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Pandemic fatigue Reinvigorating the public to prevent COVID-19 - Policy framework for supporting pandemic prevention and management - WHO | World ...
REVISED VERSION NOVEMBER 2020

Pandemic
fatigue
Reinvigorating the
public to prevent
COVID-19

Policy framework for supporting
pandemic prevention and management
Pandemic fatigue Reinvigorating the public to prevent COVID-19 - Policy framework for supporting pandemic prevention and management - WHO | World ...
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Pandemic fatigue Reinvigorating the public to prevent COVID-19 - Policy framework for supporting pandemic prevention and management - WHO | World ...
Pandemic
fatigue
Reinvigorating the
public to prevent
COVID-19

Policy framework for supporting
pandemic prevention and management
4   Pandemic fatigue

Executive summary
Despite documented public support for pandemic              Responding to a request from Member States for support
response strategies across the WHO European Region,         in this field, this document provides a framework for the
Member States are reporting signs of pandemic fatigue       planning and implementation of national and subnational
in their populations – here defined as distress which can   strategies to maintain and reinvigorate public support to
result in demotivation to follow recommended protective     prevent COVID-19.
behaviours, emerging gradually over time and affected by
a number of emotions, experiences and perceptions.          Pandemic fatigue is an expected and natural response
                                                            to a prolonged public health crisis – not least because
While pandemic fatigue is an individual reaction,           the severity and scale of the COVID-19 pandemic have
governments acknowledge their responsibility to address     called for the implementation of invasive measures with
the factors that lead to fatigue.                           unprecedented impacts on the daily lives of everyone.

                                                     Protective
                       Opportunity                                                  Capability
                                                     behaviours

                                                     Motivation

                                                       Fatigue

The framework is intended to           We propose four key strategies for governments to
support pandemic prevention and        maintain and reinvigorate public support for protective
management.                            behaviours.

Given the complex nature of
pandemic fatigue, a multifactorial
action plan is needed. Actions must
be based on the barriers and drivers   Understand people. Collect and use      Engage people as part of the
experienced by people, and must be     evidence for targeted, tailored and     solution. Find ways to meaningfully
implemented in an integrated way       effective policies, interventions and   involve individuals and communities
across all levels of society.          communication.                          at every
                                                                               level.
Strategies to maintain and
reinvigorate public support must
be informed by public health,
societal, cultural and economic                                                Acknowledge and address the
                                       Allow people to live their lives,
considerations, and must ensure                                                hardship people experience and the
                                       but reduce risk. Wide-ranging
that no one is left behind.                                                    profound impact the pandemic has
                                       restrictions may not be feasible for
                                       everyone in the long run.               had on their lives.
Pandemic fatigue       5

For any initiative, policy or communication aiming to maintain and reinvigorate public
support for protective behaviours, we propose five cross-cutting principles.

Be transparent by sharing reasons       Be as consistent as possible in          Strive for predictability in
behind restrictions and any             messages and actions, and avoid          unpredictable circumstances, for
changes made to them, and by            conflicting measures.                    example, by using objective criteria
acknowledging the limits of science                                              for restrictions and any changes
and government.                                                                  made to them.

                                        Coordinate to avoid mixed
                                        messages across experts and
Strive for the highest possible level   spokespeople.
of fairness in recommendations and
restrictions.

As a quick list of concrete actions, we propose the following.

Think local. Reach out to civil         Prepare safe solutions for               Appeal to people rather than
society groups and ask them to find     upcoming national celebrations           blame, scare or threaten them.
creative ways of motivating their       where people gather across               Recognize that everyone is
members and peers.                      geographies and generations. Engage      contributing.
                                        individuals, workplaces, public
                                        transportation systems, the retail
                                        sector, retirement homes and more in
In every workplace, school,             discussions about ways to reduce risk.   Be clear, precise and predictable.
university, youth club and              Provide clear recommendations.           Use simple and digestible info­
more, talk to users. Ask them                                                    graphics as an effective way of
how they would like to implement                                                 communicating restrictions and risks –
recommended behaviours. Ask them                                                 and how they are related.
what support they need from you.        Understand which measures may
                                        be unbearable in the long term.
                                        Amend or balance such restrictions
                                        with other measures (economic,
                                                                                 Conduct regular qualitative and
Develop guidance on living life while   social, psychological), taking into
                                                                                 quantitative population studies.
reducing risk. Find creative ways of    account the epidemiological risk.
                                                                                 Take the findings seriously. Use them
communicating such guidance, and                                                 to inform action.
avoid constant changes.

