Sustaining the public health intervention strategies in confronting the Covid-19 pandemic

Abstract

The most effective strategies that any society has while fighting against confronting the pandemic Covid-19 is affecting not just health but also economics, politics, and social order while fighting against its spread. The main intervention strategies in preventing the spread in any society are hand hygiene, wearing masks, social distancing and quarantine. The purpose of this study was to examine the characteristics of strategies and actions aim to sustain the implementation and change of a public behavior intended for facing long-term pandemics or crises. A review-research was done between August and December 2020 on some papers considering the topic of sustainability of strategies, sustainable public health actions and strategies used to face the Covid-19 and similar pandemics in various countries. This study presents the necessity to focus on strategies sustainability especially in pandemic circumstances like Covid-19. The sustainability in implementing large public health strategies is categorized by primary flexibility and vitality. The foremost intervention strategies applied to influence the community in the target of daily activities were to use enhancement guidelines, interactive educating courses, monitoring and evaluations, and dynamic involvement of stakeholders that may sustain these strategies for longer periods. Public health intervention strategies comprise different approaches depending on types of actors, shifts in the pandemic situation, contextual aspects, progress over time, and the ability for sustainability. It is necessary to guarantee that public health strategies are effectively embedded in their settings, depending on more evidence-based approaches and understanding how valuable interventions can be sustainable.

Introduction

Large-scale intervention strategies stimulating change in the health and social care sector are very challenging to be conducted. There are not many systematic researches that can enrich our understanding of strategies to facilitate large public health behavior changes especially through pandemics or crisis. The interventions’ indicators were addressed to assess the impact of these strategies. Intervention strategies that are grounded at the improper level of the social structure are unlikely to be effective nor to be sustainable. ¹

For public health strategies, this has been characterized as the focus shift from risk factor interventions to risk conditions’ interventions. While risk factor interventions are abstracted at the individual level, risk conditions such as social cohesion and access to social, educational and health services are more usually considered as a function of community-based activity. Interventions that isolate the action process far from its social context are dubious to produce sustainable health advance. ¹

Outcomes arising from health promotion and interventions’ strategies should unveil the need to maintain strategic support for these interventions, the importance of preserving the continuing potential for public health interventions and the struggle in demonstrating the quick health gain in such short-term preventive actions. Nevertheless, the benefits which can accrue to economic or governmental considerations as a result of sustainable public health efforts, individuals and communities’ preventive health issues often reinforce the expectations to consider these strategies’ sustainability. Many public health efforts fail to become sustainable because inadequate resources are provided in the rapid to medium span. ² Thus, long-term interventions’ reserves may require significant supporting guides and resources for that period ¹ or it may perish or lose its sustainability.

However, five priorities are needed to strength the public health interventions and sustaining of implemented strategies: (1) enhance means for scheming and tailoring; (2) specify and assessment mechanisms of strategy; (3) conduct more usefulness research; (4) boost evaluations; and (5) improve monitoring and reporting. ³

The main implemented strategies facing Covid-19 pandemic

The novel coronavirus disease 2019 (Covid-19) epidemic first emerged in the city of Wuhan of Hubei Province, China, on December 12, 2019. According to the WHO, the common symptoms of Covid-19 infection include fever, tiredness, dry cough, shortness of breath, aches, pains, and sore throat. Regarding its contagious nature, Covid-19 has affected the lives of human beings and obviously restricted their mobility. ⁴ Lai et al. ⁵ claimed that Covid-19 has spread via human-to-human transmission through direct contact and respiratory droplets. In this regard, it can be inferred that the people’s mobility and crowding quicken the spread of the virus.

There are few medications that have been approved by the FDA, that confirmed an effect on the virus for this global pandemic through controlled studies. Although there are cures for disease and progresses made by leaps and constraints in our day, the robust and most effective strategy that the societies have against this virus is the prevention of its spread. The main interventions in preventing the spread in society are wearing masks, hand hygiene, social distancing, and quarantine. Increasing the test capacity will also help to reduce secondary cases by detecting more Covid-19 carrier patients in the community. ⁶

Countries dealing with this virus, have taken necessary actions to stop the spread of the coronavirus, including closing down crowded places such as schools, shopping malls, movie theaters, and other sports venues. The governments have asked their citizens to keep themselves in voluntary quarantine and stay at home to reduce the number of infected cases. ⁷ In addition, people are not allowed to across between metropolitan cities except in compulsory situations.

