key: cord-0710975-vn45rnve
authors: Allegrante, John P.; Auld, M. Elaine; Natarajan, Sundar
title: Preventing COVID-19 and Its Sequela: “There Is No Magic Bullet . . . It's Just Behaviors”
date: 2020-05-30
journal: Am J Prev Med
DOI: 10.1016/j.amepre.2020.05.004
sha: 5deeeb19432711dd43205d15fd6ac49b071509f9
doc_id: 710975
cord_uid: vn45rnve

nan

Coronavirus disease 2019 , the disease caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the most devastating infectious disease in a century. 1 Rapid transmission of the virus across the U.S. since January 2020 was fueled by continued travel-associated asymptomatic and pre-symptomatic importation, community spread through large gatherings, introductions into high-risk workplaces and densely populated areas, and limited diagnostic testing hindering containment. 2 Despite implementing mitigation strategies, the acceleration during March has highlighted the deficiencies and limitations of the U.S. public health infrastructure and preparedness.

In the future, COVID-19 is expected to recur in waves (seasonal or otherwise). 3 

to serious complications including acute respiratory distress syndrome, 4 myocardial injury, 5 renal insufficiency, 6 stroke, 7 and other conditions, all associated with high mortality. As effective treatments become available for COVID-19, it is likely that mortality will be lowered but not without long-term sequela in survivors, including pulmonary fibrosis, heart failure, chronic kidney disease, neurologic deficits, and psychological problems.

The best way to prevent this potential tsunami of chronic complications and the associated increased healthcare costs is by halting the transmission of COVID-19. Although efforts to develop a vaccine are underway, a vaccine is probably not realistic in less than 18 months. Even if a vaccine becomes available, it is uncertain what its protective efficacy and durability will be and if population uptake will be sufficient to establish herd immunity. Given the relatively low effectiveness of recent influenza vaccines and concerns about serious long-lasting complications associated with their use, not all Americans are likely to readily participate in vaccination, even if they are easily accessible and affordable. 8 The dominant governmental media narrative is missing the behavioral science expertise that is central to maximally achieving protective behaviors. The effort should draw on the nation's deep reservoir of behavioral science talent to complement the leadership of renowned scientists such as Drs. Fauci and Birx. Information about COVID-19 has been disseminated to individuals through public service announcements on TV, radio, digital and social media, and in the print media. Despite this, when RTI International surveyed 1,021 Americans in March 2020 to assess their knowledge about COVID-19 and their support for community mitigation strategies, they found significant gaps in respondents' knowledge and behavior: One third of those surveyed incorrectly believed that most people infected will die from COVID-19 and that antibiotics prevent infection. Most strikingly, only 33% said they refrained from shaking hands. 10 A more recent survey of 630 U.S. adults vulnerable to complications of infection found that almost a third of respondents could not correctly identify symptoms or ways to prevent infection, with one in four adults perceiving that they were "not at all likely" to get the virus. 11 So, although to some degree the U.S. faces a health literacy challenge, the failure to adopt recommended protective behaviors is not necessarily just due to a knowledge deficit. For example, social distancing may not be possible for some people because of population density or household overcrowding, the need for public transportation, or the fact that much essential work precludes maintaining social distance. Thus, individual decisions to follow prescribed protective behaviors will ultimately depend, in part, on specific circumstances or external policies.

Fighting this pandemic will require new "weapons" and a new resolve on the part of the public.

During World War II, Americans undertook dramatic individual and collective changes in behavior to overwhelmingly support the war effort and ensure military superiority to win the war. To defeat the SARS-CoV-2 pathogen and strengthen American public health preparedness for future adversaries, a similar historic national commitment is needed in which behavior change methodology is a dominant weapon in the nation's public health arsenal. Thus, if Americans are to adopt and adhere to the complex and difficult changes in behavior to prevent further spread of COVID-19 in what Dr. Fauci has described as the "inevitable" next wave, this enemy needs to be attacked on three strategic fronts:

There is an urgent need for accurate data about the preventive behaviors of individuals, their perceived susceptibility, attitudes toward protective behaviors, and gaps in COVID-19 prevention through population-based surveys. Such surveys should build on what has been learned from previous and emerging work 12 

Network, an open-access data archive and shared resource for researchers, policymakers, and the public, which maintains probability-based public opinion surveys on COVID-19. 13 Surveys of contemporary multicultural communication and behavior also need to be linked to interventions that incorporate and respect the culture, context, and other sociocultural dynamics in their development and testing.

The nationwide prevention effort would be vastly strengthened if federal, state, and local governmental authorities utilized the full spectrum of health communication technologies to reach at-risk populations. For example, at "hotspots" or areas of impending risk, push notifications to reinforce social distancing, hand washing, and use of masks could be sent to every mobile phone there until government leaders and public health authorities believe the risk has been lowered substantially. Such notifications could be sent by the National Emergency Broadcast System, AMBER Alert (the Department of Justice's nationwide system of emergency response), or even through active alerts through the National Weather Service or other emergency mass text alert systems to provide the cues and nudges to activate behavioral change.