                                        Make recommended behaviours
                                        easy and inexpensive. This can
                                                                                 Tailor communication to specific
                                        involve the provision of fast and
                                                                                 groups that experience demotivation.
                                        cheap internet connections, free
                                                                                 Test messages and visuals with
                                        masks and hand sanitizers, accessible
                                                                                 sample populations before launching
                                        hand-washing areas, spaces for
                                                                                 them.
                                        social interaction, opportunities for
                                        teleworking, and more.
6       Pandemic fatigue

Introduction

Behavioural insights surveys consistently confirm                                       It provides a framework for Member States to help
that the majority of people generally support                                           them plan and implement national and subnational
national COVID-19 response strategies, uphold high                                      strategies in this field. It draws on the results of
knowledge levels and wish to follow recommended                                         behavioural insights surveys conducted across the
behaviours (1). This is notable after half a year of                                    European Region, including those based on a WHO
lockdowns, restrictions and significant impacts on                                      tool (2), as well as pre-COVID-19 literature related
all of our everyday lives.                                                              to public health, health crises, resilience, trust, risk
                                                                                        perception, cultural contexts, communication and
Still, Member States across the WHO European                                            more. It includes a range of country case examples
Region are reporting emerging pandemic fatigue                                          as inspiration.1 It has been reviewed by a range of
in their populations. We consider pandemic                                              Member State representatives and topic experts.
fatigue as an expected and natural reaction to the
prolonged nature of this crisis and the associated                                      This framework is intended to support pandemic
inconvenience and hardship. However, it poses a                                         prevention and management. It should be read
serious threat to efforts to control the spread of the                                  in conjunction with other key WHO resources, in
virus. Until a vaccine or effective treatments are                                      particular Risk communication and community
available, public support and protective behaviours                                     engagement readiness and initial response for novel
remain critical for containing the virus. The gains                                     coronaviruses: interim guidance (3), and the Risk
that each nation collectively achieved through                                          communication and community engagement
lockdowns and other measures – sometimes at high                                        strategy for COVID-19 template (4), which supports
social and economic costs – must be safeguarded.                                        countries to tailor their own strategies.

Very limited experience exists on how to best                                           This document includes the following sections.
maintain or reinvigorate public support during
a global health crisis that expands over months                                         What is pandemic fatigue?
(potentially years) and that affects every member                                       National plans of action
of every society in every country.                                                      – Key strategy: Understand people
                                                                                        – Key strategy: Engage people as part of the solution
While pandemic fatigue is an individual                                                 – Key strategy: Allow people to live their lives, but
reaction, governments acknowledge their                                                   reduce risk
responsibility to address the factors that lead                                         – Key strategy: Acknowledge the hardship people
to fatigue.                                                                               experience
                                                                                        – Checklist: Cross-cutting principles
This document was prepared in response to requests                                      10 suggested actions
from Member States for guidance on responding to
pandemic fatigue and reinvigorating public support
for protective behaviours.

1
    Please note that the country case examples included in this publication are included for inspiration. There is a lack of evidence related to the health outcomes if
    interventions implemented during the COVID-19 pandemic, and this relates to the case examples included here as well. Including the case examples here does not
    imply the expression of any opinion whatsoever on the part of the WHO Regional Office for Europe concerning the appropriateness, acceptability, or impact of
    these case examples.
Pandemic fatigue            7

What is pandemic
fatigue?
                                                                                            What do we mean by pandemic
                                                                                            fatigue?
                                                                                            – A natural and expected reaction to
Pandemic fatigue is understood in this document as                                            sustained and unresolved adversity in
distress as a reaction to sustained and unresolved                                            people’s lives.
adversity which may lead to complacency,                                                    – Expresses itself as a feeling of distress,
alienation and hopelessness, emerging gradually                                               and in some places as emerging
over time and affected by a number of emotions,                                               demotivation to engage in protection
experiences and perceptions (5,6).2                                                           behaviours and information search and
                                                                                              as feelings of complacency, alienation
Pandemic fatigue is expressed differently in                                                  and hopelessness.
different contexts. The pandemic fatigue reported                                           – Evolving gradually over time and affected
from countries is expressed through an increasing                                             by a number of emotions, experiences and
number of people not sufficiently following or                                                perceptions as well as the cultural, social,
accepting recommendations and restrictions                                                    structural and legislative environment.
and/or decreasing their effort to keep themselves
informed about the pandemic. Previously effective
core messages regarding washing hands, wearing
face masks, and practising proper hygiene etiquette                                   Several components related to individual motivation
and physical distancing may seem less effective,                                      have been strongly impacted by the longevity of
and many countries have identified a need for                                         the pandemic situation. First, the perceived threat
reinvigorating approaches.                                                            of the virus may decrease as people become used
                                                                                      to its existence – even if the epidemiological data
Such reactions are natural and expected at this                                       show that the risk may, in fact, be increasing. At
stage of a crisis. At the beginning of a crisis, most                                 the same time, the perceived loss resulting from
people are able to tap into their surge capacity –                                    the pandemic response (lockdowns, restrictions) is
a collection of mental and physical adaptive                                          likely to increase over time as people experience the
systems that humans draw on for short-term                                            long-term personal, social and potentially economic
survival in acutely stressful situations. However,                                    consequences of restrictions. For some people, the
when dire circumstances drag on, they have to                                         balance may shift, and the perceived costs of the
adopt a different style of coping, and fatigue and                                    response may start to outweigh the perceived risks
demotivation may emerge (7,8).                                                        related to the virus.