This uncertainty, combined with the highly infectious nature of the virus and the misconceptions surrounding coronavirus, has influenced millions of individuals around the world and have a global impact on both individual and societal levels. However, with global lockdown to diminish Covid-19 spread, several individuals have lost their jobs. In addition, it is possible that individuals do not have enough reserves to store the necessary needs and protective supplies. It was viewed as an advantage to have adequate capacity, such as hospital beds and intensive care unit capacities in all provinces. Moreover, manufacturing personal protective equipment such as gloves, surgical and respiratory masks, gowns, and other safety devices. ⁸

According to Nyström et al. ⁹ the main strategies for promoting implementation have been drawn from the comprehensive list of events and the details of the strategic efforts made during the pandemic by the respondents; (1) the first approach relates to regular emergency communications between actors and across multiple networks; (2) the second approach, enhancing cooperation and holistic views among actors; (3) the third approach aimed at fostering openness and using all forms of media to connect and exchange information. However, the totally adopted strategies in most countries confronting Covid-19 were;

Washing hands: one of the most critical strategies for the community to follow is to wash their hands regularly and avoid direct contact with their faces after engaging with potentially contaminated settings. To reduce the threat of transmission in the community, individuals have to wash hands diligently.

Wearing masks: practice respiratory hygiene (i.e. cover their cough), it has long been recommended that infected patients wear masks to reduce droplet spread for respiratory infections such as influenza. In addition to uninfected people wearing masks would possibly interrupt the transmission connection as a public health measure which would avoid these seemingly healthy sources of infections.

Social distancing: is designed to reduce interactions between people in populations, in which individuals may be infectious but have not yet been identified and not yet isolated. ¹⁰ As diseases transmitted by the respiratory systems which require certain closeness of people, social distancing of persons undoubtedly can reduce the transmission. The social distancing is mainly useful in settings where transmission has the opportunity to occur.

Quarantine: is one of the oldest and most effective strategies of controlling communicable disease or epidemic outbreaks. The quarantine of individuals is the restriction of activities or the separation of individuals who may have been exposed to an infectious agent or mediator, with the objective of tracking their symptoms and ensuring the early detection of cases. Quarantine is the most effective method in reducing both the number of infected and dead. ¹¹ It has been much more successful in countries which introduced stringent quarantine rules precisely from the beginning.

Sustaining the public health intervention strategies after vaccination

The expectations and hopes that the all-public population can get a vaccine that protects against Covid-19 is a result of the great successes that vaccines have had and continue to have in the prevention of infectious diseases. However, there is a slew of infectious diseases for which vaccines are only marginally successful, and it has been seen a rash of high-profile vaccine failures. Each infection is, in fact, an immunological issue in and of itself: even today, with all the data at one’s disposal, predicting which kind of vaccine would be fully successful is difficult. SARS-CoV2, the coronavirus that caused Covid-19, is an RNA virus, and these viruses are known for their high genetic variation. Developing successful vaccines against RNA viruses has long been thought to be difficult due to genetic instability. ¹²

However, if these restrictions are eased before an effective immunization is reached, the epidemic will most likely resurface with new major outbreaks. ¹³ Face masks are also needed or recommended in public spaces. That is, vaccination combined with a moderate degree of non-pharmaceutical interventions, such as the use of face masks in public places, may be a feasible choice for long-term disease suppression. ¹⁴

To protect population public health, health experts and public officials must help to understand and remember the importance of continuing to use preventive health interventions such as wearing masks, washing hands properly and frequently and social distancing, particularly when the population exposure to positive news about Covid-19 vaccines that can reduce their commitment to the strategies. ¹⁵ As issues like “Covid-19 fatigue” or “mask fatigue” become the case, healthcare and government officials should convince their populations to sustain the Covid-19 strategies’ guidelines.

Wearing a mask and practicing social distancing is still essential after receiving the vaccine for many reasons; (a) there was small number of doses available at first and the herd immunity threshold for Covid-19 will be reached after a long period, (b) the duration of vaccine immunity is uncertain, and (c) since people will be vaccinated in waves, it will take time to vaccinate enough people to reach populations’ herd immunity.

