities of attending a healthcare facility
In the study the healthcare or testing facility was too far away to travel to, and a lack of transportation was also an issue. Not being able to afford to travel, not having time to visit a facility, and lacking childcare were also issues.
These translated directly for the student officers I spoke to:
It’s a joke though. We can’t use the testing they’ve got at uni of and so all we know about is rumours that it’s a 45 minute drive to get a test or a home test that takes two weeks to come back”
They need to make it really close by and really fast and have multiple walk in centres in a city like ours”.
What should be done
The SAGE/DfE TAFG paper argues that being placed into isolation or quarantine is often an upsetting experience, and for students in university accommodation, this may be “compounded by being in an unfamiliar setting”, away from “usual sources of social support”, and with limited space, and “feeling that social and educational activities are moving on without you”.
- Ensuring people know the rules around self-isolation and quarantine is essential, and that it would be wise to inform students in advance what will happen when they declare symptoms. This, it says, “may help to reduce the stress involved by making the situation more predictable and may increase intention to isolate”. The evidence from my conversations suggests this should extent to explaining process and turnaround on tests and detailing the way tracing will work (and how any data given may be used and shared).
- Next, it says that policies should be in place that prevent staff or students from worrying that they will be penalised or will miss out by adhering to isolation. This, it says, will need to include clear rules and reassurance around coursework extensions, visa regulations, the ability to catch-up on missed teaching, and preventing any financial loss. There is a fine line here between mood music and messaging that acts a deterrent for risky behaviour itself and mood music and messaging that deters people from admitting they’ve done so – which could make everything worse.
- It also says that there is evidence that adherence to isolation and quarantine is higher in people who appreciate its importance for public health (rather than just being told “the rules”; that focussing on the importance of reducing transmission to others who are more vulnerable “may be useful”’ and that highlighting isolation and quarantine as a social norm “will promote adherence”.
These all need operationalising if not already, and that balance between “deterrent” and encouraging disclosure needs careful thought. Having spoken to student officers, I’d also go a little further with two additional observations:
- Officers felt that a general and universal commitment to education for all students on the spread of Covid, including translating guidance/training to main foreign languages, was essential. Some felt that students should have to demonstrate understanding rather than just be “told”.
- The focus should be on accepting you have symptoms and then telling the appropriate people quickly rather than just on resolving concerns about self-isolation. Addressing fears about data and clarifying who people should tell (the university, the NHS, the household) is also important.
Hiding from authorities because they have come up with an unworkable plan during a pandemic – opening university dorms but expecting students not to socialize – will foster cynicism, not education.
Instead of asking which measures might stop socializing among students, it’s better to understand why such gestures are, at best, futile but also fundamentally performative.”