These reactions are part of a complex interplay of                                    Second, an ingrown urge for self-determination and
many factors that affect protective behaviours.                                       freedom may grow as restrictions continue for a
These relate to individual motivation and capability                                  long time, impose inconveniences in everyday life, or
as well as to opportunities offered by the cultural,                                  continuously change in ways people feel they have
social, structural and legislative environment (see                                   little control over.
Fig. 1) (9). Each of these factors can be barriers to
and/or drivers of protective behaviours.
2
    Pandemic fatigue as a concept is not well defined in the literature. We understand this as the fatigue (distress and potential emerging demotivation) related
    specifically to the COVID-19 pandemic and the restrictions imposed to contain it. For a discussion of fatigue and how it may change perceptions and behaviours,
    refer to Increasing belief but issue fatigue: changes in Australian Household Climate Change Segments between 2011 and 2016 (5).
8    Pandemic fatigue

Third, even the most outrageous circumstances                                       pandemic and the threat it poses, and complacency
become normal when experienced over longer                                          may result.
periods of time. People may become used to the

Fig. 1. The interplay of factors affecting COVID-19 protective behaviours

                     Peers’
                  expectations
                      and
                   behaviours
    Cultural
    norms,                       Rights and                                                                                Awareness
     values                      regulations

                                                                        Protective
    Access
                                                                        behaviours
    (water,
   sanitizer,
                                 Workplace/
                                   school                                                                        Mental            (Health)
  non-public                                                                                                     ability            literacy
transportation)                   support

                    Income

                 Opportunity:                                                                                          Capability:
               Social and physical                                                                              Physical and psychological
                 Contextutual                                                Experiences                                Individual
                                                                                           Values and
                                                        Intentions
                                                                                             beliefs

                                               Perceptions                                           Emotions
                                                                              Fatigue

                                                                                                      Risk
                                                 Self-efficacy
                                                                                                  perceptions

                                                                     Trust          Complacency

                                                                  Motivation:
                                                             Automatic and reflective
                                                                   Individual

Fig 1. draws on the COM-B model, a widely used theoretical model to understand the factors affecting
behaviours (9). It proposes three overall factors that need to be in place for any behaviour to take place:
individual motivation (automatic and reflective), individual capability (physical and psychological) and
contextual opportunity (social and physical). The subcomponents of each factor can function as barriers
to and/or drivers of the behaviour.
Pandemic fatigue    9

National plans of
action
Both before and during the COVID-19 pandemic,            cutting principles for any policy, intervention or
considerable research has been conducted on fatigue      communication that aims to reinvigorate public
and factors such as trust, risk perception, social and   support for protective behaviours (see Fig. 2).
cultural norms, and structural opportunity (10–16).
Drawing on this research and on the complex nature       Surveys across countries show that most people
of pandemic fatigue, we propose a multifactorial         have a high level of knowledge related to COVID-19
plan of action.                                          protective behaviours and are mostly able to find
                                                         the information they need. Yet emotions and
Overall, we recommend understanding people by            contextual factors can have a greater impact on
drawing on evidence from epidemiological data and        behaviours than knowledge (17), which means
population research. More specifically, we recommend     that a strategy aiming to provide information
focusing on engagement, harm reduction and               and public health advice alone may not be
recognition of hardship. We also propose five cross-     the most effective. Rather, strategies should

Fig. 2. Four strategies and five cross cutting principles

  Key strategies
  in policies,                                                                                 Acknowledge
                                               Engage people           Allow people
  interventions and       Understand                                                          and address the
                                               as part of the        to live their lives,
                            people                                                            hardship people
  communication                                   solution            but reduce risk
                                                                                                experience

  Cross-cutting
  principles
                          Transparency       Fairness        Consistency       Coordination      Predictability
10   Pandemic fatigue

focus on policies and interventions as well as        Supporting documents
communication.                                        As noted above, this document should be read
                                                      in conjunction with other key WHO resources, in
The strategies and policy considerations of this      particular Risk communication and community
framework should always be considered in light        engagement readiness and initial response for
of the epidemiological situation. It is not the       novel coronaviruses: interim guidance (3), and the
intention of this framework to discourage against     Risk communication and community engagement
the implementation of pandemic control measures       strategy for COVID-19 template (4), which supports
when they are called for. However, governments        countries to tailor their own strategies.
have opportunities to alleviate the adverse impacts
of these measures through careful planning,
implementation and communication and through
additional social protection measures and policies
to ensure that no one is left behind.
Pandemic fatigue    11

Key strategy /
Understand
people
Background                                               Strategic considerations
Pandemic fatigue results from various barriers that      – Identify priority population groups – those
people experience across cultural and national             that show signs of demotivation and those with
contexts, and that require different kinds of support,     increasing transmission. Use population surveys
structures and communication.                              and surveillance data.

Understanding who is experiencing demotivation           – Understand what motivates them; understand
and the barriers and drivers impacting their ability       the barriers they face. Use qualitative and
or willingness to take up protective behaviours            quantitative population studies, media
allows decision-makers to segment and tailor               monitoring and hotline feedback.
actions to their particular needs. Barriers and
drivers can exist within various areas (see              – Use what you learn. Use it to identify emerging
Fig. 1), and may relate to individual capability or        perceptions and needs. Use it to inform pandemic
motivation, or to the social, cultural, structural or      policies, communication and other interventions.
legislative environment. Careful consideration of          Behavioural insights are only valuable if they
these elements leads to more successful and cost-          inform action.
effective policies, interventions and communication.
                                                         – Test new initiatives, messages and
For communication in particular, quality over              communication with the people whose
quantity should be the credo at this stage of              behaviours you wish to change. Use (online) focus
the pandemic. High-quality, evidence-informed,             groups or other research approaches.
tailored communication should be directed
to key population groups. Many people now                – Communicate government needs, priorities
have high knowledge levels, particularly of                and knowledge gaps to the research community
protective measures (1). At the same time, the             to ensure that the research agenda is relevant
so-called COVID-19 infodemic has resulted in an            and timely.
overwhelming amount of available information and
doubt about which sources are trustworthy (17). For
these reasons, less may be more.
12    Pandemic fatigue                                                             Case examplesPandemic
                                                                                                 for inspiration
                                                                                                         fatigue 12

