key: cord-0941922-g3gd6nf8 authors: Maqbool, Annayath; Khan, Noor Zaman title: Analyzing barriers for implementation of public health and social measures to prevent the transmission of COVID-19 disease using DEMATEL method date: 2020-06-14 journal: Diabetes Metab Syndr DOI: 10.1016/j.dsx.2020.06.024 sha: 544cb85bc58cf9f9bfb46b75557c918bfc00aed9 doc_id: 941922 cord_uid: g3gd6nf8 BACKGROUND AND AIMS: COVID-19 is a contagious disease caused by a new coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Till now there are no vaccines and explicit medicines available for the treatment of COVID-19 disease, therefore the initiatives like public health and social measures are helpful in limiting the quantity of contaminations and saving lives. Keeping this in view, an attempt has been made in the present work to identify the barriers which hinder the implementation of these public health and social measures METHODS: The barriers to implement public health and social measures for preventing transmission of COVID-19 are identified using systematic literature review and these barriers are then categorized using Decision-making trial and evaluation laboratory (DEMATEL) method. RESULTS: Results reveal that among ten identified barriers, Lack of resources for implementing public health and social measures is found to be the most influential barrier to implement public health and social measures for preventing transmission of COVID-19. CONCLUSIONS: The successful implementation of public health and social measures depends on the adequate availability of resources which include medical equipment, personnel and financial dealings. The outcome of this research work will benefit and motivate the higher authorities to consider and overcome various challenges to prevent the transmission of COVID-19. According to Wealth Health Organization (WHO) (2020), COVID-19 is a contagious disease caused by a new coronavirus known as SARS-CoV-2 (2019-nCoV). The outbreak of this disease started in Wuhan, China in December 2019 [1] . It is rapidly spreading across the world [2] [3] [4] . Breathing difficulty, fever, tiredness, dry cough, nasal congestion etc. are some of the symptoms of COVID-19, which start appearing within two to fourteen days after getting infected. The respiratory droplets of infected individuals are the main reason of its transmission. This infection is diagnosed by using an RT-PCR test [5, 6] . Polymerase chain reaction (PCR) testing uses the process of amplification [6] . There is no available evidence to indicate any particular treatment for suspected or confirmed COVID-19 patients. COVID-19 has been declared a pandemic by the WHO [7] . As there is no proper medical treatment reported for curing COVID-19, appropriate alternatives are required for preventing the transmission of COVID-19 in the form of public health and social (PHS) initiatives. Various steps that could limit COVID-19 transmission such as case isolation, contact tracing and quarantine, social distancing, foreign travel measures, and vaccinations and treatments [8] . Proper implementation of PHS measures will possible only after overcoming various challenges. These challenges act as barriers which hamper the implementation of the prevention programs [9] . There should be a proper understanding of obstacles/challenges faced during implementation of PHS measures with management techniques. Thus, it is essential to recognize the barriers that hamper the successful adoption of the PHS measures to prevent the transmission of contagious COVID-19. Further, it is also imperative to analyze these barriers using an appropriate decision making technique to enable management in taking decision regarding effective and efficient implementation of various measures for preventing COVID-19. For analyzing the barriers, an appropriate multi criteria decision making (MCDM) technique can be utilized to determine their relative importance, severity or priority [10] . In this study, the DEMATEL MCDM method is employed for analyzing the barriers. To prevent the transmission of this contagious disease, an attempt has been made in this study to first recognize the barriers of COVID-19 prevention program through systematic literature survey and expert advice and then with the application of DEMATEL, this work identifies the position of each barrier alongside their level of viability on the prevention system and on the other barriers. Public safety and social initiatives must be enforced with the complete involvement of all citizens of community to limit or curb the propagation of COVID-19 [8] . PHS measures include detection and isolation of the infected individuals, contact-tracing and quarantine, social distancing, national and international travel measures, and treatments [8] . As there are no vaccines and treatment available for COVID-19 disease, it is necessary to look for other alternatives which could be helpful in lessening the quantity of contaminations and saving lives. Measures reported by WHO include physical distancing, teleworking, distance learning, restriction on the use of non-essential facilities and services, national and international travel restrictions, home staying etc. Such actions are taken in combination with individual protective measures which is frequent hand washing and etiquette during coughing against contagious COVID-19. To be effective in containing the community transmission of this disease, PHS initiatives must be adopted by the society. The challenges which hinder the implementation of PHS measures to prevent COVID-19 are: Commitment is a force that binds an individual to a course of action of relevance to one or more targets [11] . Safety commitment from public refers to the fervor in the adoption of PHS measures as per the guidelines issued by the WHO to prevent the transmission of COVID-19. Proper knowledge of novel coronavirus among public and awareness of WHO regulations boost the safety commitment from public. Lack of Commitment from public or public resilience would result in increase in transmission rates [8] . A safety culture is a culture of government that puts a strong degree of emphasis on protection principles, values and attitudes -and these are shared by most of the citizens in the region [12] . Safety culture is defined as the set of beliefs, social and technical practices that are concerned with minimizing the exposure of people to conditions considered dangerous [13] . Poor safety culture would result in giving less preference to the prevention and safety measures shared by the WHO in containing the spread of COVID 19. Lack of administrative commitment and support at community level (Br-3). The prevention strategies profoundly depend on administrative support, which is necessary for the maintenance, participation, motivation in implementing the COVID-19 prevention process. The commitment from local administration by creating opportunities to facilitate the lock downs, ensuring the basic necessities to be provided to common people to restrict their movement [14, 15] . As per WHO guidelines, lock downs are necessary in preventing the transmission rate of COVID-19 outbreak [8] and local administrations need to impose restriction on accessing the public places. The strict enforcement of WHO regulations