While some enforcement is likely to become a challenge over time, it is critical to reignite previous efforts and encourage societies to continue doing their role. Until the pandemic is suppressed, the world must work together to communicate a straightforward, concise, and consistent message to the public—masks, personal hygiene are still required and temporary social distancing can bring the world closer in a timely manner. ¹⁵

Public health policymaking in the cultural contexts

Chaskin ¹⁶ defines community capacity building as “the interaction of human capital, organizational resources, and social capital existing within a given community that can be leveraged to solve collective problems and improve or maintain the well-being of that community.” This proposes an important task for the planning process, as it involves integrating a capacity building relationship. This interdependence means a kind of engagement that favors equality and respect, which promotes involvement, empowerment, corporate processes, mobilization of resources and critical evaluation. These values depend not only on the internal dimensions of individuals and social classes but also on public service availability and quality.^17,18

The author agrees with Cheryl and Cheryl ¹⁹ who recommends approaching community as a multi-dimensional dynamic system of which we are apart. This policy brief has been established in reaction to the increasing awareness among policymakers and the public health community of the critical relationship between community culture and health. The policy brief reveals how important cultural understanding is to consider health and well-being, and to build more successful health policies. Consequently, it states that the implementation of research from the health-related social sciences has much to learn from public health policymaking. Policymakers use specific statistics on death and morbidity to guide policy decisions, often without a clear understanding of the cultural factors affecting individual and social behaviors. Though based on carefully assembled statistical evidence, the resulting studies and policies can be out of touch with the subjectively identified perceptions and supposed needs of individuals, as well as what is feasible at the policy level. ²⁰

However, in order to create effective and sustainable wellness strategies and services, leaders need to analyze how populations, as living societies, are responding to varied and changing stressors. Measuring the results of interventions here becomes difficult without carefully evaluating the insecurity and durability as they arise locally. This being the case, qualitative analysis techniques will provide effective mechanisms for a more realistic evaluation of quantitative evidence, monitor for implicit biases, and long-term evaluation of the validity of strategies and their sustainability.

Factors influencing the success of implementation public health intervention strategies

Previous research reports on implementing new strategy methods address performance drivers such as ²¹ ; transition underlying forces ²² and/or contextual factors. The driver “planning and development” requires vision and purpose; deliberately designed interventions; sound management and appropriate services both in central government and in participating administrations. This driver reflects on the nature and clarification of tactics and the quality of their implementations.

The driver “considering individual, community, policymaking, and system variables” comprises eight secondary drivers: individual and group variables and their dynamics; champions and agents for change; leadership roles; capability development; collaborations for learning; social networks; system capability; and culture. This primary driver represents the underlying complexities of the health or social care environment, which illustrates the need for decent system awareness with multi-level agent techniques. ¹⁸

Approaches with an emphasis on delivering sound strategy and scheme include maintaining readiness to adapt, creating frameworks for execution and preparing initiatives, endorsing, advising, and reviewing—while also learning from interactions. However, many transition initiatives begin with less comprehensive and structured planning as the process progresses over time, a mixture of new and deliberate techniques where consensus on results becomes necessary. ²³

In addition to focusing on strategic measures, the goals management committee has faced difficulties such as determining intermediate and final targets and clarifying the responsibilities of each team member. ²⁴ The agents of various teams may often prefer different methods to improve public response based on the context and can therefore vary in their performance rates. ²⁵ Strategies have been suggested to address resistance, where agents of reform may opt, for example, to offer education and provide the resources that promote it.

Sustaining the public health intervention strategies

Shediac-Rizkallah and Bone ²⁶ broadly conceptualize sustainability as maintaining health benefits over time, Scheirer and Dearing ²⁷ concentrate specifically on program elements and describe sustainability as continuing use of components and practices to produce beneficial strategy and community results on a continuing basis. Schell et al. ²⁸ also modified this concept, which recognizes the factor of time and thus describes sustainability as the capacity to preserve strategy and its benefits over time. ²⁹

Proponents of using philosophy to discuss resilience claim that it promotes the interpretation of diverse effects on the execution of specific interventions, including environments, features of target populations, and the initiative itself^30,31; Others argue that using technically educated methods allows a clearer explanation of why such strategies fail and other seemingly similar methods work. ²⁷ In addition, it has been found that generalizing by theory probably provides a more effective and acceptable form of generalization than varied research replication.