France                              Germany                         Romania                      Ukraine
Documenting personal                Engaging experts from           Using a behavioural          Tailoring health
experiences using                   the health humanities           insights survey to inform    messages to target
creative and innovative             in discussions of               a strategy for reopening     groups
methods                             restrictions                    schools

Experts at Public health            Discussions of pandemic         Reopening schools            Behavioural insights
France deepened their               restrictions naturally          after the lockdown           surveys in Ukraine
understanding about                 involve virologists and         posed important policy       identified men with low
people’s experience of the          medical specialists.            challenges for authorities   education as a group with
pandemic and related                In Germany, however,            across the Region. Not       low adherence and low
restrictions through                other voices were               being able to offer          risk perception related
following a group of 60             engaged to help balance         education in a safe          to COVID-19. To tailor
people via an on-line               ethical, cultural and           environment could quickly    communication to this
community platform.                 behavioural aspects             lead to public distrust      critical group and enhance
During the 3 months of              while safeguarding public       and demotivation. The        impact and relevance,
the study, the retention            health – all critical aspects   Government of Romania        new COVID-19 messages
rate was remarkably                 of maintaining public           used findings from a         and visuals were tested
high. The participants              support and preventing          behavioural insights         in focus groups. Tailoring
who were chosen to be               demotivation. The Federal       survey conducted in          health messages to
diverse in terms of age,            Government consulted            the country to inform        specific population groups
gender and more replied             philosophers, historians        their strategy. The study    can enhance impact and
weekly to one or two                of science, theologians,        confirmed high support       relevance. Focus groups
open questions. They                pedagogical experts             for reopening schools for    can also be used to
were asked to document              and jurists who provided        both younger and older       revitalize health messages,
their life such as filming          valuable input, including       children. Such studies       which is important given
themselves while washing            on the educational              can help governments to      that sustained exposure
their hands. Although               progress of children from       identify developments over   renders messaging less
people reported regular             disadvantages families, the     time, new issues as they     effective over time.
hand-washing, researchers           legitimacy of restrictions of   emerge, and the positive
could see that this was             freedom, and the balance        and negative effects of
rarely done effectively.            between public support          restrictions, messages or
Using qualitative methods           and moral norms versus          actions.
and creative approaches             coercive state action (19).
may uncover new types of
insights that can provide
valuable information to
inform policy (18).

Please note disclaimers on page 2
Pandemic fatigue     13

Key strategy /
Engage people
as part of the
solution
Background                                              Listening to people, understanding their needs, and
Humans have an essential need to feel in control        planning policies that are responsive to those needs
of their own lives, and when this autonomy              and that reflect people’s sense of self-identity all
is threatened, motivation is easily lost (20).          promote feelings of engagement. Stories are also
Reinvigorating public support thus involves             powerful motivators: research shows that people
engaging people as part of the solution (21,22).        are more likely to follow actions if information is
Above all, engagement should give people a sense        presented in a way that matters to them (24).
that recommended behaviours are not a matter of
capitulation to authority or a reflection of despair,   For specific communities and population groups,
but a part of something positive, hopeful and (if at    engaging trusted voices in promoting protective
all possible) fun (16,23). Such engagement can take     behaviours as a social norm is likely to increase
many forms on national, community and individual        support (25–27). During the Ebola crisis, enlisting
levels.                                                 the faith-based sector and trusted community
                                                        members was seen as a turning point in the
Promoting self-efficacy and positive majority           epidemic response (28,29). Experience from the
behaviours can be a cornerstone in national             COVID-19 pandemic also demonstrates that
strategies and communication. Rather than               community cultural resources, norms and values
focusing on those who do not follow behaviours, it      offer vital resources for building and maintaining
may be more effective to highlight the many who         prevention efforts (16).
do, as well as positive majority norms and the public
health gains achieved through collective effort.        On an individual level, people can be engaged locally
                                                        in workplaces, schools, sports clubs and more.
14   Pandemic fatigue

Strategic considerations                               – Use commitment contracts. Encourage local
– Pass the baton on to others. Consider civil            initiatives to engage people in setting goals and
  society groups and leaders who could be                pledging to follow behaviours.
  engaged to take on leadership roles in enabling
  and promoting protective behaviours: consider        – Enlist trusted voices in health messaging, and
  national youth organizations, local and national       showcase those who have tackled COVID-19 in a
  housing associations, religious leaders, sports        positive way or those taking a lead in volunteering
  clubs and scouting organizations, and business or      to help others.
  community organizations.
                                                       – Focus messages on strengthening self-
– Learn from civil society and actively engage           efficacy, shifting from “the pandemic controls
  them in developing scenarios for future local/         our behaviours” to “we control the pandemic with
  national lockdowns.                                    our behaviours”. Highlight the tremendous public
                                                         health gains achieved through collective effort.
– Ask civil society to find creative ways of
  motivating their members and peers. Ask them         – Seek to inspire as well as inform. Tap into
  what support they need from you. Engage                the power of stories and those who tell them
  volunteers. Involve them in the design and             well. Find creative ways or new opportunities to
  delivery of COVID-19 policies, interventions and       reiterate messages that engage people. Work
  messaging. They can all play an active role.           with professional writers, journalists, artists, and
                                                         other types of storytellers to create narratives
– In every workplace, school, university, youth          based on the insights gathered from working with
  club and more, ask users to discuss how they           communities.
  would like to implement the recommended
  behaviours. These discussions can reveal barriers,
  inconveniences and misperceptions that can be
  addressed while still maintaining restrictions.
Case examples for inspiration                                                                     Pandemic fatigue    15