Moreover, the digital technology sector engaged in social media should be tapped to harness its full potential to tailor and disseminate interventions using behavioral science to reach specific population segments-not one-size-fits-all. 14, 15 The emerging effort by Michael Bloomberg to develop smartphone apps to trace every person who comes into contact with COVID-19-infected individuals is another example of how clever strategic use of digital technology could strengthen the national response. 16 

Much of what was learned in response to the HIV/AIDS epidemic of the 1980s and outbreaks of influenza, Ebola, and SARS provides the foundation to guide the nation's scientific response to COVID-19. 17 However, the behavioral and social science evidence needs to be updated and expanded. For example, in addition to individual threat perception, there needs to be a better understanding of other factors such as social context, how science is being communicated and the extent to which people understand and accept the science, the alignment between individual and collective interests, perceptions of leadership, and the psychological burden of stress and coping. 18 As a wide range of influences at different levels affect COVID-19-protective behaviors, and such influences interact across different levels, the ecological model ( Figure 1 ) is an ideal framework to incorporate the different levels and influences in developing and testing interventions. 19 Consequently, multilevel interventions may be most effective in achieving and sustaining the appropriate behaviors. For example, interventions designed to change individual attitudes and behavior regarding social distancing may be more effective if they are congruent with government policy that supports it and a conducive workplace environment. However, government policy and a conducive workplace alone will not be sufficient without complementary strategies to communicate, educate, and motivate the at-risk individual.

Such multilevel studies are necessary to further understand the influences on protective behavior and evaluate the effect of novel behavioral interventions-especially those that are digitally mediated-to facilitate adoption and maintenance of COVID-19-preventive behaviors. There remain major research challenges. For example: Should studies evaluate behaviors separately such as physical distancing, hand washing, and wearing masks, or should they evaluate a comprehensive composite outcome? What is the relative importance of individual-level behaviors? Are government policies for physical distancing more potent than individual messages? Finally, to achieve sufficient variation across different levels and to test interactions, such studies will need to be large.

To further strengthen U.S. evidence-based public health preparedness and response capabilities, new transdisciplinary funding opportunities for innovative strategies that use the ecological framework and incorporate behavioral science, health education, and health communication-in addition to biostatistics, epidemiology, and computer science-should be released through federal agencies and foundations. With the right supportive evidence regarding prevention, there is high potential that, through implementing multilevel approaches, the COVID-19 pandemic could be halted.

The lessons learned from the 1918 influenza pandemic are stark reminders of the daunting challenges for effective prevention. These include three main factors:

1. public indifference and complacency that can lead people to underestimate their risk; 2. using mitigation strategies that go against human nature by requiring people to shelter themselves in rigid isolation to protect others; and 3. the problem of outwardly healthy-appearing, asymptomatic people unconsciously acting as a disease-transmission vector and infecting others. 20 The COVID-19 pandemic-like the 1918 influenza pandemic-is likely to remain endemic and recur in waves in the U.S. and elsewhere, notwithstanding viral mutation. Thus, this unprecedented challenge requires audacious out-of-the-box thinking and action.

To win the war against COVID-19, it is imperative to innovatively provide health information and education that is accurate, accessible, persuasive, and relevant, as well as culturally and linguistically appropriate and targeted at different subpopulations, especially high-risk individuals. This potentially life-saving behavioral intervention needs to be delivered by a source the at-risk population trusts and in a format it prefers, tailored to health literacy and behavior, and sufficiently detailed and frequent to facilitate not only the adoption of new behaviors designed to prevent infection or reinfection, but also reinforced to maintain this behavior over time.

If "it's just behaviors," preventing further viral spread will require strengthening evidence-based behavioral change and implementation science strategies to effectively reach the large numbers of at-risk Americans who are anxiously navigating the difficult social terrain to keep themselves and their families safe from COVID-19 and its long-term sequela. In other wars, the U.S. committed resources, technology, and expertise to achieve overwhelming superiority and overcome the enemy. The strategy for winning this contemporary war will demand nothing less. No financial disclosures were reported by the authors of this paper. workplace/institutional, state/local and national) that influence behavior, the associated actions that may influence behavior, and engagement in the COVID-19 protective behaviors.

Notes: Using this framework and the mediators/actions associated with each level, it is possible to develop comprehensive strategies that work through mediators at several levels. When national, state and local policies are aligned with organizational goals in a conducive family/social environment, and the individual is motivated and receptive to behavioral change messages, COVID-19 protective behavior will be maximized. 

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