Will students adhere to test and trace rules?

In other words – was students’ level of adherence to Test and Trace better or worse than expected, and did that make things better or worse in terms of the scale of any outbreak?

The advice from the SAGE/DfE sub committee on higher education made a series of recommendations on the steps that government and institutions should put in place to secure and improve adherence, only some of which have subsequently re-emerged in guidance and/or national policy.

One piece of contributing evidence to the paper that was frustratingly unpublished was a study entitled “Adherence to the test, trace and isolate system: results from a time series of 21 nationally representative surveys in the UK”. It’s now been uploaded to the Medrxiv pre-print server, and reiterates some important potential lessons for the management of the transmission of the virus amongst students for the rest of the academic year.

(As ever, important pre-print caveats about the paper not having been peer-reviewed apply)

As a reminder here, if you don’t regularly, compulsorily mass test the population (or a section of it you think is at risk), you have to rely on other stuff. The success of any test, trace and isolation system the depends on adherence once you become symptomatic – getting a test, passing on details of close contacts if infection is confirmed, and quarantining of contacts.

So to get a sense on adherence, since the start of the outbreak researchers worked with the Department of Health and Social Care in England to develop and analyse a series of weekly cross-sectional surveys tracking relevant behaviours and their potential predictors in the UK public. Sadly, any students completing the surveys in this time frame won’t have had their “student” hat on when doing so – so we have to look for other factors in the results to guess at behaviour.

Here’s your headlines, then, from the study for the general population – let alone students:

Self-reported adherence to test, trace and isolate behaviours is low; intention to carry out these behaviours is much higher.

Identification of Covid-19 symptoms is also low.

Practical support and financial reimbursement are likely to improve adherence to test, trace and isolate behaviours.

Gulp.

Let’s look at the identification of Covid-19 symptoms first. Only 48.9% of participants identified cough, high temperature / fever and loss of sense of smell or taste as symptoms of Covid-19, and the factors most strongly associated with not identifying Covid-19 symptoms were: male gender; younger age; not identifying as White British; thinking you have had Covid-19; and not knowing that you can spread Covid-19 to others if you are asymptomatic.

This will explain the well publicised efforts in Scotland to try to explain the difference between Freshers’ Flu and Covid-19.

Then there’s self-isolation. Of those who reported having experienced symptoms of Covid-19 in the last seven days, only 18.2% said they had not left home since developing symptoms.

An intention to self-isolate if you were to develop symptoms of Covid-19 is much higher (around 70%), but doesn’t translate into practice. Factors most strongly associated with non-adherence to self-isolation were: not knowing Government guidance about what to do if you developed Covid-19 symptoms; not identifying Covid-19 symptoms; thinking you have had Covid-19; having a dependent child in the household; and working in a key sector.

What about testing? Of those who reported experiencing symptoms in the last seven days, only 11.9% reported requesting a test. And while intention to request a test has increased over time, self-reported behaviour has remained relatively stable. Common reasons for not requesting an antigen test included: not thinking that symptoms were due to Covid, because symptoms improved and because symptoms were only mild. Could be a hangover, eh.

Sharing details of contacts with the tracing service? Of those who had not experienced symptoms in the last seven days, 76.1% reported that they probably or definitely would share details of their close contacts with the NHS contact tracing service if they tested positive. But given the poor adherence in testing to start with, that might not provide us with the comfort that it oughta.

And factors associated with not intending to share details of close contacts included not knowing if data would be secure and confidential (18.8%); not knowing what would happen to the data (17.2%); and thinking that the contact tracing system was not accurate and reliable (14.2%). We can now add to that “not wanting to be deported” or “not wanting to get a whopping fine if I fess up that I was at a house party”.

Finally quarantining – of those who reported having been alerted they had been in close contact with a confirmed case just 10.9% reported that they had not left home at all in the following 14 days. The percentage is almost certainly going to be worse if you’re supposed to be quarantining because you share a household with someone who just has symptoms.

We also don’t have evidence on the level of compliance from international students – but given the number of tales I’ve heard about students claiming that “it’s OK I had a test before I came” to beleaguered security staff, I’m not optimistic.

So what can fix it? Higher knowledge in general was associated with greater uptake of protective behaviours, and there has been some work here from universities – and making testing as easy as possible, for example by introducing local testing sites in areas with high infection rates, may also increase adherence – but it may not be enough.

Financial constraints impeded adherence to self-isolation, intention to share details of close contacts, and quarantining of contacts. We don’t have a meaningful fix for students who depend on zero hours contracts jobs, and we need one fast.

Research shows that people who have received help from others outside their household because of Covid were more likely to adhere to self-isolation. Can universities get some practical help in place fast for households that aren’t in university-run halls? And can these be coupled with proper policies, practice and messaging about not missing out academically on things students will miss?

What we don’t know is whether threats like fines – either from the government or universities – will work. What this study does say is that it found no evidence for associations between perceived (health) risk to oneself or to people in the community, and adherence to test, trace and isolate behaviours.

Do students tend to take more risks generally? Yes they do. Will becoming more and more authoritarian to try to stop them work? Without surveillance that would go beyond both moral acceptability and budgets, it may well not.