Denmark                                  Turkey                                   Norway
Co-creating solutions:                   Engaging people to reflect on            Engaging staff to plan
@hvemdelerduspytmed                      their own environment                    kindergarten reopening
[who do you share saliva with]

The Danish Lung Association co-          The WHO Country Office in Turkey         National strategies for the reopening
created a campaign with its target       has carried out Twitter polls asking     of kindergartens in Norway
group of young people, encouraging       questions such as “What are you          included a degree of flexibility. This
them to enter a competition to come      doing to protect your health?”.          way, communities and individual
up with ideas for how to spend time      These types of low-cost engagement       kindergartens could operationalize
together in a safe way during the        activities may spur people to think      restrictions and protection measures
pandemic. Actively involving target      critically about their own behaviours    in ways that were tailored to their
groups in the design and delivery of     and social environments while            context. Kindergarten staff in some
engagement activities can ensure         serving as a reminder of the ongoing     places convened to discuss and
that they are tailored and responsive    pandemic.                                collectively agree on sustainable
to the perspectives and experiences of                                            local solutions to meet national
the people they strive to reach (31).                                             requirements. Recognizing that
                                         West Africa                              people are experts of their own
                                         Partnering with trusted voices           environment, this approach
United States of                                                                  demonstrates the importance of
America                                  During the Ebola epidemic, Christian     enabling local decision-making,
Sharing commitment contracts             and Muslim faith leaders used            ownership and autonomy in national
through grassroots movements             passages from religious texts to show    planning (30).
                                         that modified burial rituals were
In Florida, two brothers launched the
                                         still spiritually acceptable. In cases
“Promise to Humanity” campaign
                                         where religious rituals are affected
with a single goal: to enlist people
                                         by COVID-19 restrictions, engaging
in signing contracts pledging to
                                         religious leaders may increase the
follow all guidelines in an effort to
                                         acceptability of adapted ceremonies.
slow the spread of the virus. After
                                         Community leaders often have
signing the pledge online, followers
                                         a high level of trust and a good
could nominate three more people
                                         understanding of the community
to do the same. Such commitment
                                         norms and values, which can be of
contracts are known to influence
                                         great value to decision-makers in
people’s behaviours and keep them
                                         policy formulation (33).
dedicated for longer (32).

Please note disclaimers on page 2
16   Pandemic fatigue

Key strategy /
Allow people to
live their lives,
but reduce risk
Background
The demotivation reported among some people is          This approach can also be applied at a national
in part a reaction to the longevity of the pandemic.    level. Member States who have recently applied
While early strategies could draw on far-reaching       new restrictions to address case resurgences have
interventions such national lockdowns, long-            done so mostly locally by applying smart, time-
term strategies will need to go beyond a state of       limited and risk-based measures rather than broad
emergency and allow people to return to something       and extended restrictions. This targeted approach
that resembles normal life.                             can reduce COVID-19 spread and its impact on
                                                        society and the economy while allowing for the
Thinking in terms of harm reduction may be a way        continuance of elements of normal life.
forward. When adopted to address issues such as
alcohol abuse and sexually transmitted infections,
including HIV, harm-reduction approaches have
lowered morbidity and mortality (34). As different
as this pandemic is, such approaches may
prove useful for those who struggle to abide by
restrictions.

A harm-reduction approach recognizes that stopping
behaviours entirely may be difficult, but reducing
the harms associated with these behaviours may
be possible. With this in mind, a harm-reduction
approach encourages a spectrum of acceptable
behaviours (35). When presented with all-or-nothing
scenarios and daunting standards of success, people
are more likely to give up easily and revert to very
risky behaviour. In the context of the COVID-19
pandemic, this may take the form of throwing a
large party because not being social at all has come
to feel unsustainable. While small-group socializing
may not be 100% ideal, it is preferable to a reactive
burst of large-group activities.
Pandemic fatigue     17

Strategic considerations                                – Consider whether all cultural events need to
– Help the public differentiate between lower-            be cancelled, or if they can be implemented in
  risk and higher-risk activities, and ensure that        safe ways, for example, through a combination
  there are support mechanisms in place for the           of online and physical events with mechanisms to
  lower-risk options when sustained abstinence is         ensure safe practices. Engage in a dialogue with
  not an option.                                          organizers and find creative solutions together.