would only be possible by informing peoples, officials, leaders about WHO regulations. Some of the regulations and recommendations provided by WHO [16] to minimize the risk of transmission of COVID-19 disease are • Evading close interactions with people infected with COVID-19. • Ensuring frequent hand-washing, exclusively after direct contact with infected people. • Maintaining cough etiquettes by the people suffering from respiratory infection. If the regulations provided by WHO are not followed properly, the COVID-19 pandemic will contribute more to public hazard thereby more transmissions and loss of lives will follow [17, 18] . Enforcement of strict social distancing measures may assist in limiting the spread of COVID-19 disease. The quarantine of individuals diagnosed with the SARS-CoV-2 virus along with their family members will be effective in reducing cases [18] . Insufficient funds, improper resource allocation, short-ranged mentality, lack of interest etc. constitute the lack of resources [19] . Around the globe major portion of public is under self-quarantine to prevent spreading of the novel COVID-19 facing several trails like shortage of basic groceries. The door to door services can prove a better plan in order to avoid large gatherings at distribution centers, medical shops [22]. Communication It is obligatory for governments to formulate effective policies for the prevention, treatment and control of harmful diseases [15] . Governments must ensure that the details they share to the public about COVID-19 is accurate, timely, and consistent with human rights principles. Also, government should frame policies that could be easily implemented to prevent COVID-19 disease. Stigma arises when people adversely link a particular group with an infectious disorder, such as COVID-19. Stigma can drive people to hide their illness which prevent patient from seeking immediate health care, discourage them from following health measures. Stigmatization may progressively contribute to more severe health issues, continuous transmission and difficulty in managing infectious diseases during an outbreak [24]. Analyzing the Barriers for implementing PHS measures to prevent COVID-19 using DEMATEL The non-negative matrix attained from the respondents after assessing the relationships between n criteria ‫ܥ‬ = ‫ܥ{‬ ଵ , ‫ܥ‬ ଶ , … ‫ܥ‬ }. Suppose m respondents are asked to indicate the direct influence of criteria ‫ܥ"‬ " on criteria ‫ܥ"‬ " by an integer score of 0, 1, 2, 3 and 4 that represents no effect, very low effect, small effect, moderate effect, and very strong effect The row summation of i th row elements of matrix T is symbolized by ܴ presented in equation (5) indicates the effect of i th criterion on the other criteria, likewise the column summation of "j th " column elements of matrix T is symbolized by ‫ܥ‬ presented in equation (6) The present paper identifies and evaluates the barriers for the successful adoption of various measures to prevent COVID-19 disease. After reviewing prior research work and obtaining expert's advice, ten barriers were identified and presented in section 2.3. The identified barriers were then evaluated by DEMATEL as discussed in section 3. The Prominence (R+C) and net effect (R-C) is calculated from the total relation matrix using Eq. 5 and Eq. 6 respectively. The overall direct relation matrix is computed using equation 1 as shown in Table 1 . [Insert table 1] The normalized direct-relation matrix (B) is computed from equations (2) and (3) as presented in Table 2 . [Insert table 2] The normalized direct-relation matrix (B) changed into Total-Relation Matrix (T) using equations (4) and the same is presented in Table 3 . Finally using the equations (5) & (6), the prominence (Pi) and net effect (Ei) is computed and presented in Table 4 . [Insert table 4] In this study, the relation among various criteria were evaluated by using DEMATEL method and unlike traditional models, this technique is not limited to considering only direct effects or single directions of criteria. The results shown in Table 4 Furthermore the "net cause/effect" of each barrier are determined through the values of (R-C). If the value of difference (R-C) is positive, then the barrier is assumed to produce the "net cause" and if the difference (R-C) if found to be negative then the barrier is the "net effect". Figure 1 displays the R+C and R-C plots, thereby representing the causal relation between the barriers of the successful implementation of PHS measures. For more perspectives, these findings were discussed with the experts. The outcome of the present work will benefit and motivate the higher authorities to consider and overcome various challenges related to the prevention of COVID-19 disease transmission by understanding the severity of each barrier. Also, this study classifies the barriers into two categories viz. influential and influenced. On the basis of this classification, the administration will devise an appropriate plan to put more focus on dealing with the barriers as per their severity. The severity order provided in this study will enable the administration to concentrate only on the influential barriers while the severity of influenced barriers will be subsequently reduced. The findings of this research would also assist researchers in spreading awareness and the importance of PHS measures in controlling the virus transmission. As per the available literature accessed by the authors, it is found that more work is still need to be carried out on implementation of PHS measures in the infected areas. The initiatives like PHS measures are helpful in limiting the COVID-19 transmission. Different measures are being implemented in affected regions to control the spread of this disease. However, there are certain barriers that prevent implementation of PHS measures. Among ten identified barriers in the present study, lack of resources for implementing PHS measures is the most influential factor (barrier) against the successful adoption of PHS initiatives to prevent COVID-19. On the other hand, Lack of medical facilities at community level is the least influential factor (barrier). This study depends on literature survey and feedback from experts. There is a chance to ignore certain barriers during literature survey and obtaining expert advice. Also, categorization of barriers is based on the expert feedback and could be skewed against their degree of research. Also, the study depends on the information provided by the Indian experts and the outcome of this work may not be generalized globally. These impediments open the door for future research. In future, more barriers may be found through focused studies and similar work may be carried out by including them in different countries to establish their priority and also relationship between them by using other MCDM methods. Funding: None. Ethical approval: Not required (The current study does not involve any patient or volunteer which require any ethical approval) Annayath Maqbool contributed in the original draft preparation of the paper, barrier identification and analysis. Noor Zaman Khan contributed in reviewing and revising the language and the technical content of the paper. 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