In studying sustainability, several designs and guidelines recommendations have been made. For example, a timeframe has to be designated for the problem being studied which allows changes over time to be studied; typically, scholars have suggested this to be at least a year after implementation, and preferably two or more years later. ³² The appropriate time frame depends on the characteristic of the intervention (e.g. scale of expenses) and on what is related to the health issue itself.

However, the complex nature of the socio-political environment in which intervention strategies are presented also contributes to shifts in financing, involvement of policymakers, communities, and public participation, both of which may impact sustainability. Therefore, it is useful to test sustainability over several time points in order to catch its inherent dynamic and nonlinear existence. ²⁸ Similarly, determinations should be made as to how much modification to intervention elements is appropriate or anticipated, and whether or not there is a required threshold to be met in order to be considered sustained. ³³ This may be particularly relevant in the ever-changing sense of a new pandemic, as well as the implementation and application of emerging technology. ³³ It is also important that researchers identify strategic studies and analysis for both sustainability determinants and outcome measures of public health.

Nonetheless, getting a gold standard can be difficult when assessing sustainability as an outcome, including significant heterogeneity in individual intervention program elements ²² as well as variations through clinical outcomes, environments, and activities observed. Sustainability results have been conceptualized in recent years as ²⁸ (a) maintaining or enhancing health benefits or outcomes for particular patients; (b) preserving community-level relationships or coalitions and collective community capacity; (c) preserving the processes, procedures and policies implemented through implementation (institutionalization).

To address the conceptualization and appraisal of the efforts to implement effective intervention strategies, Proctor et al. ³⁴ proposed a taxonomy of “implementation outcomes” that attempts to address sustainability. The taxonomy indicates eight conceptually distinct assessment outcomes, including acceptability, adoption/uptake, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. ³⁰ Under this categorization, sustainability is described as “the degree to which a newly introduced policy is sustained or institutionalized in the continuing stable operations of a service setting.” ³⁰

Rabin et al. ³⁵ found that the institutionalization of an action is defined by three steps. These include sole events such as the transition from temporary to permanent funding (passage), repeated strengthening of the intervention by including it in public procedures and behaviors (cycle routine), and the degree to which the intervention is integrated into all a community’s subsystems (niche saturation). ³⁵ Despite the interest and priority given to sustainability in public health policies, the majority in initiatives remain at a conceptual stage with sustainability and related principles emerging more often in theoretical papers than empirical articles. There is also a lack of methods for measuring the sustainability of interventions. ³¹

However, in some situations, owing to preference or insufficient time and resources, significant changes can be made to the components of the strategies, despite evidence that those core components are successful and/or necessary to meet the needs of various communities. ³⁶ Concepts such as adaptive consistency were implemented to understand the value of tailoring approaches to fulfill the needs of various communities while maintaining the successful components. ³⁷ Some have proposed that to be considered as a sustainable intervention strategy it should stay identifiable. ³²

Conclusion

Although being well prepared, the pandemic is a process that requires quick action and long-term planning. Regarding the pandemic Covid-19, the changes around the world have been constantly tracked. In harmony with the pandemic reaction plans, interventions have been carried out with a multi-dimensional policy and preventive actions have been applied. The article is timely and relevant because the Covid-19 vaccine has been available for the public use, and policymakers need to make the best decisions possible to continue social distancing and wearing face masks in the post-vaccine period.

Public health intervention strategies are more likely to yield sustainable effects if they address appropriate levels of sociality to achieve the outcomes. Strategies proposal and implementation should consider the evidence concerning intervention strategies, social levels of the community and the sustainability of interventions. Furthermore, initiatives should distinguish between strategies to promote: (i) the preservation of public health prevention requirements; (ii) differences in individuals and populations that can contribute to health advance; and (iii) the possible feasibility of these measures and the need for time-depending prevention services.

In order to strengthen the national health strategies regarding this pandemic or others, defining and then adopting the elements of comprehensive health response can ensure the sustainability of the taken strategies in an integrated approach. Policymakers must recognize the overwhelming amount of current expertise to assess how effective the implementation and adaptation of intervention components are adequate or how its’ outcome threshold is expected to be. Nonetheless, more public health research is needed to identify how public health prevention-related strategies fail among certain populations and how more adaptive and resilient ones can be sustained.