– Develop guidance on how to carry on with life         – Encourage individuals and communities to
  while reducing the risk of transmission. Guidelines     identify harm-reduction strategies that fit their
  can offer options for safer dinner parties,             needs.
  children’s play dates, workplace interactions,
  dates, funerals, weddings, travel, etc. Find          – Shift messaging from “do not” to “do
  creative ways of communicating these. Stick             differently”.
  with recommendations rather than constantly
  changing them.                                        – Avoid judgment and blame related to risky
                                                          behaviours, as this can contribute to shame
– Start preparing for end-of-year celebrations,           and alienation more than engagement and
  and think ahead to other large-scale                    motivation.
  celebrations over the year. How can individuals,
  workplaces, public transportation, the retail
  sector and retirement homes, for example,
  be engaged to reduce risk leading up to these
  events where people meet across geographies
  and generations? Ask for their input and
  develop the guidance they need. Provide clear
  recommendations.
18     Pandemic fatigue                                                              Case examplesPandemic
                                                                                                   for inspiration
                                                                                                           fatigue 18

Netherlands                         Denmark                          Israel                         United States of
When abstinence is not              A new format for                 Safe social interaction:       America
an option: the “cuddle              cultural events                  the floating cinema            Keeping track with a
buddy”                                                                                              contact budget

Recognizing that people             The annual Copenhagen            In Israel, a local business    An American
need physical contact,              Pride festival is usually a      opened a floating cinema       epidemiologist suggested a
including during a                  large-scale public event         where people can rent a        basic method of reducing
crisis, authorities in              with colourful parades in        boat on a lake and enjoy       harm in everyday life: the
the Netherlands issued              the streets and widespread       a movie while respecting       use of a contact budget.
guidance to single people           celebration. This year, rather   physical distancing            Just as a household budget
seeking intimacy during the         than cancelling the event,       requirements. Encouraging      provides an overview of
pandemic. They advised              organizers extensively           and supporting start-          where money is spent
them to find just one               changed the format to            ups and local businesses       and where savings can be
cuddle buddy rather than            include mainly online as         to think creatively and        made, a contact budget
being intimate with several         well as physical activities.     “do differently” is key to     allows individuals to
partners. Similar guidance          Engagement with a broad          ensuring the provision         keep track of exposure.
has been issued in several          range of stakeholders and        of social spaces and           Recognizing that some
countries. Supporting               national health authorities      recreational opportunities –   level of risk is unavoidable,
people to balance high-             allowed for a safe event         critical elements in           methods and tools like
risk and low-risk activities        and the continuation of an       countering pandemic            this may help people to
rather than issuing all-or-         annual celebration that is       fatigue (37).                  consciously and critically
nothing recommendations             important to many people.                                       examine their own habits
may help to prevent                 Similar harm-reduction                                          and choices to minimize
demotivation (38).                  strategies and guidance                                         risk (39).
                                    can be tailored to rituals
                                    and holidays of social and
                                    cultural importance. With a
                                    specific goal in mind – such
                                    as meeting loved ones –
                                    and with people involved
                                    in setting the rules, the
                                    motivation is likely to be
                                    high (36).

Please note disclaimers on page 2
Pandemic fatigue           19

Key strategy /
Acknowledge
and address the
hardship people
experience
Background                                                                           Surveys show that the perceived loss related to
Pandemic restrictions have imposed both hardship                                     pandemic restrictions can be higher than the
and inconvenience in everyday life, and everyone                                     perceived loss related to the virus itself.
has experienced some kind of loss – of income or a                                   Behavioural insights surveys often show, for
job, of educational progress, of being with friends                                  example, that fewer people have a high perception
and family, of engaging in sports activities, or of the                              of risk related to the virus itself, and that more
chance to participate in important rituals such as                                   people indicate stress caused by concerns related to
weddings, graduations, funerals and more.2 It is well                                the pandemic response, such as losing their job or
established that the pandemic and its restrictions                                   income (1).
have led to stress, loneliness and boredom, and
have had a negative impact on well-being and                                         Under such circumstances, it is not a small request
mental health among many (1,40,41). Those already                                    to ask for continued population support. If this
experiencing disadvantages have been shown to be                                     hardship is not well understood, acknowledged and
affected even more negatively (42–45).                                               addressed by those asking for population support,
                                                                                     people may very well lose motivation and COVID-19
                                                                                     initiatives, policies or communication may become
                                                                                     unsuccessful. The fatigue resulting from hardship
                                                                                     can be addressed by building resilience and
                                                                                     alleviating difficulties where and when possible,
                                                                                     including through financial, social, cultural and
                                                                                     emotional support offered by the government and
                                                                                     civil society.

2
    The greatest losses relate to the serious illness and death caused by COVID-19. Additional guidance is needed on providing support to those who have experienced
    illness or lost loved ones.
20   Pandemic fatigue

Strategic considerations                                – Explore if difficult-to-follow restrictions
– Identify and address the barriers and                   can be balanced with other measures to
  hardships people face, and understand which             alleviate negative impact. This could take the
  measures may be difficult to follow in the long         form of financial support schemes, or social,
  run (for example, isolation that results in loss of     psychological or mental health support such as
  employment or income).                                  free online services.

– Make new habits of protection behaviours less         – Create opportunities for people to fill their
  costly. In terms of money: how can protection           time productively if isolated or unemployed due
  behaviours be as inexpensive as possible? And in        to the pandemic, such as training or employment
  terms of effort: how can we make recommended            programmes, employment subsidies, or start-up
  behaviours as effortless as possible for people?        incentives. Help them to build more structure
                                                          into everyday life and engage in activities that
– In all communication, acknowledge the                   have positive effects, such as being outdoors,
  hardships that people face or fear, such as             exercising and enjoying safe socializing.
  loneliness or loss of income. Empathy, hope and
  understanding above punishment, shame and             – Avoid an economy-versus-health dichotomy.
  blame.                                                  Personal economic hardship can result in
                                                          demotivation, and so pandemic response
– Explore how difficult-to-follow restrictions            measures may include efforts to keep the
  can be amended while taking into account the            economy and businesses going.
  epidemiological risk.
Case examples for inspiration                                                                   Pandemic fatigue     21

Norway                                                      Russian Federation
Acknowledging hardship to motivate youth                    Tackling structural barriers

The Norwegian Minister of Health gave a speech              Tackling structural barriers is a prerequisite to any
acknowledging the hardship experienced by young people      sustained behaviour change. In the Russian Federation,
and thanking them for their contributions to society.       several measures have been put in place in this regard.
Norway has also consulted with youth on safe solutions      Lump-sum payments have been provided to families with
for graduation celebrations and initiation ceremonies       children, and financially vulnerable families with children
at universities. This seems to have paid off: population    aged 3 to 7 years are eligible for a monthly allowance.
surveys in Norway show that youth are more adherent to      Citizens who have lost their jobs can apply for this
COVID-19 restrictions than those aged 50+, in contrast to   allowance in 2020 independent of their financial status.
many other countries. Even when hardship itself cannot      In Moscow, older people have been supported to engage
be alleviated, understanding and empathy can be strong      in physical activities taking place outside and in a safe
motivators for continued support (48,49).                   manner.

Spain                                   France                                  Bulgaria
Removing structural barriers            Stepping up with timely responses       Preventing domestic violence
through social protection schemes       to emerging challenges                  during the pandemic

Many countries have implemented         As in other countries, a behavioural    In response to increasing reports of
social and economic supports for        insight survey documented over time     domestic violence since the beginning
those most affected by pandemic         how the mental health of the French     of the pandemic, the Government
restrictions. Spain launched a          population was severely affected by     of Bulgaria adopted a national
national Minimum Living Income          the lockdown. In response, factual      programme to prevent violence and
scheme. Offering monthly payments       information from the survey was         protect women and children. It aims
of up to US$ 1145 to the nation’s       provided to government officials.       to maintain services and offer help to
poorest families, the programme         Practical measures to promote           those who need it. Such programmes
will support 850 000 households.        good mental health included a           have been initiated in many countries
Eligibility is not contingent on        free national telephone hotline and     and may help to alleviate some of the
unemployment or lack of income,         information as to where to get help     negative social consequences of the
which allows people to continue a       for those experiencing psychological    pandemic (47).
level of employment. As such, they      distress (41).
can meet basic needs while still
seeking to improve their situation
through employment or vocational
training (46).

Please note disclaimers on page 2
22   Pandemic fatigue

Checklist /
Cross-cutting
principles
The four key strategies for reinvigorating public                perception, social and cultural norms, and structural
support for protective behaviours must be applied                opportunity. These principles should be applied
based on the epidemiological situation and on                    across policies, interventions and communication,
societal and economic considerations to ensure                   and can be used as a checklist. They prompt
that no one is left behind. To support this process,             decision-makers to ask: will people consider these
we propose five cross-cutting principles that draw               actions to be appropriately transparent, fair,
on evidence relating to factors such as trust, risk              consistent, coordinated and predictable?

Transparency                               Fairness                                    Consistency
Knowing the rationale for decisions        To trust authorities, people need           Ensuring consistency in an ever-
increases motivation to follow             to feel that all relevant opinions          changing situation is next to
them (50). Be transparent in sharing the   have been included (10,11) and              impossible. Still, consistency can be
reasons behind recommendations             that decisions have been based on           pursued by making sure that the risk
and restrictions. Acknowledge the          objective criteria, not on arbitrary        being communicated in messages
limits of science and government in        grounds or the interests of certain         and restrictions is always in line with
terms of predicting the development        groups. Strive for the highest possible     the current epidemiological risk, and
of this pandemic and what                  level of fairness in recommendations        that the actions of leaders are in
restrictions will be necessary at any      and restrictions. All people have felt      line with what is being recommended
later stage, share uncertainty and         the consequences of the pandemic,           for the public. Authorities should also
take responsibility for the decisions      and catering only to the needs of           avoid inconsistent responses, such
that need to be made on uncertain          some will be perceived as unfair by         as lifting restrictions in one sector (for
grounds. Making promises you cannot        others. Creating structural conditions      example, increasing the number of
keep or being unwilling to share           for health equity is another critical       spectators allowed at sports events)
reasons for actions leaves room for        aspect, which involves clearly              while tightening them in another (for
misperceptions, myths and even             communicating the need for equity,          example, imposing new restrictions
conspiracy theories. Clarity and           for example, by compensating for or         on restaurants), without providing
simplicity are key: messages that          alleviating restrictions particularly for   a clear rationale and explanation.
are not clear or simple enough to          those who are suffering the most.           Consistency may also be established
understand and act upon lead to                                                        through the regular use of specific
uncertainty and distrust.                                                              terms and numbers, such as
                                                                                       transmission rates, case rates and
                                                                                       fatality rates.
Pandemic fatigue   23

Coordination                              Predictability
Stakeholder coordination creates          Predictability is a basic psychological
trust (51). Maintain relations with       need that prevents stress and
stakeholders, strive for unity, and       mental overload. This pandemic is
avoid mixed messages from                 characterized by everything but
experts, spokespeople, government         predictability. Still, countries can
representatives and health workers.       strive for predictability by setting
Everyone is entitled to their expert      objective epidemiological criteria
opinion; however, everyone also           for restrictions (and their shifts
needs to be aware that sharing early      up or down) on, for example, travel,
research results or their personal risk   gatherings, educational institutions
perceptions in the public debate may      and workplaces. Countries can also
affect trust in experts in general,       communicate clearly the timelines
particularly if these results and         for restrictions and follow up on
perceptions are not in line with those    these so people know what to expect.
of other experts.
24     Pandemic fatigue                                                   Case examplesPandemic
                                                                                         for inspiration
                                                                                                fatigue 24

Norway                                                     Kazakhstan
Making decision-making processes transparent               Showing empathy

Norway has upheld a high level of transparency in          Recognizing the significant losses that people have
decision-making and the role of expert bodies. The         experienced during the pandemic, the WHO Country
rationale for decisions has been clearly communicated to   Office in Kazakhstan addressed the nation on social
the public, including instances where decisions departed   media to remember the loss of health-care workers on the
from the recommendations made by expert bodies to the      occasion of the national day of mourning for the victims
Government (55).                                           of COVID-19. Providing space for grief and demonstrating
                                                           empathy for the considerable impact that the pandemic
                                                           has had on people are more important now than ever, as
                                                           trauma reactions are to be expected (52).

Ireland                                Germany                                Latvia
Tailoring easy-to-understand           Leaders walking the talk               Decision to be open and honest
messages for different audiences                                              about the unknowns
                                       In many countries, leaders have
Several countries have sought          sought to lead by example, including   In Latvia, a strategy of honesty was
to demonstrate the relationship        through isolating themselves,          agreed on as a fundamental political
between levels of risk and different   wearing masks, and cancelling          principle. When COVID-19 emerged,
behaviours in simple tables or         personal events or celebrations.       the authorities conducted daily press
infographics (53). Ireland prepared    When quarantine was deemed             conferences and answered each
an overview from which tailored        necessary in Germany, Chancellor       and every question. In cases where
infographics are selected and          Angela Merkel self-isolated from       they had no answer, they admitted
used individually for targeted         22 March to 2 April after her doctor   this and promised to follow up
audiences (see https://assets.gov.     tested positive for the virus. She     with more information as soon as
ie/87604/405b1065-055a-4ca8-9513-      recorded a podcast about her           possible. Demonstrating honesty and
390ce5298b10.pdf) (54).                quarantine experience, and shared      transparency is essential to building
                                       that she had been lonely.              and maintaining trust.

Please note disclaimers on page 2
Pandemic fatigue   25

10 suggested actions
We offer this list for decision-makers who are seeking recommendations for
concrete actions. All of these actions relate to the strategies and principles
outlined above.

01                                        04                                        07
Think local. Reach out to civil           Start early to prepare safe               Appeal to people rather than blame,
society groups and ask them to find       solutions for upcoming national           scare or threaten them. Recognize
creative ways of motivating their         celebrations where people gather          that everyone is contributing.
members and peers. Ask them what          across geographies and generations.
support they need from you. Engage        Engage individuals, workplaces, public
volunteers. Youth organizations,          transportation systems, the retail
housing associations, religious           sector, retirement homes and more in      08
leaders, sports clubs and scouting        discussions about ways to reduce risk     Be clear, precise and predictable.
organizations, and business and           during the time leading up to these       Use simple and digestible
community organizations can all play      events. Ask for their input and develop   infographics as an effective way
an active role.                           the guidance they need. Provide clear     of communicating restrictions and
                                          recommendations (56-58).                  epidemiological risks – and how they
                                                                                    are related.
02
In every workplace, school, university,
                                          05
youth club and more, ask the              Understand which measures may             09
users to discuss how they would like      be unbearable in the long term –          Conduct regular qualitative or
to implement the recommended              for example, extended isolation           qualitative population studies. Take
behaviours. These discussions may         that results in loss of employment        the findings seriously. Use them to
reveal barriers, inconveniences           or income. Amend or balance               inform action.
and misperceptions that can               such restrictions with other
be addressed while maintaining            measures (economic, social,
restrictions.                             psychological), taking into account
                                          the epidemiological risk.                 10
                                                                                    Tailor communication to specific
03                                                                                  groups that experience demotivation.

Develop guidance on living life
                                          06                                        Test messages and visuals with
                                                                                    sample populations before launching
while reducing risk. For example,         Make recommended behaviours               them.
make recommendations for safer            easy and inexpensive. This can
dinner parties, children’s play dates,    involve the provision of fast and
workplace interactions, dates,            cheap internet connections, free
funerals, weddings and travel. Find       masks and hand sanitizers, accessible
creative ways of communicating            hand-washing areas, spaces for
such guidance. Avoid constant             social interaction, opportunities for
changes.                                  teleworking, and more.
26     Pandemic fatigue

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